Agmatine - a Magic Bullet in Clinical Neuroscience?

Today’s post is about Agmatine, a naturally occurring metabolite of the amino acid arginine, which is referred to in recent studies as both a “magic bullet” and a “magic shotgun”.

Normally when things sound too good to be true, you do need to be rather suspicious, but our reader Tyler has already been trialing Agmatine over the summer months and he continues to be a big believer.

As we will see in this post Agmatine has multiple different effects and while this is often the case with drugs and gives them both good and bad effects, in the case of Agmatine this ability to affect multiple targets is put forward as an advantage.

NAC, the antioxidant now widely used in autism, also has numerous beneficial effects and can even reverse propionic acid induced autism. I think we can call NAC a silver bullet.

You will recall that amino acids are the building blocks of proteins. Nine amino acids are called essential for humans because they cannot be produced by the human body and so must be taken in as food. Arginine is classified as a conditionally essential amino acid, depending on the developmental stage and health status of the individual. Preterm infants are unable to synthesize or create arginine internally, making the amino acid nutritionally essential for them.

Agmatine

Agmatine was discovered in 1910.  It is a chemical substance which is naturally created from the chemical arginine. Agmatine has been shown to exert modulatory action at multiple molecular targets, notably neurotransmitter systems, ion channels, nitric oxide (NO) synthesis and polyamine metabolism.

Many of agmatine’s effects are potentially relevant to neurological conditions like autism. My initial thought was that with so many different effects, how likely would it be that the overall effect would be positive?

• Neurotransmitter receptors and receptor ionophores. Nicotinic, imidazoline I1 and I2, α2-adrenergic, glutamate NMDAr, and serotonin 5-HT2A and 5HT-3 receptors.
• Ion channels. Including: ATP-sensitive K+ channels, voltage-gated Ca²⁺ channels, and acid-sensing ion channels (ASICs).
• Membrane transporters. Agmatine specific-selective uptake sites, organic cation transporters (mostly OCT2 subtype), extraneuronal monoamine transporters (ENT), polyamine transporters, and mitochondrial agmatine specific-selective transport system.
• Nitric oxide (NO) synthesis modulation. Differential inhibition by agmatine of all isoforms of NO synthase (NOS) is reported.
• Polyamine metabolism. Agmatine is a precursor for polyamine synthesis, competitive inhibitor of polyamine transport, inducer of spermidine/spermine acetyltransferase (SSAT), and inducer of antizyme.
• Protein ADP-ribosylation. Inhibition of protein arginine ADP-ribosylation.
• Matrix metalloproteases (MMPs). Indirect down-regulation of the enzymes MMP 2 and 9.
• Advanced glycation end product (AGE) formation. Direct blockade of AGEs formation.
• NADPH oxidase. Activation of the enzyme leading to H₂O₂ production.

Different effects are likely to predominate at different doses, as with many drugs.

Of the above effects many are implicated in autism.

Nicotinic, NMDA, and serotonin receptors are all deeply implicated in autism.

All the above ion channels including ASICs, which have not yet been covered in this blog, are implicated in autism. Acid Sensing Ion Channels (ASICs) are implicated in autism via the genetic research and surprisingly brain pH is disturbed in many neurological conditions. 

“Maintaining the physiological pH of interstitial fluid is crucial for normal cellular functions. In disease states, tissue acidosis is a common pathologic change causing abnormal activation of acid-sensing ion channels (ASICs), which according to cumulative evidence, significantly contributes to inflammation, mitochondrial dysfunction, and other pathologic mechanisms (i.e., pain, stroke, and psychiatric conditions). Thus, it has become increasingly clear that ASICs are critical in the progression of neurologic diseases.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4449961/

Nitric oxide is relevant to autism and any vasodilatory effect might be helpful to those with reduced cerebral blood flow. This benefit potentially goes beyond those with vascular dementia and may enhance memory and cognition in some.

It the effect on nitric oxide which body builders think gives them a benefit from taking Agmatine.

Polyamines and spermidine in particular are involved in autophagy, which is the intra-cellular garbage disposal service. When autophagy is impaired, as in many neurological conditions, this accumulating garbage gets in the way of cellular function. We already know that improving autophagy is one method of combating cognitive decline. We know that autophagy is impaired in autism.

NADPH oxidase and nNOS (Neuronal nitric oxide synthase) redox signaling cascades interact in the brain to affect both cognitive function and social behavior. I am not sure whether Agmatine will have a good or bad effect.                                                                  

The Research

I would be the first to point out that the Agmatine research is not like the high powered research we see from the scientists on this blog’s Dean’s List, but that does not mean the Agmatine may not be highly beneficial.  It is more like the copious research on antioxidants.

Agmatine: multifunctional arginine metabolite and magic bullet in clinical neuroscience? 

Agmatine, the decarboxylation product of arginine, was largely neglected as an important player in mammalian metabolism until the mid-1990s, when it was re-discovered as an endogenous ligand of imidazoline and α₂-adrenergic receptors. Since then, a wide variety of agmatine-mediated effects have been observed, and consequently agmatine has moved from a wallflower existence into the limelight of clinical neuroscience research. Despite this quantum jump in scientific interest, the understanding of the anabolism and catabolism of this amine is still vague. The purification and biochemical characterization of natural mammalian arginine decarboxylase and agmatinase still are open issues. Nevertheless, the agmatinergic system is currently one of the most promising candidates in order to pharmacologically interfere with some major diseases of the central nervous system, which are summarized in the present review. Particularly with respect to major depression, agmatine, its derivatives, and metabolizing enzymes show great promise for the development of an improved treatment of this common disease.                                                                                                                         

Agmatine: Clinical applications after 100 years in translation

Agmatine (decarboxylated arginine) has been known as a natural product for over 100 years, but its biosynthesis in humans was left unexplored owing to long-standing controversy. Only recently has the demonstration of agmatine biosynthesis in mammals revived research, indicating its exceptional modulatory action at multiple molecular targets, including neurotransmitter systems, nitric oxide (NO) synthesis and polyamine metabolism, thus providing bases for broad therapeutic applications. This timely review, a concerted effort by 16 independent research groups, draws attention to the substantial preclinical and initial clinical evidence, and highlights challenges and opportunities, for the use of agmatine in treating a spectrum of complex diseases with unmet therapeutic needs, including diabetes mellitus, neurotrauma and neurodegenerative diseases, opioid addiction, mood disorders, cognitive disorders and cancer.

“Agmatine is now considered to be capable of exerting modulatory actions simultaneously at multiple target sites, thus fitting the therapeutic profile of a ‘magic shotgun’ for complex disorders”

  

Mitochondrial protection 

Agmatine has been shown to exert direct protective effects on mitochondria at nanomolar concentrations. It has also been shown

to alleviate oxidative stress-induced mitochondrial swelling, possibly by acting as a free radical scavenger, and prevent Ca2+-dependent induction of mitochondrial permeability transition (MPT) by modulating itochondrial membrane potential and NF-kappaB activation and references therein). Importantly, these effects are implicated in apoptotic cell death. Therefore, mitochondrial protection is considered essential in contributing to the general cytoprotective effects of agmatine in various bodily systems and, thus, to its beneficial effects in a spectrum of disease models. Of special interest is a potential for agmatine utility in neurodegenerativediseases where mitochondrial malfunctions have been implicated (e.g., Parkinson’s disease).  

Drug development: therapeutic potential outweighing risks 

There remain constraints on progress towards practical development of agmatine as a drug. First, the lower level of protection against commercial competition afforded by ‘usage’ patents for new indications of known compounds, such as agmatine with its long known methods of chemical synthesis, is viewed as being much less lucrative by drug developers than that provided by ‘composition of matter’ patents for new chemical entities. Second, although research of new compounds to modulate endogenous agmatine metabolism holds promise, it is rudimentary and remains speculative. Third, even though agmatine, as a naturally occurring substance, has been developed and introduced to the dietary supplement and nutraceutical market, nutraceutical products in the USA fall under the ‘Dietary Supplement Health and Education Act (DSHEA)’, which forbids promotion of nutraceuticals for the treatment, cure, or prevention of any disease. Similar regulatory restrictions exist worldwide and severely limit the advertising of nutraceuticals to the medical market. 

Despite these constraints, compelling evidence indicates the therapeutic potential of agmatine for a spectrum of diseases. A summary of the advances made and the gaps still remaining for future research are indicated in Table 2. Although comparative efficacy studies with presently available drugs are still required, the broad safety profile of agmatine has been established with no serious adverse effects, either as a stand-alone or as an add-on treatment. This should be a paramount advantage when compared with most existing drugs and certainly to combination therapy.

Moreover, its general cytoprotective actions suggest that agmatine should be considered not only as a curative, but also as a preventive therapeutic.

Tyler’s Comments

Tyler’s comments in this blog regarding the use of Agmatine suggest that at different doses, the effect does indeed vary. At lower doses there can be negative effects like anxiety and aggression, but at 1.2 g (in a 50kg boy) the main affect is enhanced cognition.

https://epiphanyasd.blogspot.com/2017/06/modulating-wnt-signaling-in-autism-and.html?showComment=1498387748575#c1577296526823968689

https://epiphanyasd.blogspot.com/2017/08/music-for-autism-acquired-taste.html?showComment=1503773056629#c1943101059018652346

In treating strictly defined autism, cognitive function is often the most important target, unlike in milder forms of autism.

Tyler’s main purpose for trialing Agmatine was that it is thought to normalize the opioid system in the brain, via its action on adrenoreceptors.  Then came a mouse study in the valproic acid model of autism.

Agmatine rescues autistic behaviors in the valproic acid-induced animal model of autism

Autism spectrum disorder (ASD) is an immensely challenging developmental disorder characterized primarily by two core behavioral symptoms of social communication deficits and restricted/repetitive behaviors. Investigating the etiological process and identifying an appropriate therapeutic target remain as formidable challenges to overcome ASD due to numerous risk factors and complex symptoms associated with the disorder. Among the various mechanisms that contribute to ASD, the maintenance of excitation and inhibition balance emerged as a key factor to regulate proper functioning of neuronal circuitry. Interestingly, our previous study involving the valproic acid animal model of autism (VPA animal model) has demonstrated excitatory-inhibitory imbalance (E/I imbalance) due to enhanced differentiation of glutamatergic neurons and reduced GABAergic neurons. Here, we investigated the potential of agmatine, an endogenous NMDA receptor antagonist, as a novel therapeutic candidate in ameliorating ASD symptoms by modulating E/I imbalance using the VPA animal model. We observed that a single treatment of agmatine rescued the impaired social behaviors as well as hyperactive and repetitive behaviors in the VPA animal model. We also observed that agmatine treatment rescued the overly activated ERK1/2 signaling in the prefrontal cortex and hippocampus of VPA animal models, possibly, by modulating over-excitability due to enhanced excitatory neural circuit. Taken together, our results have provided experimental evidence suggesting a possible therapeutic role of agmatine in ameliorating ASD-like symptoms in the VPA animal model of ASD. 

in addition to a study in OCD:-

AGMATINE AMELIORATES SOCIAL ISOLATION INDUCED OBSESSIVE-COMPULSIVEBEHAVIOR IN MICE

Obsessive-compulsive disorder (OCD) is a neuropsychiatric condition characterized by persistent intrusive thoughts (obsessions), repetitive ritualistic behaviors (compulsions) and excessive anxiety. Obsessive-compulsive disorder is classified as an anxiety disorder under DSM-IV-TR guidelines. In OCD, the levels of serotonin and nitric oxide decreased; whereas levels of dopamine and glutamate increased in brain. Environmental conditions such as isolation from social surroundings lead to anxiety and increased level of aggression. The present study was designed to examine the effect of agmatine in social isolation induced obsessive-compulsive behavior on marble burying behavior and locomotor activity. Agmatine (20, 40 and 80 mg/kg, i.p.) was administered in different groups of mice; activity was observed 30 min after dosing. Acute treatment of agmatine (40 and 80 mg/kg, i.p.) significantly reduced marble burying behavior. Moreover, hyperlocomotion was observed in socially isolated animals and agmatine was found to attenuate the same without affecting basal locomotions. In conclusion, agmatine effectively decreases social isolation induced obsessive-compulsive behavior in mice

I think it is fair to say that we do not know which mode(s) of action are in effect at this dosage. Clearly dosage is very important.

Given the importance of maximizing cognitive function in those with some cognitive dysfunction, Agmatine is clearly well worthy of further investigation.

Conclusion

Agmatine does indeed seem to have to potential to benefit some people with neurological disorders.  Is it a magic bullet for everyone? I doubt it, but that is an unrealistic expectation for any drug.

If it can improve cognition, even in a minority of autism, that would be a significant finding. Hopefully other readers of this blog will have the same positive experience as Tyler.  It will be interesting to find out how the effective dose varies. Depending on which brand you use, 1 teaspoon (5ml) of agmatine powder contains between 2.2 and 3.5 grams, which looks odd.  Probably best to weigh it to be sure.

Agmatine sulphate/sulfate is widely available in North America as a body builder’s supplement, but is banned in Europe. It was not banned for safety reasons, rather some odd EU rule that since it was not sold before 1997, it now needs to go through an approval process, that someone would have to pay for, before it can continue to be sold. Agmatine is not such an effective body building supplement to warrant anyone investing much in it. Hopefully the FDA will not ban it in the US.

Inflammatory Response to GAS (Group A Strep) and Dysmaturational Syndrome (Tourette’s Syndrome with Autism “Recovery” by 6 Years Old)

Michele Zappella was Head of the Department of Child Neuropsychiatry

 at Siena Hospital from 1973 to 2006

Today’s post is the one I mentioned some time ago about odd behavioral reactions to Group A Streptococcus.  It does veer off to Italy and Tourette’s Syndrome and the interesting sounding Dysmaturational Syndrome, which probably accounts for many of those autism “recovery” stories that are used to support some pretty odd therapies.

Several readers of this blog have noticed that exposure to Group A Streptococcus causes their child’s autism to worsen.  Quotes range from facial grimacing, to raving like a lunatic.

Much has been written about the conditions PANDAS and PANS.  The proposed mechanism behind PANDAS/PANS is highly disputed, with some strong evidence showing it not to be valid.

What is clear is that in some people, following a strep infection, they change overnight from completely normal to something quite different.  This is the PANDAS/PANS phenomenon.

In people with autism, it is possible that a different mechanism is in play, rather similar to the allergy induced behavioral change that has been discussed in depth in this blog and that is triggered by mast cell degranulation.

Parents naturally assume that if their child has autism and strep infections make it worse, that they must have PANDAS/PANS.  Maybe they do, but there is another completely different explanation.

TICS, OCD and Stereotypy

There are only a limited number of behavioral responses a human can make, whereas there seem to be an endless list of possible biological or genetic dysfunctions.  The end result is that entirely different dysfunctions can lead to apparently similar behaviours and a lot of confusion and misdiagnoses.

In autism, Obsessive Compulsive Disorder (OCD) and Tourette’s Syndrome common features are repetitive behaviors, physical tics and stereotypy. These three disorders are diagnosed solely based on observation, rather than any biological testing.

The underlying biological causes for these behaviors are not understood and there are likely many different causes, some overlapping, between the three observational diagnoses.

We can also work backwards from a therapeutic perspective and see what therapies work in each condition.  One well documented compulsive behavior is trichotillomania, which is when people compulsively pull out their own hair.

Many people with this type of OCD find near complete relief from the same therapy that benefits people with autism and stereotypy.  Both groups respond to the antioxidant NAC and their compulsive behaviors abate.

I recently noted that some people with trichotillomania find Inositol also makes these compulsive behaviors abate.  A very small trial showed that Inositol did not help autism.

I think it is fair to say that there is some overlap between what is causing stereotypy and what is causing some OCD.

When it comes to tics, there seems to be an endless list of causes.  Numerous conditions are known to cause foot flapping and restless leg syndrome.

Breath holding is a common problem in Rett Syndrome, it occurs in classic autism, but it is also seen as a tic disorder.

Most people with OCD, Tourette’s and tic disorders do not have autism.  However, some very young children with Tourette’s and apparent autism, actually may have something termed “Dysmaturational Syndrome”.

Dysmaturational syndrome was identified and documented by Michele Zappella, an Italian doctor interested in autism and Tourette’s syndrome.

He identified a sizable subgroup of autism in very young children that was comorbid with the Tourette’s Syndrome tic disorder.  The unusual thing is that by the age of six, these children had “grown out” of their autism entirely.

Zappella’s study in 2010 suggests that his Dysmaturational syndrome applies to about 6% of early childhood autism.  In effect, he is saying that 6% of the children diagnosed before 5 years old with autism, fit this Dysmaturational syndrome and “recover” to have normal IQ, no seizures, and no signs of autism.  The tics though do not go away.

Early-onset Tourette syndrome with reversible autistic behaviour: A dysmaturational syndrome. European Child and Adolescent Psychiatry

ABSTRACT

Early-onset Tourette syndrome comorbid with reversible autistic behaviour is described in twelve young males. After a normal gestation, delivery and first-year development, regression set in between the age of one and two with loss of various abilities and the emergence of autistic behaviour. At this time, or slightly later, they showed multiple motor and vocal tics, simple and complex: the latter could also be traced to most of their parents. Following an intervention based on intense cuddling, motor activation and paedagogic guidance, these children's abilities rapidly improved, reaching at follow-up a normal or borderline intellectual functioning and with the disappearance of their initial autistic behaviour. At follow-up tics were present in all, usually with the features of a full-blown Tourette syndrome, often comorbid with ADHD, and in some cases with OCD.

Autistic regression with and without EEG abnormalities followed by favourable outcome.

Abstract

OBJECTIVES:

To explore the relationship between autistic regression (AR) with and without EEG abnormalities and favourable outcome.

METHODS:

Follow up data on children with favourable outcome in a series of 534 cases aged below 5 years and diagnosed as ASD.

RESULTS:

Cases with regression were 167 (31.8%), usually with persistent ASD, intellectual disabilities and EEG abnormalities. Thirty nine children (7.3%) went off autism and recovered entirely their intellectual and social abilities. Few of them included examples of pharmacologically treated Landau and Kleffner syndrome and other similar complex cases with abnormal EEG. The majority was represented by 36 (6.7%) children, mostly males, with a dysmaturational syndrome: their development was initially normal up to 18 months when an autistic regression occurred accompanied by the appearance of motor and vocal tics. Relational therapies were followed by rapid improvement. By 6 years all children had lost features of ASD and their I.Q. was in most cases between 90 and 110. Convulsions were absent and EEG was normal in all cases except one. In a few of them recovery was spontaneous. Seventeen children were followed after 5 years 6 months: 12 (70%) had ADHD, 10 (56%) persistent tics. Tics were often present in parents and relatives, ASD absent, suggesting a genetic background different from cases with persistent ASD. With one exception all "off autism" children had a previous autistic regression.

Back to Group A Strep

For those of you not familiar with PANDAS/PANS.  The term ‘PANDAS’ is short for ‘Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus’.  A child can be diagnosed with PANDAS when Obsessive Compulsive Disorder (OCD) or tic symptoms suddenly appear for the first time, or the symptoms suddenly get much worse, and the symptoms occur during or after a strep infection in the child.

PANDAS factsheet

Stanford PANS-PANDAS

Five youth with pediatric acute-onset neuropsychiatric syndrome of differing etiologies.

Faced with a pediatric patient demonstrating the abrupt onset or exacerbation of psychiatric and physical symptoms, clinicians should consider PANS in their differential diagnosis.

Even though Dr Swedo, the leading researcher in the field, says that PANDAS/PANS is not autism, many parents of children with autism think they do have PANDAS/PANS.  This is likely because they have noticed that a strep infection makes their kind of autism worse.

All I can say is that there are very good reasons why strep infections can make autism worse and this has nothing to do with the autoantibodies that are the disputed cause of PANDAS/PANS.

Response to Group A Strep

Your immune system has two levels of defense:-

·        The innate immune system

·        The adaptive immune system

When you have a strep infection both systems respond.  Both of these responses could cause problems for people with autism.  The response from the innate immune system should continue only as long as the bacteria is present, while the response from the adaptive immune system may in some cases continue long after the bacteria is gone.

Innate Immune Response

It is well known that GAS is followed by a robust inflammatory response.

As you can see from the figure below, the inflammatory response results in a wave of pro-inflammatory cytokines including the “arch enemy” of autism, IL-6.

This surge in IL-6 will likely cause a sub-set of those with autism and an over activated immune system (activated microglia and so the “immunostat” is set to high) to go crazy.  This is the same IL-6 surge triggered by mast cell degranulation and the Il-6 surge used to signal milk teeth roots to dissolve.

Host Responses to Group A Streptococcus: Cell Death and Inflammation

Infections caused by group A Streptococcus (GAS) are characterized by robust inflammatory responses and can rapidly lead to life-threatening disease manifestations. However, host mechanisms that respond to GAS, which may influence disease pathology, are understudied.

Figure 1. Cellular receptors and signalling pathways involved in GAS recognition and inflammatory mediator release.

Inflammatory mediators are released from multiple leukocyte types during GAS infection; including PMNs, monocytes, macrophages, and dendritic cells . GAS and GAS-derived LTA, SLO, and soluble M1 protein (sM1), activate cellular responses to infection . Receptors involved in recognition of GAS include TLRs, TREM-1, complement receptors (CR), immunoglobulin receptors (FcR), Mac-1, and NLRP3 . Ligand binding to these receptors leads to downstream signalling via MyD88, HIF-1α, STING, IFR3, IRF5, and TBK1 . Recognition of GAS triggers release of interleukins, TNF-α, IFN-β, HBP, resistin, and LL-37 .

The Adaptive Immune Response:

Streptococcal Infection Causing Rheumatic Fever

Acute rheumatic fever (ARF) may occur following an infection of the throat by the bacteria Streptococcus pyogenes. If it is untreated ARF occurs in up to three percent of people.

Acute rheumatic fever (ARF) is not caused by the strep bacteria, but to aberrant immunological reactions to Group A streptococcal antigens.  The underlying mechanism is believed to involve the production of antibodies against a person's own tissues.

ARF, is an inflammatory disease that can involve the heart, joints, skin, and brain. The disease typically develops two to four weeks after a throat infection. Signs and symptoms include fever, multiple painful joints, and involuntary muscle movements.

It would appear that in some children, following a strep infection, they develop tics.  These involuntary muscle movements are a symptom of acute rheumatic fever (ARF).  So rather than calling it by a new name PANDAS, perhaps better just to use the old name?

Strep infections PANDAS, OCD and Tourette’s

There is quite a lot of research on this subject, but much is contradictory. The idea put forward by researchers like Swedo is that elevated streptococcal antibodies causes PANDAS, but other researchers appear to have disproved this.

So you can make what you will of the research.

What is undisputed is that a strep throat can lead to acute rheumatic fever, which can affect the brain and cause involuntary muscle movements (tics) amongst other things.

Passive transfer of streptococcus-induced antibodies reproduces behavioral disturbances in a mouse model of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection

Streptococcal infections can induce obsessive-compulsive and tic disorders. In children, this syndrome, frequently associated with disturbances in attention, learning and mood, has been designated pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). Autoantibodies recognizing central nervous system (CNS) epitopes are found in sera of most PANDAS subjects, but may not be unique to this neuropsychiatric subset. In support of a humoral immune mechanism, clinical improvement often follows plasmapheresis or intravenous immunoglobulin. We recently described a PANDAS mouse model wherein repetitive behaviors correlate with peripheral anti-CNS antibodies and immune deposits in brain following streptococcal immunization. These antibodies are directed against group A β-hemolytic streptococcus matrix (M) protein and cross-react with molecular targets complement C4 protein and α-2-macroglobulin in brain. Here we show additional deficits in motor coordination, learning/memory and social interaction in PANDAS mice, replicating more complex aspects of human disease. Furthermore, we demonstrate for the first time that humoral immunity is necessary and sufficient to induce the syndrome through experiments wherein naive mice are transfused with immunoglobulin G (IgG) from PANDAS mice. Depletion of IgG from donor sera abrogates behavior changes. These functional disturbances link to the autoimmunity-related IgG1 subclass but are not attributable to differences in cytokine profiles. The mode of disrupting blood–brain barrier integrity differentially affects the ultimate CNS distribution of these antibodies and is shown to be an additional important determinant of neuropsychiatric outcomes. This work provides insights into PANDAS pathogenesis and may lead to new strategies for identification and treatment of children at risk for autoimmune brain disorders.

Serum auto antibodies do not differentiate PANDAS and Tourette syndrome from controls

ABSTRACT

Background: An autoimmune-mediated mechanism has been proposed for both pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS) and Tourette syndrome (TS). Confirmatory evidence has, in part, been based on controversial findings of autoantibodies in the sera of children with these disorders.

Objective: To compare antineuronal antibody profiles in subjects with TS and PANDAS to age-matched controls.

Methods: Sera were obtained from 48 children with PANDAS, 46 with TS, and 43 age-matched controls. Serum autoantibodies were measured by use of ELISA and Western immunoblotting against a variety of epitopes, including human postmortem caudate, putamen, and prefrontal cortex (Brodmann area 10). Immunoreactivity was also measured against commercially available α- and γ-enolase, aldolase C, and pyruvate kinase M1. Several assays were repeated after preabsorption of sera with M6 strain streptococci.

Results: Median ELISA optical density readings were similar among the groups. Western blot analyses showed complex staining patterns with no differences in any tissue region based on the number of bands, reactivity peaks at molecular weights 98, 60, 45, and 40 kDa, or total area under ScanPack (Biometra, Gottingen, Germany)–derived peaks. Immunoreactivity against four putative pathologic antigens did not differentiate the clinical groups. Repeat immunoblotting after serum preabsorption with streptococci showed no loss of reactivity. ELISA values exceeding a specified cutoff did not predict changes in binding to either brain epitopes or commercial antigens.

Conclusions: Results do not support the hypothesis that PANDAS and Tourette syndrome are secondary to antineuronal antibodies. Longitudinal studies are required to determine whether autoantibodies correlate with fluctuations in clinical activity

Serial Immune Markers Do Not Correlate With Clinical Exacerbations in Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections

CONCLUSIONS. The failure of immune markers to correlate with clinical exacerbations in children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections raises serious concerns about the viability of autoimmunity as a pathophysiological mechanism in this disorder.

Streptococcal infection, Tourette syndrome, and OCD

Is there a connection?

Conclusions: The present study does not support a strong relationship between streptococcal infections and neuropsychiatric syndromes such as obsessive-compulsive disorder and Tourette syndrome. However, it is possible that a weak association (or a stronger association in a small susceptible subpopulation) was not detected due to nondifferential misclassification of exposure and limited statistical power. The data are consistent with previous reports of greater rates of diagnosis of Tourette syndrome or tics in white populations.

Behavioral and neural effects of intra-striatal infusion of anti-streptococcal antibodies in rats

Our results demonstrate the potential pathogenic role of autoantibodies produced following exposure to GAS in the induction of behavioral and motor alterations, and support a causal role for autoantibodies in GAS-related neuropsychiatric disorders.

Cytokine Correlations in Youth with Tic Disorders

Background: Studies have noted immunological disruptions in patients with tic disorders, including increased serum cytokine levels. This study aimed to determine whether or not cytokine levels could be correlated with tic symptom severity in patients with a diagnosed tic disorder.

Methods: Twenty-one patients, ages 4–17 years (average 10.63±2.34 years, 13 males), with a clinical diagnosis of Tourette's syndrome (TS) or chronic tic disorder (CTD), were selected based on having clinic visits that coincided with a tic symptom exacerbation and a remission. Ratings of tic severity were assessed using the Yale Global Tic Severity Scale (YGTSS) and serum cytokine levels (interleukin [IL]-2, IL-4, IL-5, IL-10, IL-12p70, IL-13, interferon [IFN]-γ, tumor necrosis factor [TNF]-α, and granulocyte macrophage-colony stimulating factor [GM-CSF]) were measured using Luminex xMAP technology.

Results: During tic symptom exacerbation, patients had higher median serum TNF-α levels (z=−1.962, p=0.05), particularly those on antipsychotics (U=9.00, p=0.033). Increased IL-13 was also associated with antipsychotic use during exacerbation (U=4.00, p=0.043) despite being negatively correlated to tic severity scores (ρ=−0.599, p=018), whereas increased IL-5 was associated with antibiotic use (U=6.5, p=0.035). During tic symptom remission, increased serum IL-4 levels were associated with antipsychotic (U=6.00, p=0.047) and antibiotic (U=1.00, p=0.016) use, whereas increased IL-12p70 (U=4.00, p=0.037) was associated with antibiotic use.

Conclusions: These findings suggest a role for cytokine dysregulation in the pathogenesis of tic disorders. It also points toward the mechanistic involvement and potential diagnostic utility of cytokine monitoring, particularly TNF-α levels. Larger, systematic studies are necessary to further delineate the role of cytokines and medication influences on immunological profiling in tic disorders.

Characterization of the Pediatric Acute-Onset Neuropsychiatric Syndrome Phenotype

Objective: Pediatric acute-onset neuropsychiatric syndrome (PANS) is a subtype of obsessive compulsive disorder (OCD) marked by an abrupt onset or exacerbation of neuropsychiatric symptoms. We aim to characterize the phenotypic presentation of youth with PANS.

Methods: Forty-three youth (ages 4–14 years) meeting criteria for PANS were assessed using self-report and clinician-administered measures, medical record reviews, comprehensive clinical evaluation, and laboratory measures.

Results: Youth with PANS presented with an early age of OCD onset (mean=7.84 years) and exhibited moderate to severe obsessive compulsive symptoms upon evaluation. All had comorbid anxiety and emotional lability, and scored well below normative means on all quality of life subscales. Youth with elevated streptococcal antibody titers trended toward having higher OCD severity, and presented more frequently with dilated pupils relative to youth without elevated titers. A cluster analysis of core PANS symptoms revealed three distinct symptom clusters that included core characteristic PANS symptoms, streptococcal-related symptoms, and cytokine-driven/physiological symptoms. Youth with PANS who had comorbid tics were more likely to exhibit a decline in school performance, visuomotor impairment, food restriction symptoms, and handwriting deterioration, and they reported lower quality of life relative to youth without tics.

Conclusions: The sudden, acute onset of neuropsychiatric symptoms, high frequency of comorbidities (i.e., anxiety, behavioral regression, depression, and suicidality), and poor quality of life capture the PANS subgroup as suddenly and severely impaired youth. Identifying clinical characteristics of youth with PANS will allow clinicians to diagnose and treat this subtype of OCD with a more strategized and effective approach.

Conclusion

If exposure to strep causes your child to “go crazy” I think this is a case of IL-6 triggering an autism flare-up.  Once the strep is treated, IL-6 levels will fall and the crazy behavior and raging will subside.  This should be a short term problem.  This is unrelated to PANDAS/PANS.  IL-6 autism flare-ups caused by an inflammatory response, as opposed to an allergic response, do respond remarkably well to a small dose of ibuprofen. Ibuprofen can even be used to prevent this type of flare-up.  If the IL-6 surge was triggered by mast cell degranulation, ibuprofen will not help.

If exposure to strep causes facial grimacing and other tics then the short term increase in IL-6 and TNF-α is exacerbating a, likely already existing, tic disorder.  If the tics do not go away after the strep has been treated, then it may be that strep autoantibodies are indeed the problem and you may have a variant of rheumatic fever, in which case you could look at the suggested PANDAS/PANS therapies.

Tics, Ticks, Autism - Wnt signaling & PAK1

I was interested to receive a comment from a reader of this blog who finds that the anti-parasite drug Ivermectin has a major impact on her child’s  autism, debilitating tics and OCD (Obsessive Compulsive Disorder).

Regular readers may recall that when looking at so-called PAK1 inhibitors, which look like the Holy Grail for both common cancers and autism, it turned out that two already exist.  One is an old anti-parasitic drug called Ivermectin and the other is a substance found in certain types of bee propolis from Brazil and New Zealand.

It then turned out that a handful of “alternative” practitioners in the US are already using Ivermectin for autism, but for entirely different reasons.  They believe that various parasites exist inside the children and cause/exacerbate autism.

I thought this was intriguing and quite likely another case of “the right therapy, for the wrong reason”.

Tics and Ticks

Tics are those sudden, repetitive involuntary actions that can vary from annoying to debilitating.

Ticks are tiny parasites that like to attach themselves to your skin, they can fall from trees/bushes or attach themselves to skin as you pass through long grass. Some ticks carry Lyme Disease.

Tics are common in autism, PANDAS, PANS and many forms of OCD (Obsessive Compulsive Disorder).

It seems that some “alternative” practitioners in the US are treating PANDAS and PANS on the assumption that it is caused by Lyme Disease.  Others are recommending “de-worming” for autism, on the assumption that intestinal parasites are to blame.

Here is a link to somebody writing about these alternative practitioners, for those who are curious.

My take

This all sound highly odd to me, partly because it seems that you have to keep taking the de-worming tablets for the long term.  With regular mild parasites found in developed countries, drugs therapy can eliminate the parasites.  In some tropical climates more aggressive parasites exist that are almost impossible to eradicate 100%.

So regular de-worming of humans in the United States, in 2014, sounds bizarre.

On the other hand, you cannot dispute when somebody finds their child’s tics and OCD have disappeared with the de-worming therapy and that they return when the therapy stops.

Is it, as I suggested in the early posts, that the PAK1 inhibiting properties of Ivermectin are behind its effect?  Hopefully yes, but I am not sure.  So I will take a look at Ivermectin and see if it has any other properties that could impact autism, tics and OCD.

Ivermectin - not just for your dog

Most people would only come across Ivermectin at the vet, but there is much more to it.

Ivermectin, ‘Wonder drug’ from Japan: the human use perspective

Discovered in the late-1970s, originating solely from a single microorganism isolated at the Kitasato Institute, Tokyo, Japan from Japanese soil, Ivermectin has had an immeasurably beneficial impact in improving the lives and welfare of billions of people throughout the world. Originally introduced as a veterinary drug, it kills a wide range of internal and external parasites in commercial livestock and companion animals. It was quickly discovered to be ideal in combating two of the world’s most devastating and disfiguring diseases which have plagued the world’s poor throughout the tropics for centuries. It is now being used free-of-charge as the sole tool in campaigns to eliminate both diseases globally. It has also been used to successfully overcome several other human diseases and new uses for it are continually being found.

The origins of ivermectin as a human drug are inextricably linked with Onchocerciasis (or River Blindness), a chronic human filarial disease caused by infection with Onchocerca volvulus worms. The disease causes visual damage for some 1–2 million people, around half of who will become blind.

Lymphatic Filariasis, also known as Elephantiasis, is another devastating, highly debilitating disease that threatens over 1 billion people in more than 80 countries. Over 120 million people are infected, 40 million of whom are seriously incapacitated and disfigured. The disease results from infection with filarial worms

Modes of Action

Let us look at the various modes of action proposed for Ivermectin.

1.     GABA

Initially, researchers believed that Ivermectin blocked neurotransmitters, acting on GABA-gated Cl⁻ channels, exhibiting potent disruption at GABA receptors in invertebrates and mammals.

In mammals the GABA receptors occur only in the central nervous system (CNS), i.e. in the brain and the spinal cord. But mammals have a so-called blood-brain barrier (BBB) that prevents microscopic objects and large molecules to get into the brain. Ivermectin, while paralyzing body-wall and pharyngeal muscle in nematodes has no such impact in mammals.  Consequently Ivermectin is much less toxic to mammals than to parasites without such a barrier, which allows quite high safety margins for use on livestock, pets and humans.

2.     Glutamate

Subsequently, researchers discovered that it was in fact glutamate-gated Cl⁻ channels (GUCl⁻) that were the target of Ivermectin and related drugs.

3.     Reversing Immunosuppression

The growing body of evidence supports the theory that the rapid parasite clearance following Ivermectin treatment results not from the direct impact of the drug but via suppression of the ability of the parasite to secrete proteins that enable it to evade the host’s natural immune defence mechanism.

Researchers discover how key drug kills worms in tropical diseases

In a major breakthrough that comes after decades of research and nearly half a billion treatments in humans, scientists have finally unlocked how a key anti-parasitic drug kills the worms brought on by the filarial diseases river blindness and elephantitis

Regular readers will recall that a beneficial parasite therapy in inflammatory diseases is the TSO worm.  This worm also modulates the host’s immune system so as not to be ejected.  This calming of the over activated immune system appears to be beneficial in several conditions and possibly autism.

4.     Inhibitor of Wnt-TCF Pathway

Recent cancer research has shown the Ivermectin has a highly unexpected property; it can block a pathway called Wnt-TCF on which many cancers are dependent.

The river blindness drug Ivermectin and related macrocyclic lactones inhibit pathway WNT-TCF responses in human cancer

Wnt signaling is also a strong activator of mitochondrial biogenesis. This leads to increased production of reactive oxygen species (ROS), in other words oxidative stress, known to cause DNA and cellular damage.

Perhaps aberrant Wnt signaling is involved in the mechanism of autism?

Well it appears to be the case.

Role of a novel Wnt pathway in autism spectrum disorders

The canonical Wnt signaling pathway in autism.

 Mounting attention is being focused on the canonical Wnt signaling pathway which has been implicated in the pathogenesis of autism in some our and other recent studies. The canonical Wnt pathway is involved in cell proliferation, differentiation and migration, especially during nervous system development. Given its various functions, dysfunction of the canonical Wnt pathway may exert adverse effects on neurodevelopment and therefore leads to the pathogenesis of autism.

5.     Inhibitor of PAK1

We already know from earlier in this blog, that Ivermectin is a PAK1 inhibitor.  Blocking PAK1 should prevent several common cancers, according to researchers at MIT, who also suggest that autism cannot occur without PAK1.\

Not entirely surprisingly, if you look into the cancer research you will see that PAK and WNT are interrelated.

p21-Activated kinase (PAK) interactswith Wnt signaling to regulate tissue polarity and gene expression

Wnt signaling is mediated by three classes of receptors, Frizzled, Ryk, and Ror. In Caenorhabditis elegans, Wnt signaling regulates the anterior/posterior polarity of the P7.p vulval lineage, and mutations in lin-17/Frizzled cause loss or reversal of P7.p lineage polarity. We found that pak-1/Pak (p21-activated kinase), along with putative activators of Pak, nck-1/Nck, and ced-10/Rac, regulates P7.p polarity. Mutations in these genes suppress the polarity defect of lin-17 mutants. Furthermore, mutations in pak-1, nck-1, and ced-10 cause constitutive dauer formation at 27 °C, a phenotype also observed in egl-20/Wnt and cam-1/Ror mutants. In HEK293T cells, Pak1 can antagonize canonical Wnt signaling. Moreover, overexpression of Ror2 leads to phosphorylation of Pak1. Together, these results indicate that Pak interacts with Wnt signaling to regulate tissue polarity and gene expression.

So there at least five possible effects that Ivermectin can have.

Too much Ivermectin is not good

According to the literature in the developing world, there are 200 million people (http://onlinelibrary.wiley.com/doi/10.15252/emmm.201404084/abstract) currently taking Ivermectin, which is provided free for river blindness; some of those have been using the drug for over 20 years - so much is known about it.

It is suggested that at excessive doses, Ivermectin starts to cross the BBB and then affects the neurotransmitter GABA.  Ivermectin stimulates the release of the GABA in the presynaptic neurons and enhances its postsynaptic binding to its receptors. This increases the flow of chloride ions in the neurons, which causes hyperpolarization of the cell membranes. This on its turn disturbs normal nervous functions and causes a general blockage of the stimulus mechanisms in the CNS. The resulting cerebral and cortical deficits include mainly:

• Ataxia (uncoordinated movements)
• Hypermetria (excessive or disproportionate movements)
• Disorientation
• Hyperesthesia (excessive reaction to tactile stimuli)
• Tremor (uncoordinated trembling or shaking movements)
• Mydriasis (dilatation of the pupils); in cattle and cats also myosis (contraction of the pupils)
• Recumbency (inability to rise)
• Depression
• Blindness
• Coma

So, too much Ivermectin is not a good idea.

So why is Ivermectin good for Tics, OCD and Autism?

At low doses Ivermectin does not cross the BBB (blood brain barrier), but in autism it appears that the BBB can be more permeable than it should be.  So possibly Ivermectin produces an increase in GABA, like that caused by Valproic Acid.  Some people with autism find Valproic Acid very beneficial.

Perhaps those glutamate-gated Cl⁻ channels (GUCl⁻) play a, yet unidentified, role in autism.

Or, perhaps we got it right and PAK inhibiting property is what matters. 

Perhaps being an PAK1 inhibitor will also make it a Wnt inhibitor, or maybe not, worth checking though?

Perhaps the MIT guys got it wrong and it is Wnt rather than PAK that we should be focused on? 

I hope the blog reader that prompted this post does indeed give the bee propolis a go and see if it has the same effect as Ivermectin.

Cancer

Having said in an earlier post that I will not try and out-smart the cancer researchers, I will just say that the extremely cheap drug Ivermectin does seem to have some potent anti-cancer properties.  

I know that cancer drugs are supposed to be hugely expensive.

An earlier post mentioned Ivermectin’s positive effect on Leukemia, but it seems that the WNT-TCF Pathway is involved in very many cancers.  This is not to mention that just being a PAK1 inhibitor should be enough to prompt further interest.

Conclusion

Well it looks like Dr Wu and Dr Klinghardt have indeed got the therapy right, but I believe for entirely the wrong reasons. By promoting themselves via organisations like Autism One, they are almost guaranteed to be ignored by mainstream doctors and researchers. The therapy will therefore remain on the fringe, with the quacks and cranks.

From my perspective, what really matters is whether a therapy works.  We can always later on figure out why it works.  So thank you Dr Wu and Dr Klinghardt.