There have been yet more autism studies recently, highlighting neuroinflammation and the role of cells called microglia. The result is this rather long post; but there is film to watch, if it gets heavy going.
Glia derives from a Greek word for glue. The original thought was that the glial cells “glued” the neurons together.
It turned out that glial cells do very much more and might be better thought of as “resident immune cells”. They have other functions including synaptic pruning, which appears to have gone awry in autism. They also form myelin, and when this goes wrong, big problems follow.
Microglia are inside the blood brain barrier and one of their jobs is to swallow up any foreign bodies that should not be there, before they can do damage. It appears that this process is mainly modulated via potassium channels. The majority of research focuses on the calcium-activated K+ channels, particularly KCNN4/KCa2 and 3.1, and ATP-sensitive K+ channels (KATP). Administration of diazoxide, a classic KATP channel activator, is shown to reduce microglial activation and is neuroprotective in a variety of models involving neuroinflammation.
However, Kv 1.3 and Kv 1.5 are also involved in activated glia. We have seen in earlier posts, that blocking Kv 1.3 can be effective in autism (remember those TSO worms).
For the scientists among you:-
Synaptic pruning
A very small Acer Palmatum
Synaptic pruning could itself be the subject of an entire blog. I will just use the analogy of a different kind of pruning.
With ornamental trees, to obtain the perfect form, pruning is very important. You have to clear away the dead wood and encourage growth in particular areas to achieve the optimal shape. You need to know when to cut, where to cut and how much to cut.
The human brain develops with far too many synapses and they too need pruning. The weak ones need to give way for the strong ones to prosper. Too many synapses lead to poor brain function. This process is going on from childhood to early adulthood. Microglia are heavily involved in this pruning process, as you will see in the video shortly.
We know that synaptic pruning is implicated in autism and very likely in its big brother, schizophrenia.
Activation of Microglia
Microglia can be in either a resting or activated state. In the activated state, for no good reason, they can do damage. They can also react with mast cells to produce more inflammation.
(here is a link for the mast cell followers of Theoharides; they know who they are)
The subject is very complex. For those with an hour to spare there is an excellent presentation by Beth Stevens from Harvard. Click on the link below to go to the SFARI website and the video.
By a bizarre coincidence, there is another B Stevens researching glial cells and autism. This time it is Bruce Stevens, in Florida.
His paper is interesting because he is using a known anti-oxidant (alpha lipoic acid, ALA) to affect brain glial cells.
One of the odd things is that we know in autism there is both oxidative stress and neuro-inflammation; they are a self-perpetuation combination. There are numerous effective anti-oxidants; almost too many. There is, however, a paucity of effective, safe, anti-inflammatory drugs. In fact the best anti-inflammatory drug is probably an anti-oxidant. So called Reactive Oxygen Species (ROS) are among the biggest causes of neuroinflammation. With anti-oxidants you can neutralize the ROS, and thereby you take a big bite out of the neuroinflammation.
Abstract
Double-stranded RNAs (dsRNA) serve as viral ligands that trigger innate immunity in astrocytes and microglial, as mediated through Toll-like receptor 3 (TLR3) and dsRNA-dependent protein kinase (PKR). Beneficial transient TLR3 and PKR anti-viral signaling can become deleterious when events devolve into inflammation and cytotoxicity. Viral products in the brain cause glial cell dysfunction, and are a putative etiologic factor in neuropsychiatric disorders, notably schizophrenia, bipolar disorder, Parkinson's, and autism spectrum. Alpha-lipoic acid (LA) has been proposed as a possible therapeutic neuroprotectant. The objective of this study was to test our hypothesis that LA can control untoward antiviral mechanisms associated with neural dysfunction. Utilizing rat brain glial cultures (91% astrocytes:9% microglia) treated with PKR- and TLR3-ligand/viral mimetic dsRNA, polyinosinic-polycytidylic acid (polyI:C), we report in vitro glial antiviral signaling and LA reduction of the effects of this signaling. LA blunted the dsRNA-stimulated expression of IFNα/β-inducible genes Mx1, PKR, and TLR3. And in polyI:C treated cells, LA promoted gene expression of rate-limiting steps that benefit healthy neural redox status in glutamateric systems. To this end, LA decreased dsRNA-induced inflammatory signaling by downregulating IL-1β, IL-6, TNFα, iNOS, and CAT2 transcripts. In the presence of polyI:C, LA prevented cultured glial cytotoxicity which was correlated with increased expression of factors known to cooperatively control glutamate/cysteine/glutathione redox cycling, namely glutamate uptake transporter GLAST/EAAT1, γ-glutamyl cysteine ligase catalytic and regulatory subunits, and IL-10. Glutamate exporting transporter subunits 4F2hc and xCT were downregulated by LA in dsRNA-stimulated glia. l-Glutamate net uptake was inhibited by dsRNA, and this was relieved by LA. Glutathione synthetase mRNA levels were unchanged by dsRNA or LA. This study demonstrates the protective effects of LA in astroglial/microglial cultures, and suggests the potential for LA efficacy in virus-induced CNS pathologies, with the caveat that antiviral benefits are concomitantly blunted. It is concluded that LA averts key aspects of TLR3- and PKR-provoked glial dysfunction, and provides rationale for exploring LA in whole animal and human clinical studies to blunt or avert neuropsychiatric disorders
The obvious question is whether other antioxidants have the same effect. Most likely nobody knows. I did ask both B Stevens #1 and B Stevens #2 for their thoughts on this – so far no answer.
Brain inflammation a hallmark of autism, according to large-scale analysis
Finally to the subject of this post, the recent Johns Hopkins study that shows inflammation in the autistic brain.
While many different combinations of genetic traits can cause autism, brains affected by autism share a pattern of ramped-up immune responses, an analysis of data from autopsied human brains reveals. The study, a collaborative effort between Johns Hopkins and the University of Alabama at Birmingham, included data from 72 autism and control brains. It was published online today in the journal Nature Communications.
“There are many different ways of getting autism, but we found that they all have the same downstream effect,” says Dan Arking, Ph.D., an associate professor in the McKusick-Nathans Institute for Genetic Medicine at the Johns Hopkins University School of Medicine. “What we don’t know is whether this immune response is making things better in the short term and worse in the long term.”
The causes of autism, also known as autistic spectrum disorder, remain largely unknown and are a frequent research topic for geneticists and neuroscientists. But Arking had noticed that for autism, studies of whether and how much genes were being used — known as gene expression — had thus far involved too little data to draw many useful conclusions. That’s because unlike a genetic test, which can be done using nearly any cells in the body, gene expression testing has to be performed on the specific tissue of interest — in this case, brains that could only be obtained through autopsies.
To combat this problem, Arking and his colleagues analyzed gene expression in samples from two different tissue banks, comparing gene expression in people with autism to that in controls without the condition. All told, they analyzed data from 104 brain samples from 72 individuals — the largest data set so far for a study of gene expression in autism.
Previous studies had identified autism-associated abnormalities in cells that support neurons in the brain and spinal cord. In this study, Arking says, the research team was able to narrow in on a specific type of support cell known as a microglial cell, which polices the brain for pathogens and other threats. In the autism brains, the microglia appeared to be perpetually activated, with their genes for inflammation responses turned on. “This type of inflammation is not well understood, but it highlights the lack of current understanding about how innate immunity controls neural circuits,” says Andrew West, Ph.D., an associate professor of neurology at the University of Alabama at Birmingham who was involved in the study.
Arking notes that, given the known genetic contributors to autism, inflammation is unlikely to be its root cause. Rather, he says, “This is a downstream consequence of upstream gene mutation.” The next step, he says, would be to find out whether treating the inflammation could ameliorate symptoms of autism.
The full study is here:-
What I liked about the study was the comment made by Arking, a specialist in genetics, that it did not seem to matter what the genetic cause was, all the brain samples exhibited the same inflammation. So it does not matter which of millions of possible combinations of genetic dysfunction is present, one key physiological result is shared neuroinflammation.
Take home message: Treat the neuroinflammation in people with Autism.
The question of course is how.
Since it seems easy to treat oxidative stress, a leading cause of neuroinflammation, we should go to extreme lengths to finish that job.
I started it with NAC and recently added Sulforaphane/broccoli. I suspect there are more “low hanging fruit” to be gathered here. Perhaps just an additional supplemental (exogenous) antioxidants, or perhaps something clever like increasing the amount DJ-1, which is needed to support Nrf2 which turns on the anti-oxidant genes. Early 2015 will see my oxidative stress therapy optimized.
Treating Neuroinflammation in Autism
There are lots of possible ways to treat neuroinflammation, some of which we have already covered in this blog. Sometimes it gets called immunomodulatory therapy.
There are some natural options like quercetin and turmeric. Turmeric is also possibly chemo-protective:-
“Currently there is no research evidence to show that turmeric or curcumin can prevent or treat cancer but early trials have shown some promising results.”
Interestingly, people who eat a lot of curry (Indians) have a very low incidence of cancer.
1. Steroids, like Prednisone
These are already used, particularly in regressive autism. They are potent, but have side effects.
2. Blockers of Potassium channel Kv1.3
This is a clever approach, since it appears that this potassium channel is involved in mediating the inflammatory response. By blocking these channels the response we have seen that the immune response can be moderated and in some people, there autism moderated.
3. Activators of Potassium channel KATP
We learned earlier in this post about diazoxide
4. Other Microglial Ion Channels
The various other potassium, calcium and sodium channels need to be considered.
5. Ibuprofen
This common painkiller reduces inflammation and is used to reduce inflammation associated with autism secondary to mitochondrial disease.
Do not use acetaminophen/paracetamol/Tylenol. These will increase oxidative stress, since it depletes GSH and also affect mitochondria.
These are interesting because they are used to treat asthma and so are very widely used. They are not steroids and so do not have their side effects. They are proved to have anti-inflammatory effects.
Montelukast/Zafirlukast is used to reduce inflammation associated with autism secondary to mitochondrial disease.
7. Pregnenolone
I wrote a post a while back on Pregnenolone, which is interesting, since you do not need a prescription. But does it work?
Well, after I wrote the post below, the results from a clinical trial in adults with autism was finally published.
Abstract
The objective of this study was to assess the tolerability and efficacy of pregnenolone in reducing irritability in adults with autism spectrum disorder (ASD). This was a pilot, open-label, 12-week trial that included twelve subjects with a mean age of 22.5 ± 5.8 years. Two participants dropped out of the study due to reasons unrelated to adverse effects. Pregnenolone yielded a statistically significant improvement in the primary measure, Aberrant Behavior Checklist (ABC)-Irritability [from 17.4 ± 7.4 at baseline to 11.2 ± 7.0 at 12 weeks (p = 0.028)]. Secondary measures were not statistically significant with the exception of ABC-lethargy (p = 0.046) and total Short Sensory Profile score (p = 0.009). No significant vital sign changes occurred during this study. Pregnenolone was not associated with any severe side effects. Single episodes of tiredness, diarrhea and depressive affect that could be related to pregnenolone were reported. Overall, pregnenolone was modestly effective and well-tolerated in individuals with ASD.
Trial doses were:-
Days 1-14: 100 mg
Week 1 and 2: 200 mg
Week 3 and 4: 350 mg
Week 5 and 6: 400 mg
Week 7 -12: 500 mg
So it was modestly effective, but the doses were huge. It is a hormone and our endocrinologist did not much approve of the idea.
I will give this idea a miss.
8. Statins
The current treatment for neuroinflammation in my Polypill is Atorvastatin.
I have already written a great deal about why statins may be effective in some people with autism; just make sure you do not have low cholesterol or mitochondrial disease.
Arthritis is another disease mediated by inflammation:-
To me it is no surprise that statins have therapeutic value in rheumatoid arthritis.
9. NF-κB inhibitors
Because NF-κB controls many genes involved in inflammation, it is not surprising that NF-κB is found to be chronically active in many inflammatory diseases, such as inflammatory bowel disease, arthritis, sepsis, gastritis, asthma, atherosclerosis and others.
So perhaps NF-κB is for inflammation ,what Nrf2 is for oxidative stress, a force multiplier?
There are very many other inflammatory diseases like rheumatoid arthritis and so it is quite a well-trod path looking for inhibitors of NF-κB.
Before we get into that, a quick check on what we already know from research to schizophrenia (adult-onset autism).
Abstract
BACKGROUND:
Many reports suggest that schizophrenia is associated with the inflammatory response mediated by cytokines, and nuclear factor-kappa B (NF-kappaB) regulates the expression of cytokines. However, it remains unclear whether the interaction between NF-kappaB and cytokines is implicated in schizophrenia and whether the effect of neuroleptics treatment for 4 weeks is associated with the alteration of cytokines.
METHODS:
Sixty-five healthy subjects and 83 first-episode schizophrenic patients who met DSM-IV criteria and who were never treated with neuroleptics previously were included. Serum levels of cytokines such as interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) were examined by using sandwich enzyme immunoassay (EIA). Peripheral blood mononuclear cell (PBMC) mRNA expressions of cytokines (IL-1beta, TNF-alpha) and NF-kappaB were detected by using semiquantitative reverse transcription polymerase chain reaction (RT-PCR). NF-kappaB activation was examined by using transcription factor assay kits.
RESULTS:
Schizophrenic patients showed significantly higher serum levels and PBMC mRNA expressions of IL-1beta and TNF-alpha compared with healthy subjects. However, treatment with the neuroleptic risperidone for 4 weeks significantly decreased serum levels and PBMC mRNA expressions of IL-1beta in schizophrenic patients. NF-kappaB activation and PBMC mRNA expression in patients were significantly higher than those in healthy subjects. Furthermore, PBMC mRNA expressions of IL-1beta and TNF-alpha were positively correlated to NF-kappaB activation in both schizophrenic patients and healthy control subjects.
CONCLUSIONS:
Schizophrenic patients showed activation of the cytokine system and immune disturbance. NF-kappaB activation may play a pivotal role in schizophrenia through interaction with cytokines.
It seems fair to conclude that NF-κB inhibitors are well worth investigating.
Interestingly, one of my new “pet” compounds, alpha lipoic acid appears to have another role here:-
Abstract
OBJECTIVE:
α-Lipoic acid (LA) exerts beneficial effects in cardiovascular diseases though its antioxidant and/or anti-inflammatory functions. It is postulated that the anti-inflammatory function of LA results from its antioxidant function. In this study we tested whether inhibition of NF-κB by LA is dependent on its antioxidant function.
METHODS:
Human umbilical vein endothelial cells (HUVECs) were treated with tumor necrosis factor-α (TNFα) in the presence of various antioxidants, including LA, tiron, apocynin, and tempol. The activation of the nuclear factor-κB (NF-κB) signaling pathway was then analyzed.
RESULTS:
LA, but not other tested antioxidants, inhibited TNFα-induced inhibitor-kappaB-α (IκBα) degradation and VCAM-1 and COX2 expression in HUVECs. Although LA activated the phosphatidylinositol-3-kinase (PI3-kinase)/Akt pathway in HUVECs, inhibition of Akt by LY294002 did not affect inhibition of TNFα-induced IκBα degradation by LA. In transient co-transfection assays of a constitutively active mutant of IκB kinase-2 (IKK2), IKK2(EE), and a NF-κB luciferase reporter construct, LA dose-dependently inhibited IKK2(EE)-induced NF-κB activation in addition to inhibiting IKK activity in in vitro assays. Consistent with the effect on luciferase expression, LA inhibited IKK2(EE)-induced cyclo-oxygenase-2 (COX2) expression, suggesting that IKK2 inhibition by LA may be a relevant mechanism that explains its anti-inflammatory effects.
CONCLUSIONS:
LA inhibits NF-κB activation through antioxidant-independent and probably IKK-dependent mechanisms.
This really makes ALA look very interesting. It is cheap, widely available and well tolerated.
10. Low Dose Naltrextone
Your local doctor will probably tell you that Low Dose Naltrexone (LDN) is a load of quack nonsense, partly because it is claimed to help so many unrelated disorders.
I would not have questioned that opinion, before I had started by investigation into the biology of the brain and seen how many apparently unrelated conditions are actually interrelated. This can be established by science, not quackery.
First to note is that tiny doses of some substances do indeed sometimes have effects quite different to large doses.
We saw earlier how a tiny stimulation of the body’s nicotinic receptors produces a different effect to a large dose.
My own experience showed that a tiny, but specific, dose of Clonazepam has a marked effect, whereas conventional medical wisdom would say such a small dose would do absolutely nothing. In this case, I was just following the clever idea of Professor Catterall, from the University of Washington.
I also found that tiny doses of a TRH analog had a positive effect and quite different to the “regular” dose.
The advocates of LDN suggest it for conditions including Crohn's disease, fibromyalgia and multiple sclerosis (MS). As I mentioned earlier in this blog, some Fibromyalgia appears to be a condition that was almost autism; perhaps the final hit, in a multiple-hit process failed to occur. Crohn’s is an immune disease and is a type of inflammatory bowel disease (IBD). MS is an inflammatory disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged.
Preliminary research suggests LDN may have an effect on inflammation. Naltrexone has an antagonistic effect on Toll-like receptor 4 (TLR4), which are found on microglia, which can modulate the body's response to inflammation. It has been hypothesized that LDN may have anti-inflammatory effects through this pathway.
Conclusion
The immediate conclusion is that there are plenty of ways, already existing, that might very well help reduce neuroinflammation in autism. They just requires a little further thought and investigation.
The broader conclusion here is about the merit of genetic testing.
Undoubtedly, if you could analyze the entire genome in a person with autism and also measure the expression of those suspect genes in the brain, you would gain a great deal of information. In a few cases, where there is a single gene causing the “autism”, you might well be able to figure out a therapy.
You cannot take brain biopsies from living people. We did come across that clever Ricardo Dolmetsch, growing brain samples from skin cells. He has now moved over to the private sector.
So for the moment genetic testing will just generate a vast amount of data, that in many cases will not be of any immediate clinical relevance.
The good news, as pointed out by Dan Arking, from Johns Hopkins, is that many of these numerous, unrelated, genetic dysfunctions end up with the same biological manifestations.
There may be thousands, or even millions of combinations, of genetic dysfunctions that lead to autism with neuro-inflammation.
You can go ahead and treat the neuro-inflammation, without any knowledge of exactly which gene has which SNP (single nucleotide polymorphisms) or who had what CNV (copy number variant).
For me, the identification of so-called autism genes like PTEN and BCL2 is interesting, as are the single gene causes of autism. We can then see that a reduced expression of that gene might contribute to autism, caused by multiple gene dysfunction (multiple-hits). For the great majority of people with ASD, they have had multiple-hits.
I read Ricardo Dolmetsch’s Stanford research into Timothy syndrome, which is caused just by one gene, albeit a very important one. I considered that perhaps a partial dysfunction might occur, leading to disturbance in the protein expressed by this gene. I had no idea whether in my son this dysfunction existed, whether it might be caused by a SNP (there are several known ones) or if a dysfunction was caused as a consequence of a metabolic disruption caused by autism, such as oxidative stress or neuroinflammation, affecting the function of an undamaged gene.
It did not matter; I just carried on and did a little practical test. This led me to include Verapamil in my Polypill. No genetic testing was required.
It was suggested to me that genetic testing might help point me in the right direction. I think it would likely point me in all directions. We all carry many genetic errors, and most of us thrive regardless, so most genetic errors are irrelevant.
Clusters
From now, I will consider autism in terms of a manageable group of clusters. Once you know, based on symptoms and some measurable biomarkers, which cluster you are in, you would have a good chance of predicting which drugs would be effective.
The underlying genetic causes may, or may not, overlap with other people in that cluster.
Some clusters may overlap. Note the case of siblings with autism, when one is early onset and the other is regressive. Was the regressive one really symptom free early one? Or, was it just a second hit nudged him “over the edge” and then people noticed?
This would be a practical approach that could be used. I think when people talk of phenotypes and autisms, they are thinking about very precise biological causes and then it just becomes too complicated to expect your local doctor to ever figure out.
90+% of people quite probably fit into a handful of clusters. Then you just need a diagnostic flowchart leading to the relevant cluster and then a specific drug toolkit.
My Polypill is the drug toolkit for one cluster; and it is not a rare one.
