Monty in Montevideo and Recent Advances in Autism Research

It is nice to have a city named after you and Monty finally visited “his” city, Montevideo in Uruguay.

I suppose my city would be St Petersburg, which I have visited several times.

A really impressive city in Latin America is Buenos Aires; it has a very large central area with beautiful architecture. It enjoyed several decades of great wealth, the “golden age,” when the city was laid out. In 1930 there was a military coup and the party was over. It has been boom and bust ever since.

We visited what they call the Southern Cone of Latin America, which is made up of Argentina, Chile and Uruguay. We went from Buenos Aires all the way down to Tierra del Fuego.

Santiago, the capital of Chile, looks to be booming. It has a small historic centre and everything else is new.

Montevideo was more what I expected, except for the graffiti everywhere which makes it look less safe than it likely is. Uruguay has many beautiful beaches, but until you get away from the vast River Plate estuary (Río de la Plata = river of silt) and to the Atlantic ocean the water is a dirty brown colour.  Monty would not go in the water.

Southern Chile and Argentina have some stunning scenery with volcanoes, mountains and glaciers.  It looks great, but it is no longer the cheap backpacker destination it once was.

 

 

Back to the Autism Research

The highlight from the recent research comes from The RIKEN institute in Japan. It does go some way to explaining why so many people with autism appear to have nothing in their genetic results to explain their condition.

Normally, when you have your state of the art whole genome screening (WGS) the geneticist who interprets the results is looking for mutations in one of the many hundreds of known “autism genes” and nowadays, hopefully, in the non-coding areas next to them. Whole exome screening (WES) just looks at the 2% of the genome that has the instructions for how to make each of your 22,000 genes. The other 98% includes things like promoters that increase activity of a specific gene.

Many people with autism appear to show no mutations that are relevant.

The Japanese have figured out one of the reasons why this is the case. There are other reasons.

Our genetic material is not stored on something like a long role of paper, which is like a two-dimensional object.  It is a three-dimensional twisted object all folded up. As a result, the DNA physically closest to each autism gene may not be the part expected. The Japanese use the term “topologically associating domain” (TAD) to define which zones of DNA are actually interacting with each other.

They found that de novo mutations in promoters heightened the risk of ASD only when the promoters were located in TADs that contained ASD-related genes. Because they are nearby and in the same TAD, these de novo mutations can affect the expression of ASD-related genes.

This means that geneticists now need to go back to school and learn about the TAD of each autism gene. Or else just replace the geneticist with an AI generated report.

 

Mutation butterfly effect: Study reveals how single change triggers autism gene network

Researchers in the RIKEN Center for Brain Science (CBS) examined the genetics of autism spectrum disorder (ASD) by analyzing mutations in the genomes of individuals and their families. They discovered that a special kind of genetic mutation works differently from typical mutations in how it contributes to the condition. In essence, because of the three-dimensional structure of the genome, mutations are able to affect neighboring genes that are linked to ASD, thus explaining why ASD can occur even without direct mutations to ASD-related genes. This study appeared in the scientific journal Cell Genomics on January 26.

The researchers analyzed an extensive dataset of over 5,000 families, making this one of the world's largest genome-wide studies of ASD to date. They focused on TADs-;three-dimensional structures in the genome that allow interactions between different nearby genes and their regulatory elements. They found that de novo mutations in promoters heightened the risk of ASD only when the promoters were located in TADs that contained ASD-related genes. Because they are nearby and in the same TAD, these de novo mutations can affect the expression of ASD-related genes. In this way, the new study explains why mutations can increase the risk of ASD even when they aren't located in protein-coding regions or in the promotors that directly control the expression of ASD-related genes.

 

"Our most important discovery was that de novo mutations in promoter regions of TADs containing known ASD genes are associated with ASD risk, and this is likely mediated through interactions in the three-dimensional structure of the genome."  

Atsushi Takata at RIKEN CBS

 

 

Topologically associating domains define the impact of de novo promoter variants on autism spectrum disorder risk

Whole-genome sequencing (WGS) studies of autism spectrum disorder (ASD) have demonstrated the roles of rare promoter de novo variants (DNVs). However, most promoter DNVs in ASD are not located immediately upstream of known ASD genes. In this study analyzing WGS data of 5,044 ASD probands, 4,095 unaffected siblings, and their parents, we show that promoter DNVs within topologically associating domains (TADs) containing ASD genes are significantly and specifically associated with ASD. An analysis considering TADs as functional units identified specific TADs enriched for promoter DNVs in ASD and indicated that common variants in these regions also confer ASD heritability. Experimental validation using human induced pluripotent stem cells (iPSCs) showed that likely deleterious promoter DNVs in ASD can influence multiple genes within the same TAD, resulting in overall dysregulation of ASD-associated genes. These results highlight the importance of TADs and gene-regulatory mechanisms in better understanding the genetic architecture of ASD.

 

Bumetanide

 

I did come across a Chinese study with an eye-catching title:-

 

Can bumetanide be a miraculous medicine for autism spectrum disorder: Meta-analysis evidence from randomized controlled trials

 

Highlights

• Bumetanide showed significant and large effects on the overall core symptoms of ASD.
• Bumetanide’s efficacy on ASD is influenced by subjects’ age, dosage form, duration.
• Results of RCTs on bumetanide in ASD are moderated by study designs, measurement tools

A systematic search was conducted on PubMed, EMBASE, MEDLINE, PsyclNFO, Web of Science, Clinical Trials.gov, and references in reviews from the earliest available date to September 2023. Randomized controlled trials (RCTs) were identified that evaluated the efficacy of bumetanide in improving overall core symptoms (OCS) of ASD. Therefore, nine studies with 1036 participants were included in the study.

Results

Bumetanide showed significant effects on OCS of ASD (WMD = － 1.91, p = 0.006), particularly in sub-domains including relation to inanimate objects, adaption to environment changes, auditory response, near sensory responses, anxiety and hyperactivity. Moderating analysis indicated that a significant effect size of bumetanide on OCS of ASD was observed in specific subgroup, including 3–6 years old (WMD = －1.08, p = 0.008), the tablet (WMD = －2.80, p = 0.003), 3-month intervention (WMD = －2.54, p = 0.003), and the single-center studies (WMD = －2.80, p = 0.003).

Conclusions

Bumetanide has a large and significant impact on the OCS of ASD. Given the limited number and quality of included RCTs, future research should prioritize conducting large-scale trials focusing on sub-parameters or specific clinical features to comprehensively evaluate the efficacy of bumetanide in subpopulations of children with ASD.

Meanwhile, Professor Ben Ari has written another paper on why the phase 3 trial failed and has also published a book.

 

Bumetanide to treat autism spectrum disorders: are complex administrative regulations fit to treat heterogeneous disorders?

Introduction:

Extensive experimental observations suggest that the regulation of ion fluxes and, notably, chloride are impacted in autism spectrum disorders (ASD) and other neurodevelopmental disorders. The specific NKCC1 cotransporter inhibitor Bumetanide has been shown to attenuate electrophysiological and behavioral features of ASD in experimental models. Both pilot and phase 2 double-blind randomized independent trials have validated these effects with thousands of children treated successfully. Both brain imaging and eye tracking observations also validate these observations. However, final large phase 3 trials failed, with no significant differences between placebo and treated children.

Methods:

Here, I discuss the possible reasons for these failures and discuss the exclusive reliance on complex patent cooperation Treaty (PCT) regulations. Indeed, available data suggest that bumetanide responders could be identified by relying notably on EEG measures, suggesting that biological sub-populations of patients might benefit from the treatment.

Results:

These observations raise important debates on whether treating only a % of children with ASD is acceptable.

Discussion:

It is likely that in many disorders, the heterogeneity of the pathological event precludes a single general treatment for all, suggesting that trials centered on selective populations of responders might be essential for large clinical trials to succeed.

  Here is the new book:-

Treating Autism with Bumetanide

https://www.cambridgescholars.com/product/978-1-5275-1890-2/

In spite of its high incidence, extensive media coverage and major clinical burden to families, there is not a single approved European or American drug treatment of Autism Spectrum Disorders (ASDs). The dominant genetic and psychiatric approaches to treat ASDs have various limitations, suggesting that a novel global approach to understand and treat ASDs is warranted. Based on the authors’ converged expertise on brain development, ASD treatment and brain imaging, this book provides a fresh view of the disorder which is validated by experimental imaging and large clinical trials, culminating in the first large phase 3 final pediatric trial (on 400 children in EU countries and the US) using a repositioning of a drug used for decades to treat hypertension and edema. The convergence of experimental and clinical data on this disorder is unprecedented, confirming the potential of the drug to be the first pediatric treatment of ASDs.

After explaining the mechanisms underlying ASDs, we describe specific cases of children who, after treatment, considerably improved their sociability and reduced their agitation. The book also discusses the skepticism that the authors met from the tenants of pure genetics and psychiatry, and why the abyssal poverty of information on developmental disorders has hampered progress in understanding and treating ASD.

 

Bumetanide dosage is key – “wonderful effects from increasing from 0.5mg to 1mg” 

One recuring feature I have noticed from bumetanide use in the United States is the low dosage often used, as if these doctors want to show the drug is ineffective.

A reader recently contacted me about his young son who responded to the low dose of 0.5mg, but his autism doctor would not increase the dose.  The parent took matters into his own hands and increased the dose and then wrote to tell me about the “wonderful effects.”

 

Diuresis has stopped, but restarts at a lower dose

In a minority of cases bumetanide causes no diuresis. The question is whether it can have any effect in the brain if it causes no diuresis. Has the drug been absorbed at all?

One reader contacted me to tell me that her son, who has responded well to bumetanide for several years, stopped experiencing any diuresis. Then she told me that when she reduces the dose the diuresis returns.

There are many possible explanations, but perhaps those people who find bumetanide causes no diuresis should try a lower dose and see what happens.

 

Vasopressin/Desmopressin

Much of the research into the hormone vasopressin comes from Stanford. They have published a string of papers over the years. I think they are definitely on to something, but they are taking their time and may never commercialize the result.  

The very recent one is:

Vasopressin deficiency: a hypothesized driver of both social impairment and fluid imbalance in autism spectrum disorder

 

For some reason there is no abstract. 

Thanks to our reader Seth, I have now added the link below that takes you directly to  Stanford's website, which holds the full text version of the paper. 

https://med.stanford.edu/content/dam/sm/parkerlab/documents/da035ad7-7c80-41bd-a9a6-ee03a8bcc58d.pdf

The same group previously published a paper showing that people with ASD have a reduced level of vasopressin in their spinal fluid. As you can see in the chart below the level of oxytocin was normal.

There have also been successful trials using intranasal vasopressin in humans.

Cerebrospinal fluid vasopressin and symptom severity in children with autism

 

Vasopressin and oxytocin are closely related hormones and possibly some interactions are not yet fully understood.

Both these hormones can be given via a nasal spray.

 

The Bumetanide-Vasopressin interaction

Under normal circumstances you would never combine vasopressin with a diuretic.

Vasopressin stops you peeing and that it is why it is given to some children who wet their bed at night.

Bumetanide is a fast-acting diuretic that causes you to pee a lot.

So if you gave a diuretic to an elderly overweight person to reduce their blood pressure, it would be mad to also prescribe vasopressin.  The drugs are therefore contraindicated.

In autism we do not actually want the diuretic effects of bumetanide. We just want its effects on the brain.

The social and emotional beneficial effects of vasopressin have already been established by the existing Stanford research.

The combined effects of bumetanide + intranasal vasopressin might then be a win-win. Less autism and without the diuresis.

I was contacted long ago by a father whose daughter was prescribed Desmopressin, a synthetic analog of vasopressin that is an approved drug, and her autism markedly improved.

The Stanford research in humans uses a nasal spray that they have compounded specially rather than the commercially available Desmopressin.

 

 

Vasopressin, Oxytocin, the Lateral Septum, Aggression and Social Bonding, Autism gene NLGN3 and MNK inhibitors for reversing Fragile-X and likely more Autism

 

The Lateral Septum, in green, turns the volume

 up or down in aggression

Today’s post started by me checking for anything new in the research about the hormone Vasopressin and autism. I was surprised by just how much research continues to be published on the subject – no smoke without fire, perhaps.

We also get another insight into how aggressive raging develops in the brain; we even have a photo.

A novel therapy for Fragile-X is also thrown into the mix, due to a link to oxytocin.

So, what is cooking in the research?

The first thing to note is that you really do have to look at both Oxytocin and Vasopressin, because these two hormones are very closely related.

We have previously looked at the autism gene NLGN3, this gene encodes the cute sounding neuroligin-3.

 

https://epiphanyasd.blogspot.com/search/label/neuroglin

 

The reason people with Fragile-X have autism is because they lack the protein FMRP (Fragile X mental retardation protein).

In healthy neurons, FMRP modulates the local translation of numerous synaptic proteins. Synthesis of these proteins is required for the maintenance and regulation of long-lasting changes in synaptic strength. In this role as a translational inhibitor, FMRP exerts profound effects on synaptic plasticity.

When you look at the interactions of the FMRP protein you can find ways to compensate for this deficiency.  This is nicely illustrated in the graphic below. You just need to find another way to influence elF4E and elF4G.

Some people have told me they find these charts a bit overwhelming, but they precisely show what is going on.  You just have to look up all the terms, you do not know.  In the chart below there is NF1 autism, there is PTEN autism, problems with Ras are called RASopathies and cause MR/ID plus autism. We have at least one reader with TSC (Tuberous sclerosis) type autism. We have readers whose kids lack FMRP, because they have Fragile-X syndrome. 

Today we see that an inhibitor of MnK (in yellow in the chart below) is another via option to treat Fragile-X.

Beyond Fragile-X, we can see that numerous other upstream dysfunctions in the chart can result in miss-expression of neuroligins (NLGNs) in the chart below and then result in autism.

 

 One of the papers below goes further and suggests

“This work uncovers an unexpected convergence between the genetic autism risk factor Nlgn3, translational regulation, oxytocinergic signalling, and social novelty responses”

“We propose that pharmacological inhibition of MNKs may provide a new therapeutic strategy for neurodevelopmental conditions with altered translation homeostasis”

“Our work not only highlights a new class of highly-specific, brain-penetrant MNK inhibitors but also expands their application from fragile X syndrome to a non-syndromic model of ASD”

 

Regarding Fragile X 

“Collectively, this work establishes eFT508 (an MNK inhibitor) as a potential means to reverse deficits associated with FXS.”

 

What is the connection to Oxytocin?

A problem with your neuroligins causes an impairment in oxytocin signalling.

 

The role of the Lateral Septum (LS) in both aggression and desirable social behavior 

If you scan through the research on vasopressin and oxytocin you will eventually come across references to the LS.  The LS is a part of your brain called the Lateral Septum.

In the picture below you see a mouse brain and the green part is the Lateral Septum (LS).

 

Source: https://neurosciencenews.com/rage-lateral-septum-3637/ 

“Our research provides what we believe is the first evidence that the lateral septum directly ‘turns the volume up or down’ in aggression in male mice, and it establishes the first ties between this region and the other key brain regions involved in violent behavior”

Both social bonding and offensive aggression involve vasopressin receptors in a part of the brain called the Lateral Septum (LS).  Activity in the Lateral Septum (LS) is regulated by inhibitory GABA, and excitatory glutamate.

There is a notable difference between males and females, at least in rats.  No sex differences were found in extracellular GABA concentrations during social playing; however, glutamate plays a major role in female social playing. When glutamate receptors are blocked in the LS pharmacologically, there is a significant decrease in female social playing, while males had no decrease in playing. This suggests that in the lateral septum, GABA neurotransmission is involved in social play behavior regulation in both sexes, while glutamate neurotransmission is sex-specific, involved in regulation of social play only in females.

 

Aggressive behavior in females 

Neural mechanisms of female aggression: Implications on the oxytocin and vasopressin systems

These models allowed me to investigate the role of the brain oxytocin (OXT) and vasopressin (AVP) systems on aggressive behavior. Both neuropeptides are known to regulate social including aggressive behaviors in males and lactating females.

Taken together this part of my thesis shows that the balance between OXT and AVP release within the LS regulates female aggression in a receptor and region-specific manner via modulating GABAergic neurotransmission.

Overall, this thesis shows that females are able to develop escalated as well as abnormal aggression just like males. In addition, the OXT and the AVP system seem to be main players in regulating aggressive behavior in female Wistar rats, especially, regarding their role in controlling aggression by acting on the LS.

 

The effect of Vasopressin as a therapy

 

Correction of vasopressin deficit in the lateral septum ameliorates social deficits of mouse autism model 

Intellectual and social disabilities are common comorbidities in adolescents and adults with MAGE family member L2 (MAGEL2) gene deficiency characterizing the Prader-Willi and Schaaf-Yang neurodevelopmental syndromes. The cellular and molecular mechanisms underlying the risk for autism in these syndromes are not understood. We asked whether vasopressin functions are altered by MAGEL2 deficiency and whether a treatment with vasopressin could alleviate the disabilities of social behavior. We used Magel2-knockout mice (adult males) combined with optogenetic or pharmacological tools to characterize disease modifications in the vasopressinergic brain system and monitor its impact on neurophysiological and behavioral functions. We found that the activation of vasopressin neurons and projections in the lateral septum were inappropriate for performing a social habituation/discrimination task. Mechanistically, the lack of vasopressin impeded the deactivation of somatostatin neurons in the lateral septum, which predicted social discrimination deficits. Correction of vasopressin septal content by administration or optogenetic stimulation of projecting axons suppressed the activity of somatostatin neurons and ameliorated social behavior. This preclinical study identified vasopressin in the lateral septum as a key factor in the pathophysiology of Magel2-related neurodevelopmental syndromes.

 

In humans, intranasal administration of AVP increased activity in the LS and reciprocated social collaboration (47). Intranasal OXT administration enhances the suppression of oscillatory activity (8–25 Hz) during execution and observation of social actions (48). Altogether, OXT- and AVP-dependent modulation of neural activity in response to social stimuli directly affect EEG activity, which may have a predictive value for the impact of such treatment in ASD-associated disorders. Furthermore, an imbalance between inhibition and excitation is associated with ASD, and AVP treatment could reset the balance by altering the functions of SST neurons (49).

  

Predicting Autism measuring Neonatal CSF vasopressin concentration 

We have yet another predictor of future autism.

Neonatal CSF vasopressin concentration predicts later medical record diagnoses of autism spectrum disorder

The Russian paper below is very thorough. At least in the case of autism, I do not agree with the therapeutic implications.  The paper suggests Oxytocin agonists (like oxytocin itself) and Vasopressin antagonists.

I propose Oxytocin agonists and Vasopressin agonists, as a practical solution today.  It is not a perfect solution, but totally doable today.

  

The role of oxytocin and vasopressin dysfunction in cognitive impairment and mental disorders 

Oxytocin (OXT) and arginine-vasopressin (AVP) are structurally homologous peptide hormones synthesized in the hypothalamus. Nowadays, the role of OXT and AVP in the regulation of social behaviour and emotions is generally known. However, recent researches indicate that peptides also participate in cognitive functioning. This review presents the evidence that the OXT/AVP systems are involved in the formation of social, working, spatial and episodic memory, mediated by such brain structures as the hippocampal CA2 and CA3 regions, amygdala and prefrontal cortex. Some data have demonstrated that the OXT receptor's polymorphisms are associated with impaired memory in humans, and OXT knockout in mice is connected with memory deficit. Additionally, OXT and AVP are involved in mental disorders' progression. Stress-induced imbalance of the OXT/AVP systems leads to an increased risk of various mental disorders, including depression, schizophrenia, and autism. At the same time, cognitive deficits are observed in stress and mental disorders, and perhaps peptide hormones play a part in this. The final part of the review describes possible therapeutic strategies for the use of OXT and AVP for treatment of various mental disorders.

 

4.4. Autism

Autism spectrum disorder (ASD) is a group of disorders that are characterized by early disturbances of social communication and limited, repetitive behaviour. Individuals with autism have impaired social cognition and social perception, executive dysfunction, and atypical perceptual and information processing. Additionally, they exhibit atypical neural development at the systems level . Autism is characterized by a disturbance of social interaction first of all, but it is also characterized by cognitive dysfunctions, including working memory impairment. The OXT/AVP system plays a role in such deficits. In male mice with a mutation in the Magel2 gene, social behaviour and cognitive functions are disrupted in adulthood, which makes this model similar to ASD. The lack of Magel2 causes a change in the OXT system. Subcutaneous administration of OXT to mice with this mutation during the first week of life suffices to restore normal social behaviour and learning abilities in adult mice. Exogenous OXT stimulates the release of endogenous OXT and inhibits the accumulation of intermediate forms of OXT (this is observed in OXT neurons in mice with the Magel2 mutation). This was revealed by neuroimaging methods. Human ASD is associated with altered face processing and decreased activity in brain areas involved in this process. OXT enhances the importance of social stimulus in ASD, and probably can stimulate face processing and eye contact in people with ASD. Genetic polymorphisms of the OXT and AVP receptor genes are associated with ASD. Additionally, this review revealed a link between social cognition disorders in autism and some SNPs in the OXTR and V1a receptor genes. The most significant associations between SNPs in OXTR and social cognition were found for rs2254298, rs53576 and rs7632287. SNP rs2254298 has been associated with a diagnosis of ASD. SNP in the V1a receptor gene, rs7294536, is closely associated with a deficit in social interactions. In addition, OXTR rs237887 polymorphism affects facial recognition memory in families with autistic children.

 

 

 

 

Fig 1. The role of oxytocin and vasopressin systems in the pathogenesis of mental disorders. Stress activates the HPA axis and rises in plasma glucocorticoid levels, which leads to social through the cortisol release. HPA axis activation increases the risk of development of psychopathologies. OXT and AVP regulate emotional behaviours, multiple aspects of social behaviour and cognitive functions. Negative environment, including stress factor, causes an imbalance of the OXT/AVP system, which also leads to psychopathological behaviour: aggression, social impairment, anxiety, emotional and cognitive disorders. At the same time, the OXT/AVP system forms a reaction to stress oppositely. OXT inhibits the HPA axis stress induced activity (anxiolytic effect). AVP activates the HPA axis (anxiogenic effect). OXT and AVP can be used as the treatment of mental diseases associated with social and cognitive dysfunctions. OXT – oxytocin; AVP – arginine-vasopressin; iOXT – intranasal oxytocin; iAVP – intranasal arginine-vasopressin; ACTH - adrenocorticotropic hormone; CRH – corticotropin releasing hormone; HPA axis - hypothalamic-pituitary-adrenal axis.

 

 

5. OXT and AVP systems in mental disorder treatments in recent years, interest in the usage of OXT as the treatment of various psychiatric diseases is growing. OXT and AVP systems that exist in balance produce the contrary effect on emotional behaviour. Positive social stimuli and/or psychopharmacotherapy can shift this balance towards OXT and can help to stimulate emotional behaviour and restore mental health through this shifting. OXT produces an effect on several neurobiological systems, including the HPA axis, limbic system, neurotransmitters, and immune processes related to stress disorders. The exact effects of iOXT still remain unclear; nevertheless, it is known that iOXT action depends on individual sensitivity. Data from functional magnetic resonance imaging demonstrated that iOXT induces temporary activation of some cortex areas and prolonged activation of hippocampus and forebrain areas. These structures are characterized by a high density of OXT receptors. At the same time, iAVP causes stable deactivation in the parietal cortex, thalamus, and mesolimbic pathway. Importantly, the intravenous administration of OXT and AVP does not repeat activation patterns caused by intranasal administration of OXT and AVP. Nevertheless, it is possible that a small amount of OXT which crosses the blood-brain barrier may lead to an additional central OXT release since OXT is able to bind to brain OXT ergic neurons and cause its own release. Generally, OXT doses administered in studies vary from 15 IU to more than 7000 IU. As the table indicates, the results of these studies are very different. The most frequently used dose is 24 IU. Many studies are focused on the capability of OXT in the treatment of depressive disorders. It was demonstrated that iOXT reduces the time of concentration on aggressive facial expressions and increases the time of concentration on happy faces in men and women with chronic depression. Therefore, iOXT regulates emotion recognition in depression. iOXT can be used in combination with antidepressants, enhancing antidepressant efficiency. iOXT administration positively affects mother-child relationship in mothers with postpartum depression (PPD). iOXT activates the protective behaviour of mothers with PPD towards their children. Similar results were found in animal experiments. In rats, iOXT reduced the depressive-like behaviour in adult animals subjected to early maternal separation. Moreover, the research of specific neurogenesis markers Ki67 and BrdU demonstrated that iOXT promotes hippocampal neurogenesis, which is impaired in depressed rats. Many studies investigate the therapeutic properties of iOXT and iAVP for the treatment of schizophrenia and autism. It is known that schizophrenia disturbs social behaviour; and cognitive function. iOXT has the potential for usage as a therapeutic tool to restore impaired functions during schizophrenia. Some data suggest that iOXT reduces the negative symptoms of schizophrenia, improves working memory, verbal memory and cognitive function, and also improves social function in patients with schizophrenia and schizoaffective disorder. Although many studies indicate a positive effect of iOXT on cognitive function in people with schizophrenia, the neuropeptide has a very selective action on behaviour. The exact mechanism of iOXT action is also indefinite; therefore, its therapeutic potential requires further research. Eventually, iOXT can be used as an additional therapeutic agent in traditional schizophrenia treatment. iOXT can also be applied to ASD treatment. It was found that iOXT improves social abilities in children and emotionality in adult men with ASD. Moreover, the improvement of emotional state was observed in adults after an 8 IU dose, but not after 24 IU. The study of iOXT's therapeutic properties was also carried out using a mouse valproate autism model. iOXT improved social behaviour in that model, and reduced anxiety, depressive-like behaviour, and repetitive behaviour. iOXT has some positive effects in the ASD treatment. Despite this, studies of the potential therapeutic usage of iOXT are still at an early stage, and doctors have insufficient data to prescribe iOXT to patients. A few data indicate the therapeutic possibilities of AVP compared to OXT. It is known that iAVP was used in the treatment of the first episode of schizophrenia, in addition to the traditional benzodiazepine treatment. Cognitive functions (namely the memorization process, long-term and short-term memory) improved in patients. iAVP treatment ameliorated social ability in children with ASD. Additionally, iAVP treatment reduced anxiety and repetitive behaviors in these children. These data indicate the necessity of further investigation of AVP's treatment potential.

 

 

Rescue of oxytocin response and social behaviour in a mouse model of autism

A fundamental challenge in developing treatments for autism spectrum disorders is the heterogeneity of the condition. More than one hundred genetic mutations confer high risk for autism, with each individual mutation accounting for only a small fraction of cases^1-3. Subsets of risk genes can be grouped into functionally related pathways, most prominently those involving synaptic proteins, translational regulation, and chromatin modifications. To attempt to minimize this genetic complexity, recent therapeutic strategies have focused on the neuropeptides oxytocin and vasopressin^4-6, which regulate aspects of social behaviour in mammals⁷. However, it is unclear whether genetic risk factors predispose individuals to autism as a result of modifications to oxytocinergic signalling. Here we report that an autism-associated mutation in the synaptic adhesion molecule Nlgn3 results in impaired oxytocin signalling in dopaminergic neurons and in altered behavioural responses to social novelty tests in mice. Notably, loss of Nlgn3 is accompanied by a disruption of translation homeostasis in the ventral tegmental area. Treatment of Nlgn3-knockout mice with a new, highly specific, brain-penetrant inhibitor of MAP kinase-interacting kinases resets the translation of mRNA and restores oxytocin signalling and social novelty responses. Thus, this work identifies a convergence between the genetic autism risk factor Nlgn3, regulation of translation, and oxytocinergic signalling. Focusing on such common core plasticity elements might provide a pragmatic approach to overcoming the heterogeneity of autism. Ultimately, this would enable mechanism-based stratification of patient populations to increase the success of therapeutic interventions. 

Social recognition and communication are crucial elements in the establishment and maintenance of social relationships. Oxytocin and vasopressin are two evolutionarily conserved neuropeptides with important functions in the control of social behaviours, in particular pair-bonding and social recognition7,8 . In humans, genetic variation of the oxytocin receptor (OXTR) gene is linked to individual differences in social behaviour9 . Consequently, signalling modulators and biomarkers for the oxytocin or vasopressin system are being explored for conditions with altered social interactions such as autism spectrum disorders (ASDs)5,6 . In mice, mutation of the genes encoding oxytocin or its receptor results in a loss of social recognition and social reward signalling10–14. Mutation of Cntnap2, a gene linked to ASD in humans, resulted in reduced levels of oxytocin in mice, and the addition of oxytocin improved social behaviour in this model15. However, the vast majority of genetic risk factors for autism have no known links to oxytocinergic signalling. 

Thus, modification of translation homeostasis in Nlgn3KO mice by MNK inhibition restores oxytocin responses and social novelty responses. This work uncovers an unexpected convergence between the genetic autism risk factor Nlgn3, translational regulation, oxytocinergic signalling, and social novelty responses. Although loss of Nlgn3 impairs oxytocin responses in VTA DA neurons, the behavioural phenotype does not fully phenocopy genetic loss of oxytocin. Oxytocin knockout mice exhibit impaired habituation in the social recognition task10, whereas Nlgn3KO mice habituate normally but exhibit a selective deficit in the response to a novel conspecific. This is probably due to differential roles of Nlgn3 and oxytocin across several neural circuits and over development. Moreover, Nlgn3 loss-of-function also affects signalling through additional GPCRs23. We propose that pharmacological inhibition of MNKs may provide a new therapeutic strategy for neurodevelopmental conditions with altered translation homeostasis. Notably, MNK loss-of-function appears to be overall well tolerated. MNK1/2 double-knockout mice are viable46 and several MNK inhibitors are entering clinical trials for cancer therapy47. Previously available MNK inhibitors were greatly limited by specificity and brain penetrance. Our work not only highlights a new class of highly-specific, brain-penetrant MNK inhibitors but also expands their application from fragile X syndrome41 to a non-syndromic model of ASD. The common disruption in translational machinery and phenotypic rescue in two very different genetic models indicate that genetic heterogeneity of ASD might be reduced to a smaller number of cellular core processes. This raises the possibility that pharmacological interventions targeting such core processes may benefit broader subsets of patient populations.

 

A Highly Selective MNK Inhibitor Rescues Deficits Associated with Fragile X Syndrome in Mice 

Fragile X syndrome (FXS) is the most common inherited source of intellectual disability in humans. FXS is caused by mutations that trigger epigenetic silencing of the Fmr1 gene. Loss of Fmr1 results in increased activity of the mitogen-activated protein kinase (MAPK) pathway. An important downstream consequence is activation of the mitogen-activated protein kinase interacting protein kinase (MNK). MNK phosphorylates the mRNA cap-binding protein, eukaryotic initiation factor 4E (eIF4E). Excessive phosphorylation of eIF4E has been directly implicated in the cognitive and behavioral deficits associated with FXS. Pharmacological reduction of eIF4E phosphorylation is one potential strategy for FXS treatment. We demonstrate that systemic dosing of a highly specific, orally available MNK inhibitor, eFT508, attenuates numerous deficits associated with loss of Fmr1 in mice. eFT508 resolves a range of phenotypic abnormalities associated with FXS including macroorchidism, aberrant spinogenesis, and alterations in synaptic plasticity. Key behavioral deficits related to anxiety, social interaction, obsessive and repetitive activities, and object recognition are ameliorated by eFT508. Collectively, this work establishes eFT508 as a potential means to reverse deficits associated with FXS.

  

Conclusion

I think I have written enough about Oxytocin and Vasopressin.

The research is not entirely consistent regarding Vasopressin, but my assumption is that for my kind of autism I want an Oxytocin Agonist and a Vasopressin Agonist, some people might think it would be a Vasopressin Antagonist.

The good news is that there is significant research in humans, reported in previous posts, to support the use of both Oxytocin Agonist and a Vasopressin Agonist

I also think there will be both short-term, or immediate effects, from both treatments but also potentially different long-term effects from continued therapy, that is indeed suggested by the animal research models.  For example, neurite outgrowth is stimulated by oxytocin.  It is suggested that oxytocin may contribute to the regulation of scaffolding proteins expression.

Is it worth using oxytocin as a therapy to generate some extra hugs? You can argue both ways, but the longer-term benefits of correcting low oxytocin levels may be more profound.

The effects of vasopressin and oxytocin are somewhat overlapping. We know that low levels of vasopressin in spinal fluid are a good marker for autism, so putting a little extra vasopressin in the brain does not seem unreasonable.

As usual with the human body, the effects of oxytocin and vasopressin are different within the brain and in the rest of your body.  Also, the levels of these hormones in your blood are not a good predictor of their levels within the brain.  This is a reoccurring problem.  Because taking a spinal fluid sample is an invasive procedure, it is rarely taking place and then endless time and money is wasted on blood tests that may well send the doctor in the wrong direction, or just no direction.

It is highly likely that increasing Oxytocin and Vasopressin in the brain is going to affect aggressive behaviors, via actions in the Lateral Septum (LS).  Due to the role of GABA potentiating activity in the Lateral Septum (LS) you might expect a possible difference in bumetanide-responders and bumetanide non-responders (because GABA is acting as excitatory).

I would consider Oxytocin and Vasopressin as fine-tuning autistic behavior and you would have to personalize the dosage. In some people it might be a case of either or, rather than both.

Using MNK inhibitors to treat human Fragile-X looks a great idea and hopefully a commercialized therapy could then be trialed in broader autism.

 

2021 Autism PollyPill To Do List – Speech ↑ and Misophonia ↓

 

 A few ideas remain to be fine-tuned

Having started to develop my son’s polytherapy for autism back in December 2012, is there anything left to develop in 2021?

As we have seen, the biggest impact from interventions is when you start them very young, but improvement is possible at any age.

I was asked at the recent Synchrony autism conference what is next for the PolyPill?  and I replied that more spontaneous expressive language is my main target.  I have a good idea of what may help.

·        Calcium folinate, increased over 6 weeks to 45mg/day

·        Sulforaphane, with added Myrosinase in the form of Wasabi

I was contacted by a researcher from that Synchrony conference, suggesting that Low Level LED Therapy (LLLT) was worth trying to improve the use of speech.  It does seem to benefit people with many types of brain injury.  I did write a post on LLLT using lasers, not LEDs, in autism and there was a promising trial in Havana, which I shared with the researcher.

 

https://epiphanyasd.blogspot.com/2018/12/low-level-laser-therapy-lllt-for-autism.html

https://epiphanyasd.blogspot.com/2019/07/homeclinic-based-photobiomodulationlase.html

 

Many of the suggested modes of action of LLLT were in this graphic.

Click to enlarge the graphic

Another suggested mode of action for LLLT concerns improved drainage of lymph from the brain.  This is a known problem in some forms of dementia. Among alternative autism practitioners there are all kinds of manual lymphatic draining therapies.

  

PDE4 inhibitors 

Some readers are using PDE4 inhibitors as the anti-inflammatory component of their personal autism polytherapy.

The 3 “common” choices are: -

·        Pentoxifylline, cheap and even trialled a few decades ago in children with autism. It has a short half-life and is a non-selective PDE inhibitor.  It also has an interesting effect on HDAC, that can make chemotherapy work better.

·        Roflumilast, more expensive and normally used to treat exacerbations in COPD, but patented at a lower dose as a cognitive enhancer. It is more selective for PDE4 than Pentoxifylline and has a long half-life.

·      Ibudilast, common in Japan as an asthma therapy and now a potential treatment for MS (multiple sclerosis).  It is available in Germany, imported to order, with a prescription.

 

PDE inhibitors are not very selective and so some people get side effects.  The big one seems to be nausea. Side effects may well fade over time.

I did try Roflumilast at the supposedly cognitively enhancing dose of 100mcg, a couple of years ago, but it did cause nausea. The nausea may well fade away after a few weeks.  Roflumilast may also reduce the sensory gating problem common, in autism, but only at a dose of 100mcg, higher doses lost this effect.  All is in this old post below.

Impaired sensory gating is driven by HCN channels that need to be blocked.  The science shows us various ways this can be achieved, as I explained in the post below. You can target alpha-2A adrenergic receptors, reduce stress or reduce cAMP.

What is cAMP?  Look here: -

https://en.wikipedia.org/wiki/Cyclic_adenosine_monophosphate

 

Cognitive Loss/Impaired Sensory Gating from HCN Channels - Recovered by PDE4 Inhibition or an α2A Receptor Agonist

… in earlier post we saw that α7 nAChR agonists, like nicotine, improve sensory gating and indeed that people with schizophrenia tend to be smokers. It turns out that nicotine is also an HCN channel blocker.

Stress appears to flood PFC neurons with cAMP, which opens HCN channels, temporarily disconnects networks, and impairs higher cognitive abilities.

This would explain why stress makes people’s sensory gating problems get worse. So, someone with Asperger’s would get more distracted/disturbed at exam time at school for example, or when he goes for a job interview. Reducing stress is another method to improve sensory gating and indeed cognition. 

Alpha-2A adrenergic receptors near the HCN channels, on those dendritic spines, inhibit the production of cAMP and the HCN channels stay closed, allowing the information to pass through into the cell, connecting the network. These Alpha-2A adrenergic receptors are stimulated by a natural brain chemical norepinephrine, or by drugs like Guanfacine.

While the researchers at Yale patented the idea of HCN blockers to improve cognition, we can see how other existing ideas to improve cognition may indeed have the same mechanism, most notably PDE4 inhibitors.

One effect of a PDE4 inhibitor is that it reduces cAMP. So, a PDE4 inhibitor acts indirectly like an HCN blocker.

Not surprisingly recent research showed that low doses of Roflumilast improves sensory gating in those affected by this issue.

So rather than waiting for a brain selective HCN blocker, the potential exists to use a one fifth dose of Roflumilast today.

 

HCN channels play a role in many neurological conditions.  It does get rather complicated, but if you successfully target these ion channels you are definitely at the cutting edge of science. 

Hyperpolarization-Activated Cyclic Nucleotide-Gated Channels: An Emerging Role in Neurodegenerative Diseases 

The low dose Roflumilast might be a good choice for Aspies who get bothered by noises like clocks ticking and people chewing gum.

Pentoxifylline is very cheap, but the short half-life means you might need to take it three times a day.

100mcg of Roflumilast is 1/5^th of a standard Daxas pill for COPD, which means crushing it and dividing in 5 parts.  This does also make it much cheaper, one pack would last you 5 months.

I will retry Roflumilast and also give Pentoxifylline a try. 

Based on the science, I think 100mcg of Roflumilast really should have a benefit in much autism.

I know other readers are using Pentoxifylline or Ibudilast.

All these PDE inhibitor drugs are normally used in adults. 

 

Misophonia

https://www.webmd.com/mental-health/what-is-misophonia#1

 

Misophonia is a disorder in which certain sounds trigger emotional or physiological responses that some might perceive as unreasonable given the circumstance. Those who have Misophonia might describe it as when a sound “drives you crazy.” Their reactions can range from anger and annoyance to panic and the need to flee.  The disorder is sometimes called selective sound sensitivity syndrome.

Individuals with Misophonia often report they are triggered by oral sounds  -- the noise someone makes when they eat, breathe, or even chew. Other adverse sounds include. keyboard or finger tapping or the sound of windshield wipers. Sometimes a small repetitive motion is the cause -- someone fidgets, jostles you, or wiggles their foot.

 

Impaired P50 gating

https://en.wikipedia.org/wiki/P50_(neuroscience)

 

In electroencephalography, the P50 is an event related potential occurring approximately 50 ms after the presentation of a stimulus, usually an auditory click.The P50 response is used to measure sensory gating, or the reduced neurophysiological response to redundant stimuli.

Research has found an abnormal P50 suppression in people with schizophrenia, making it an example of a biological marker for the disorder. Besides schizophrenia, abnormal P50 suppression has been found in patients with traumatic brain injury, recreational drug use, and post-traumatic stress disorder.

 

It looks to me that:-

 

Misophonia = Impaired P50 gating  = Impaired sensory gating

 

Recent clinical trials using Roflumilast: -

 

Cognitive Effects of Roflumilast in MCI Patients (ROMEMA)

dose 50 mcg   100 mcg

 

Roflumilast and Cognition (EEGrofl) 

dose 100mcg, 300mcg, 1,000 mcg

 

Roflumilast: A potential drug for the treatment of cognitive impairment?

 Roflumilast is the one and perhaps the only drug which shows a dose dependent occupancy of PED-4 in primate models and at doses proven to be very safe in humans, has shown its efficacy in enhancing memory and cognition.

 

An experimental medicine study of the phosphodiesterase-4 inhibitor, roflumilast, on working memory-related brain activity and episodic memory in schizophrenia patients

This study consisted of a randomised, double-blind, placebo-controlled, crossover design involving 15 schizophrenia patients. In 3 treatment periods, patients were given 8 days of placebo or one of the two doses of roflumilast (100 and 250 μg daily) with 14 days of washout between treatments.

Results

Verbal memory was significantly improved under 250 μg roflumilast (effect size (ES) = 0.77) compared to placebo. fMRI analyses revealed that increasing dose of roflumilast was associated with reduction of bilateral DLPFC activation during working memory compared to placebo, although this was not statistically significant (ES = 0.31 for the higher dose). Working memory was not improved (ES = 0.03).

Conclusions

Results support the mechanistic validation of potential novel strategies for improving cognitive dysfunction in schizophrenia and suggest that PDE4 inhibition may be beneficial for cognitive dysfunction in schizophrenia.

 

Improvisation

I did recently write about Desmopressin nasal spray as a possible alternative to specially compounded vasopressin nasal spray.  I did actually order some, but what arrived was the tablet form of Desmopressin.

The advantage of Desmopressin over Vasopressin is that there already exists a nasal spray in your pharmacy. There is currently a worldwide availability issue. 

Fine tuning Social Behavior in Autism with an existing pediatric drug, Desmopressin?

Having recently been making Christmas Pudding and sweet mincemeat for mince pies, from raw ingredients and improvising for those not available, I think I can safely make my own Desmopressin nasal spray, and with the correct excipients. 

Due to Covid, we did not go to England at Christmas; setting Christmas Pudding on fire is something that Monty looks forward to.

Christmas pudding takes days to make and 8 hours to cook, then you leave it to mature.  You re-heat for Christmas lunch.

 

Sweet mincemeat is something that came to England with the returning crusaders.  Nowadays it is just made with dried fruit.  When the English established colonies in New England, they took the older version with them, which included actual meat.  Today in the US you have store-bought sweet mincemeat with ground beef in it, in the UK it has been meat-free for many decades. 

The fat in sweet mincemeat is suet.  In the UK and US, pre-packaged suet sold in supermarkets is dehydrated suet.

I had no idea what suet was, but I know it is not in my supermarket.  Suet is actually raw, hard fat of beef or mutton, found around the loins and kidneys.  Jewish people are not supposed to eat suet, but Muslim people apparently seek it out.  These days I think most is actually a vegetable substitute.  To follow the recipe, a friend helped out with some of this fat; I put a chunk of it in the freezer for a couple of hours and then grated it. You are supposed to coat with rice flour, if you want to store it for later use.

The recipe said 300g (10 oz) of suet but having grated half, I decided it was pretty disgusting and substituted butter for the remainder.

In the recipe are raisins, currants and sultanas, they are actually all slightly different.  In effect they are all dried grapes

 

Raisins, sultanas and currants

 

In the US, the term raisin is applied to both raisins and sultanas. To distinguish the two, sultanas are referred to as “golden” raisins.

Where we live, they are all just “dried grapes”.  The different types exist, but are called the same thing.

Candied peel and glace cherries were also a struggle to find, by this time I had decided to add dried blueberries and cranberries.

One day after the mincemeat jars were already full and maturing in the garage, candied peel and glace cherries turned up and got added.  There is a lot of brandy in the recipe and this is why you leave the jars to mature.

 

It was a lot of bother to make, but the resulting mince pies were really good.  The brandy carries the spices making it very fragrant, not at all like store-bought mince pies.

The Christmas pudding was set alight, in fact twice for good measure.

Compared to all that, how hard can it be to make desmopressin nasal spray?  It only has a handful of ingredients, after all. 

Sulforaphane

I first wrote about Sulforaphane from broccoli, back in 2014. Johns Hopkins have been researching this substance for decades.

What has happened to Sulforaphane for autism? Stuck as Complementary and Alternative Medicine (CAM) therapy forever?  Apparently so.

Sulforaphane has anti-cancer effects and is suggested for common cancers like that of the prostate.  A stable man-made version (an analog) was developed in the UK as drug to treat prostate cancer.  In France a modified broccoli-based OTC product is sold as another prostate therapy.

 

When it comes to autism, there have been a series of positive clinical trials.

Sulforaphane treatment for autism spectrum disorder: A systematic review

Autism Spectrum Disorder (ASD) is defined as a neurodevelopmental condition characterized by social communication impairment, delayed development, social function deficit, and repetitive behaviors. The Center for Disease Control reports an increase in ASD diagnosis rates every year. This systematic review evaluated the use of sulforaphane (SFN) therapy as a potential treatment option for individuals with ASD. PubMed.gov, PubMed Central, Natural Medicines, BoardVitals, Google Scholar and Medline were searched for studies measuring the effects of SFN on behavior and cognitive function. All five clinical trials included in this systematic review showed a significant positive correlation between SFN use and ASD behavior and cognitive function. The current evidence shows with minimal side effects observed, SFN appears to be a safe and effective treatment option for treating ASD.

 

The Johns Hopkins' researchers did spin off the idea to commercially exploit their findings.  The result is “True broc” from Brassica Protection Products.

 

https://truebroc.com/what-is-truebroc/ 

 

https://brassica.com/

 

Here you will find Avmacol and Thorne Crucera-SGS, among the products than include “True broc”.  

These products, along with Prostamol from France, are actually used in clinical trials.

The UK company Evgen is developing its stable analog of Sulforaphane for autism and other conditions.

https://evgen.com/technology/

I spoke to Evgen a few years ago and suggested their prostate drug might be used for autism.  You still cannot buy it, but there is a clinical trial for autism planned.

 

Do you need expensive broccoli supplements?

There are numerous cheap broccoli supplements and some moderately priced ones.

We know from the research that supplements generally are not reliable, because they often do not contain what is on the label.  This matters more with some products than others.  With broccoli products the big question is whether they really contain active myrosinase.  This is an enzyme that you need to make Sulforaphane when you eat broccoli.

Several years ago, when I started with Sulforaphane, I bought large tubs of Australian broccoli powder and one pack of Daikon radish powder.  Daikon radishes are rich in myrosinase and it is relative stable, so it can survive processing.  My idea was to start with just the broccoli powder and then, if not effective, add some Daikon radish powder for the extra myrosinase.  In the end I did not need to even open the Daikon radish powder.  A small scoop of this broccoli powder produced a profound effect, euphoria after minutes and then much more “speech”. Back then “speech” was more like babbling single words – but it was some kind of speech at least. 

Many people report broccoli powder improved speech, even parents of young Aspies report it. 

Some people found the effect on mood to be remarkable.

Long term users report that over time they have to increase the dose to maintain the effect.

It is important to note that for some people the benefit may not be from Sulforaphane, but rather from indole-3-carbinol (I3C).

 

Here I am quoting myself …

 

“PTEN is best known as a tumor suppressor affecting RAS-dependent cancer, like much prostate cancer. Activating PTEN is good for slowing cancer growth. As I mentioned in a recent comment to Roger, many substances are known to activate PTEN; a good example being I3C (indole-3-carbindol) which is found in those cruciferous vegetables (broccoli, Brussels sprouts, cabbage etc) that many people choose not to eat. PTEN is a well-known autism gene.” 

The research has now caught up: - 

Study hints at dietary chemical as therapy for type of autism

A compound derived from cruciferous vegetables, such as broccoli and kale, might limit the impact of certain mutations in a top autism gene, a new study suggests.

The compound, called indole-3-carbinol, or I3C, acts on the gene PTEN, a tumor suppressor. 

This does raise questions about the prostate cancer research.  A sulforaphane analog drug contains no indole-3-carbinol (I3C).

  

Does Broccomax “work” 

The easy to buy product is Broccomax.  In the research they do not seem to like it, but it does not include the True Broc product from the Johns Hopkins spin-off.

Anecdotally, Broccomax does “work” for autism, but less so than some expensive products.

My Australian broccoli powder is no longer made, but it was not expensive and it did “work”.

 

Spice up Broccoli with Wasabi?

In the original research from decades ago, the Johns Hopkins researchers combined Daikon radish sprouts with broccoli sprouts, the Daikon radish sprouts where there to provide myrosinase.  The product had to kept deep frozen.

Daikon radish is widely available and is a good source of myrosinase.

I was re-reading old research and noted one researcher advocating putting Wasabi on your broccoli – the spicier the better apparently. Wasabi is Japanese horseradish and is widely available.  If it comes on a large bottle is likely fake wasabi - yes like they fake saffron, they fake wasabi.

Is it crazy to add wasabi to your broccoli capsules?

Look at what is in the expensive Avmacol supplement that they only sell in North America.

 

 

In the research they found that adding just 0.25% Daikon to frozen broccoli “brought it back to life” and sulforaphane was found in the person eating it. 

If you are using gelatine capsules with broccoli powder you can open them and, using a pointed knife, add a small amount of wasabi, re-seal and then swallow.  There is no taste or smell of wasabi.

It is bit fiddly to do this, but you soon master doing it.

 

Calcium Folinate (Leucovorin)

 

There is a lot in this blog already about Calcium Folinate.  It should give some benefit to the 75% of autism who have a problem with folate transport across the blood brain barrier. 

One of the most prominent effects in responders is improved speech. Just look at the tittle of the clinical trial

 

Leucovorin for the Treatment of Language Impairment in Children With Autism Spectrum Disorder

The only issue with Calcium Folinate (Leucovorin) are the side effects, but Professor Ramaekers assures me that if you gradually increase the dose over several weeks, there should not be any.

The summer before Covid, at 45mg a day of Calcium Folinate, my son had much more expressive language and it was also more complex language.  The problem was aggression.

 

Conclusion

As you can see the 2021 to do list is mainly tying up the loose ends remaining from previous ideas, so I anticipate success.

Broccoli powder does still have an effect, but much milder than a few years ago.  Does wasabi increase the effect?  This is very subjective, having bought the little jar of Wasabi, I will continue to adding it to two capsules of Broccomax before breakfast.

Calcium Folinate did increase speech significantly at the large dose (3 x 15mg a day) in my original trial.  At the lower dose of 15mg the effect is present, but is mild, and short-lived for the first few days.   I will very gradually increase from a starting dose of 15 mg a day and see if it possible to avoid the negative effects.

I do like the idea of the tiny dose of Roflumilast.  It has multiple potential benefits:-

1.     Improve sensory gating and reduce Misophonia

2.     Improve cognition

3.     Potentially reduce NKCC1/KCC2 expression and so make bumetanide more effective.

Can this be achieved without nausea? I think it is likely a matter of perseverance.  In COPD the starting dose of roflumilast is half the maintenance dose, but the likely “autism dose” of 100mcg in an adult is less than half the COPD starting dose of 250mcg. 

The research already tells us the effective dosage (for 1 & 2), 100mcg in an adult, and importantly that the effect is lost at higher dosage; indeed, the recent trial in Mild Cognitive Impairment (MCI) included a dose as low as 50mcg.

You would have to find the therapeutic window.  You are changing the intracellular level of cAMP, which will have numerous effects, not just on HCN channels, but also on things like pCREB and BDNF.

I think 80mcg will be a good place to start.

There may, or may not be, an equivalent dose of Pentoxifylline/Ibudilast that gives a similar effect.  Ideally you would want all 3 effects.

A dose higher than 100mcg might have a beneficial anti-inflammatory effect and so help reduce NKCC1/KCC2 expression which increases (3) but at the loss of (1) and (2).

It would be interesting to know if Maja’s daughter has/had Misophonia and what has been the effect of her Pentoxifylline use.

The next question is how to reliably measure such small doses of Roflumilast.  This drug does not dissolve in water, but is highly soluble in ethanol.  You have the choice of cutting a pill containing 500mcg into 5-6 pieces (fortunately, it is a large pill), or just crushing the pill and then using microscales to fill new capsules, or make a tincture.  The tincture should be the most accurate.  Tinctures are widely used for OTC remedies like propolis.  A tincture has the advantage that you can easily vary the dose. In phase 1, where I just try it on myself, I have opted for the tincture. One tablet dissolves in 2ml of vodka (dilute ethanol) to make a paste, but was much more fluid in 3 ml (the 3rd ml added probably could be just water).  One half of an old propolis pipette contains 100 mcg duly dissolved in 0.6 ml of vodka. It tastes exactly like the original propolis tincture, because all you really notice is the ethanol. Most commercial propolis tincture is made with alcohol and uses a much more concentrated ethanol than you will find in vodka. 

I was asked by an autism Grandad at the 2019 Thinking Autism conference how his Grandson could be helped.  The young man is highly intelligent, but has a severe problem with sound sensitivity.  His family paid extra money for him to sit his final school exams in a room with no other students, but the invigilator was opening up candy to chew all through the exams and so the boy flunked the exams.   This young man has Misophonia and I bet would exhibit impaired P50 gating if given an EEG. Before exam time, he needs to block some of the HCN channels in his brain and reduce stress/anxiety.  He might well benefit from Roflumilast 100 mcg and Propranolol 20mg and then sail through his exams. 

I actually think that many people reading this post likely have Misophonia, that is if they are a relative of someone with polygenic autism.  In the literature Misophonia is claimed to affect more women than men, but I doubt that is actually true.  If you have autism, your doctor is highly unlikely to add a diagnosis of Misophonia. 

Is Desmopressin going to be helpful?  I had put Vasopressin down as a potential therapy more for Aspies, but our reader whose young child was prescribed Desmopressin nasal spray by her neurologist, noted a broad range of substantial improvements. Desmopressin is water soluble, so no vodka required.