Modulation of IP3 receptors in Autism – Pancreatitis and Caffeine?

This post stems from our Greek reader Petra's original observations about the combined effects of coffee and bumetanide.

In earlier posts we learned that one likely nexus in autism is the IP3 receptor that releases calcium from a store within each cell.

It turns out that too little/too much activity from IP3 receptors is a feature of a wide range of disease, some of which you may not have heard of, including:-

·      Gillespie syndrome, a genetic condition leading to MR/ID, ataxia and notably part of the iris to be missing

·      Spinocerebellar ataxias, genetic conditions that cause loss of movement control

·      Glioblastoma, an aggressive and “untreatable” brain cancer

·      Alzheimer’s disease

·      Huntington’s disease

·      Pancreatitis, inflammation of the pancreas where your body makes its digestive enzymes and insulin 

For detail, refer to this Japanese paper:- 

IP3 receptor mutations and brain diseases in human and rodents

Of the three types of IP₃Rs, the type 1 receptor (IP₃R1) is dominantly expressed in the brain and is important for brain function. Recent emerging evidence suggests that abnormal Ca²⁺ signals from the IP₃R1 are closely associated with human brain pathology. In this review, we focus on the recent advances in our knowledge of the regulation of IP₃R1 and its functional implication in human brain diseases, as revealed by IP₃R mutation studies and analysis of human disease‐associated genes. 

I suspect that both hyper and hypo-active IP3 receptors will be found in different types of autism. I assume the variant I deal with in my son is more likely to be hyperactive. The research by Gargus suggested “dysregulated IP3R” in autism in 3 single gene autisms; he found depressed Ca²⁺ release through inositol trisphosphate receptors (IP₃Rs) in patient-derived fibroblasts.

Shared functional defect in IP3R-mediated calcium signaling in diverse monogenic autism syndromes

Your body contains a lot of calcium, but almost all of it is in your bones, as calcium phosphate.  Only the residual amount (about 1%) of calcium is present in solution as the ion Ca²⁺. Ca²⁺ plays an important role in many physiological functions.  An excessive elevation of Ca²⁺ inside cells will kill them. Cells must maintain the intracellular Ca²⁺ concentration at the low level of ~10⁻⁷ mol/L, against the much higher extracellular Ca²⁺ concentration (~10⁻³ mol/L).

Cells must be able to rapidly and dynamically change the intracellular Ca²⁺ concentration in response to extracellular stimuli to regulate physiological functions such as cell proliferation, fertilization, immune response, and brain functioning.

To dynamically change the intracellular Ca²⁺ level, cells use two sources of Ca²⁺:

·      Ca²⁺ influx from outside (the extracellular space)

·      Ca²⁺ release from inside (the intracellular Ca²⁺ store, the endoplasmic reticulum – ER)

Many Ca²⁺ handling molecules (Ca²⁺ ion channels, Ca²⁺ pumps, Ca²⁺ sequester proteins) work to maintain the correct balance. The IP3 receptor is a key protein in the regulation of the intracellular Ca²⁺ dynamics, because it  controls the release of intracelluar Ca²⁺.

If IP3R is left open, Ca²⁺ levels inside cells become too high; if it is left shut Ca²⁺ becomes too low.

No medical therapy currently exists to inhibit/block IP3 receptors, but today’s post considers one potential therapy – caffeine. 

Caffeine

Caffeine is a drug, although it is not regulated as one.  At high doses caffeine is toxic, but at non-toxic doses caffeine does have some potent medical effects and it does protect against certain diseases.

It protects against pancreatitis, for example.

It would be very hard to drink yourself to death with coffee. Just like eating numerous bananas does not cause death by having too much potassium in your blood. Supplements have more risks than food. 

Pancreatitis IP3R and Caffeine 

Caffeine protects against experimental acute pancreatitis by inhibition of inositol 1,4,5-trisphosphatereceptor-mediated Ca2+ release 

Significance of this study

What is already known on this subject?

·       Acute pancreatitis is a major health problem without specific drug therapy.

·       Coffee consumption reduces the incidence of acute alcoholic pancreatitis.

·       Caffeine blocks physiological intracellular Ca²⁺ oscillations by inhibition of inositol 1,4,5-trisphosphate receptor-(IP₃R)-mediated signalling.

·       Sustained cytosolic Ca²⁺ overload from abnormal Ca²⁺ signalling is implicated as a critical trigger in the pathogenesis of acute pancreatitis.

What are the new findings?

·       Caffeine and its dimethylxanthine metabolites inhibit IP₃R-mediated, sustained cytosolic Ca²⁺ elevations, loss of mitochondrial membrane potential and necrotic cell death pathway activation in pancreatic acinar cells.

·       Neither specific phosphodiesterase inhibitors nor cyclic adenosine monophosphate and cyclic guanosine monophosphate inhibit sustained Ca²⁺ elevations in pancreatic acinar cells.

·       Serum levels of xanthines after 25 mg/kg caffeine administration are sufficient to inhibit IP₃R-mediated Ca²⁺ overload in experimental acute pancreatitis.

·       Caffeine but not theophylline or paraxanthine administered at 25 mg/kg significantly ameliorated pancreatic injury in experimental acute pancreatitis through IP₃R-mediated signalling inhibition.

How might it impact on clinical practice in the foreseeable future?

·       These findings support an approach of inhibition of Ca²⁺ overload and of its consequences as novel potential therapy for acute pancreatitis.

·       Methylxanthine-based structures are suitable starting points for drug discovery and development to treat acute pancreatitis. 

The Pancreas and Autism

The biomarker proposed by Joan Fallon/Curemark for her autism treatment (CM-AT) is low fecal chymotrypsin level. Chymotrypsin is a digestive enzyme produced in the pancreas and it can be used as a test for early cystic fibrosis. In adults low chymotrypsin indicates a pancreatic disease like pancreatitis.

Many people with autism have GI problems, but there are several distinct sub-groups. Some people have inflammatory bowel disease (IBD) potentially leading to ulcerative colitis, but most do not. Some people with autism have GI dysfunctions that remain undiagnosed, for some it is as if they do not digest food the same way as other people.

If IP3R hyperactivity is a feature of some autism and IP3R hyperactivity is inherent in pancreatitis, is it a surprise that some people with autism do not seem to digest their food properly? Or is it just a coincidence?

Brain Cancer

We did come across glioblastoma in a previous post that looked at off-label therapies for some cancers. In that post we came across an academic from San Diego, who decided to read the research and try and reverse his incurable aggressive brain cancer. This involved driving across the border to Mexico to freely acquire the prescription drugs he used to treat himself.  Two decades later he is still very much alive. 

More Wnt Modulation for Autism and More Inexpensive Potential Cancer Therapies

According to the study below, a hot cup of strong Greek coffee might be a good choice to maintain Professor Williams in good health.

Caffeine-mediated inhibition of calcium release channel inositol 1,4,5-trisphosphate receptor subtype 3 blocks glioblastoma invasion and extends survival.

IP₃Rs are known to be difficult to study especially due to the lack of suitable inhibitors and subtype specific blockers. We found that caffeine paradoxically inhibited IP₃R-mediated Ca²⁺ responses in a subtype 3 specific manner (Figure 5). Using caffeine as a tool to inhibit IP₃R3-mediate Ca²⁺ release, we have demonstrated that inhibiting IP₃R3 effectively reduced the migration, invasion, and survival of glioblastoma cells (Figure 2). The gene silencing of IP₃R3 by shRNA also effectively reduced the caffeine sensitivity of Ca²⁺ signaling and invasiveness in the Matrigel invasion assay (Figure 5). Our results are the first to demonstrate the involvement of IP₃R3 in glioblastoma Ca²⁺ signaling and invasion. Furthermore, we suggest that IP₃R3 can be specifically targeted for therapeutic intervention in glioblastoma patients with minimal influence on normal glial as well as neuronal functions.

Whether caffeine can directly affect the gating of IP₃R3 channels or not is still unknown. However, according to previous studies demonstrating that caffeine can compete with ATP binding to IP₃Rs (21) at millimolar concentrations (20), caffeine could selectively bind to IP₃R3 and affect the gating of IP₃R3. Further work is required to investigate the direct role of caffeine on IP₃R3 gating in comparison to other subtypes of IP₃R.

In summary our study provides IP₃R3 as a novel therapeutic target for glioblastoma treatment. Our study also provides new insights into the detailed molecular mechanism of caffeine action on migration and invasion of glioblastoma. The apparent beneficial effect of caffeine suggested by our study should trigger future investigations of the therapeutic potential for caffeine to treat this deadly disease that otherwise has no cure. 

Conclusion

Caffeine is the most obvious modulator of IP3R in your kitchen or at the local pharmacy.

cAMP plays a complex role in IP3R, PKA is involved so PDE4 should be. Parathyroid hormone (PTH) is also important. PTH is secreted to tell your bones to release Ca²⁺ into the bloodstream, but it has multiple roles. PTH causes the release of IP3 and DAG and hence release of calcium from the store within cells (the ER). PTH release is stimulated when Ca²⁺ is low but also by other things, such as notably by histamine. PTH also is reported to increase the sensitivity of IP3R receptors, so too much PTH would clearly be a bad idea.

Primary Hyperparathyroidism (PHPT) is characterized by hypercalcaemia and elevation of parathyroid hormone.  Children with PHPT may present with non-specific complaints such as behavioural change and deteriorating school performance.  As we know, behavioural change in the form of aggression sometimes occurs in autism, ADHD and various other mood disorders. It may also present as a psychiatric manifestation of an endocrine disorder such as Primary Hyperparathyroidism (PHPT).

It is not surprising that histamine can cause aggression in the same way that Primary Hyperparathyroidism does. Aggression in all psychiatric disorders very likely has a biological cause, you just have to look for it. 

Aggression and Homicidal Thoughts in a Patient with Primary Hyperparathyroidism: A Case Report.

How about checking kids with aggression/SIB for PHPT, or just high levels of calcium (hypercalcaemia). Or perhaps:-

Going Loco? Think histamine, calcium and hyper-parathyroidism, before taking antipsychotics.

Back to caffeine.

In people with hyperactive IP3 receptors, such as those who damaged their pancreas by drinking too much alcohol, caffeine looks a smart therapy. The same would apply to people with autism and hyperactive IP3 receptors. So for those people, drink coffee, preferably Greek coffee (or Turkish coffee, which is the same thing). Some Latin American countries also make potent coffee drinks. Your cup of instant coffee, or chain store coffee is not going to do much.

There are numerous interesting substances in less processed coffee, not just caffeine. The key is to process it as little as possible, as we saw cocoa. In instant coffee only the caffeine is going to have much effect.

Chlorogenic acid, an OAT3 inhibitor, that should enhance bumetanide, is there in coffee.

Coffee contains small amounts of Caffeic acid. What we would really like is Caffeic Acid Phenethyl Ester (CAPE), which is a substance found in some bee propolis. CAPE acts as a PAK1 inhibitor, among other potentially beneficial effects.

Catechin, epicatechin, and surprisingly vanillin are present in coffee.

Roasting coffee makes big changes to its chemical composition and of course to its taste. Green coffee bean extract, used as a supplement for weight loss, is a rich source of chlorogenic acid.

Perhaps someone should do a study on adults with autism using 2 cups of Greek coffee a day.  Alternatively you could just use caffeine pills, with or without coffee bean extract for those interesting flavanols.

Enhancing the effect of Bumetanide in Autism

Many readers of this blog, and some of those who leave comments, are using the Bumetanide therapy proposed by Ben-Ari and Lemonnier.

At some point it should become an approved autism drug and Ben Ari has already patented it for use in Down Syndrome, so I guess that will come later on.

I have been developing my own add-on therapies that might help people for whom a high level of intracellular chloride is part of their autism, or indeed Down Sydrome.  If Bumetanide has a profound impact on your autism, this is almost certainly you.

Monty, aged 13 with ASD

After 4 years of Bumetanide, it continues to be effective and if Monty stops taking it there is a gradual cognitive decline over a few days, presumably as chloride concentration gradually increases.

In spite of an odd temporary Tourette’s type verbal tic that developed after an infection before Christmas, I have been getting plenty of feedback that Monty has got cleverer in 2017.  So it looks like some bumetanide add-on does indeed work.

The Colosseum

Monty’s big brother continues to be a fan of Lego and indeed Nanoblocks from Japan.  Nanoblocks is like extremely small Lego.

Having completed the Colossuem, his latest Nanoblocks model, he asked Monty “where is it?”.

Back came the answer, unprompted, “Italy”.

This was a big surprise.

That was not the answer big brother expected, he expected no answer or a silly answer like “over there”.

Add-ons

The first is potassium bromide (KBr) which was the original epilepsy therapy 150 years ago.  One of its effects is that the bromide (Br^-) part competes with chloride (Cl-) to enter neurons and bromide is known to be faster.  As a result some of the chloride inside cells is replaced by bromide.  Bromide is extremely similar to chloride, but is not reactive; this is why it can be used with any anti-epileptic drug (AED) without fear of negative interactions.

KBr has an extremely long half-life, meaning that if you take it every day it will take 4-6 weeks to reach its stable level in your body.

KBr is used for pediatric epilepsy in Germany and Austria and for epilepsy in pet dogs all over the world.  

A dose of 8mg/kg is far below the dose used for epilepsy, but does have a bumetanide enhancing effect in one 50kg boy.

The even more recent add-on is based on the experience of our reader Petra’s son with Asperger’s, who found that taking his bumetanide with Greek coffee seemed to make it more effective.

It turns out that dopamine is known to increase the effect of diuretics on the chloride cotransport NKCC2 in your kidneys.  There is a myth that coffee is a diuretic, but it is clear where this myth has come from.  Coffee will increase diuresis and so does caffeine.

In the brain it is the chloride cotransporter NKCC1 that is also blocked by bumetanide.  So it would be plausible that dopamine/coffee/caffeine it might have the same effect on NKCC1 as it does on the very similar NKCC2.

The cheap and widely available 50mg caffeine tablets do seem to serve as a proxy for a steaming cup of Greek coffee.  Indeed 50mg of caffeine is more like a weak cup of instant coffee.

I did much earlier propose the use of Diamox/ Acetazolamide to reduce chloride.  It seems that in some neurons 2/3 of the chloride enters via NKCC1 and 1/3 via the exchanger AE3.  Diamox/ Acetazolamide works via AE3.

Diamox has some other ion channel effects, making it useful in some epilepsy.

Some readers of this blog use Diamox, but in Monty it seems to cause reflux.

Caffeine is a very simple add-on to try.

Synergistic Benefit of Low Dose Dopamine (Greek Coffee) and Diuretics (Bumetanide/Furosemide); better than Bromocriptine?

I did think of highlighting this post to the Bumetanide researchers in France, but I do not think they would take it seriously.

Another one to mention would be this new study, funded by Rodakis, to look at why some antibiotics improve some autism.  Dr Luna at Baylor College is running the study.  Its basic assumption is that the effect must be to do with bacteria, but as our reader Agnieszka has highlighted, common penicillin type antibiotics increase expression of the gene GLT-1 which then reduces glutamate in the brain.  It has nothing to do with bacteria.  Maybe for other antibiotics the effect does relate to bacteria.

But if you tell Dr Luna about GLT-1, quite likely she will not be interested.  

Study to investigate connection between antibiotic use and autism symptoms

Researchers will compare the gut microbiome (bacteria, yeasts and fungi found in the gut) and metabolome (small biological molecules produced by the microbes) of those who experience a change in symptoms during antibiotic use to those who do not. The study may provide valuable insight into when and why these changes occur and how this information can be harnessed for future interventions.  

There is even a case study very well documented here:-

Beta-Lactam Antibiotics as A Possible Novel Therapy for Managing Epilepsy and Autism, A Case Report and Review of Literature

Petra, our regular reader from Greece, has pointed out that Bumetanide has a greater effect in her adult son, with Asperger’s, when taken with Greek coffee and suggested why this might be. 

Her reference is this article:- 

Added to Diuretics, Low-Dose Dopamine Renoprotective in Small Acute-HF Trial

It shows that the diuretic effect of low dose furosemide, with dopamine, is greater than the effect of high dose furosemide.

The diuretic effect of Furosemide is via the transporter NKCC2, which is the same affected by Bumetanide. 

NKCC2 is found in your kidneys, while the very similar NKCC1 is found in your brain.  Furosemide and Bumetanide affect both NKCC1 and NKCC2.

The caffeine in coffee is known to indirectly produce dopamine in your body.

Greek coffee is nothing like your instant coffee or watery Starbucks coffee, it contains a serious amount of caffeine. 

The question is how does dopamine interact with furosemide/bumetanide and will the effect in the kidney (NKCC2) also affect the brain (NKCC1). 

By more effectively blocking NKCC1 in neurons you would further lower chloride levels and potentially further improve cognitive functioning.  

This would further validate Petra’s observation. 

Then we would consider if there is an alternative to Greek coffee, or just accept that caffeine is the simplest and safest method to enhance Bumetanide.    

In the then end my conclusion is that coffee, or just the caffeine, is a better option than a selective Dopamine D2 receptor agonist.  But there is an interesting drug called Bromocriptine that may be better in some cases. 

Not only is it a dopamine D2 receptor agonist, but Bromocriptine also “inhibits the release of glutamate, by reversing the GLT-1 (EAAT2) transporter”. 

We came across the GLT-1 (EAAT2) transporter when we found why some people with autism improve when on beta-lactam antibiotics (that include the penicillin ones).   

GLT-1/ EAAT2 is the principal transporter that clears the excitatory neurotransmitter glutamate from the extracellular space at synapses in the central nervous system. Glutamate clearance is necessary for proper synaptic activation and to prevent neuronal damage from excessive activation of glutamate receptors. EAAT2 is responsible for over 90% of glutamate reuptake within the brain 

We saw that the drug riluzole approved for the treatment of ALS (Amyotrophic Lateral Sclerosis) upregulates EAAT2/GLT-1.

I suggested that people with autism who improve on penicillin types antibiotics should get a similar effect from riluzole.  But riluzole is one of those monstrously expensive drugs.  

Based on my logic, we would then think that bromocriptine should help treat ALS (Amyotrophic Lateral Sclerosis).  What did I find when I looked it up:- 

Bromocriptine Mesylate Attenuates Amyotrophic Lateral Sclerosis: A Phase 2a, Randomized, Double-Blind, Placebo-Controlled Research in Japanese Patients. 

So then how much does Bromocriptine cost?  It is a cheap generic.  So a cost effective potential drug for ALS. 

Bromocriptine has two potentially useful functions (Dopamine D2 and GLT-1),but it has numerous other effects:- 

Bromocriptine blocks the release of a hormone called prolactin, but this should not be an issue for males. 

Risperidone, one of only two drugs approved for side effects of autism, can boost levels of prolactin.  Elevated prolactin levels are linked to a range of side effects, including gynecomastia, or growth of breasts, in men and boys.  This did not stop the drug being approved.

Bromocriptine agonizes the following monoamine receptors

• Dopamine D₁ family
• D₁ (K_i=682 nM)
• D₅ (K_i=496 nM)
• Dopamine D₂ family
• D₂ (K_i=2.96 nM)
• D₃ (K_i=5.42 nM)
• D₄ (K_i=328 nM)
• Serotonin 5-HT
• 5-HT_1A (K_i=12.9 nM)
• 5-HT_1B (K_i=355 nM)
• 5-HT_1D (K_i=10.7 nM)
• 5-HT_2A (K_i=107 nM)
• 5-HT_2B (K_i=56.2 nM)
• 5-HT_2C (K_i=741 nM)
• 5-HT₆ (K_i=33 nM)
• Adrenergic α family
• α_1A (K_i=4.17 nM)
• α_1B (K_i=1.38 nM)
• α_1D (K_i=1.12 nM)
• α_2A (K_i=11.0 nM)
• α_2B (K_i=34.7 nM)
• α_2C (K_i=28.2 nM)
• Adrenergic β family
• β₁ (K_i=589 nM)
• β₂ (K_i=741 nM)

  

This is why drugs have side effects. 

But for people with ALS who cannot afford riluzole, the cheap generic bromocriptine might be a good choice.

How about bromocriptine for autism? 

Well there was a trial in Italy a long time ago on girls with Rett syndrome 

Bromocriptine in the Rett syndrome

Twelve typical cases of the Rett syndrome and one forme fruste were treated with bromocriptine for six months and then had a washout for two months followed by resumption of the bromocriptine treatment. During the first bromocriptine treatment there were improvements in communication and relaxation in some of the girls: a more regular sleep pattern was observed in 4 and a more varied facial expression in 8, and 4 girls began to utter a few words. The bouts of hyperpnea disappeared in 5 and grinding of the teeth in 3. There was also a reduction in stereotypic hand activities in 5 girls and signs of improved motor abilities in 3. The washout caused a general decrease in the positive effects of the previously administered bromocriptine and resumption of the treatment with this drug led to less marked improvement. Metoclopramide was tested in all the girls before the treatment, and it was noted that, while endorphins were hyporesponsive, prolactin was hyperresponsive. This test was repeated two months after the bromocriptine treatment had been performed and, while beta-lipotropin remained unchanged, beta-endorphin showed increased responsiveness.

Current use of Dopamine with Lower Dose Diuretics 

There is extensive knowledge of the effect of taking dopamine with a bumetanide type diuretic. 

Bumetanide by itself has a plateau above which a higher dose causes no further diuresis, but when combined with dopamine there is more diuresis.  Alternatively you can use a lower dose of bumetanide and get the same amount of diuresis by adding dopamine. 

Of interest to people with autism, it is found that you can reduce the amount of potassium lost for the same amount of diuresis.

    

Added to Diuretics, Low-Dose Dopamine Renoprotective in SmallAcute-HF Trial

Synergetic Effects of Dopamine and High－Dose Bumetanide in Patients with oliguria

The effects of a combination of dopamine and bumetanide were studied in eight patients with oliguria not responsive to conventional treatment. Dopamine was infused at a rate of 3 чg/kg/min and bumetanide was given as a 0.05-0.1 mg/kg bolus every 2 hours intravenously. Administration continued for 3 to 15 days. Urine output, blood urea nitrogen, serum creatinine, the ratio of urine to plasma osmolarity, free water clearance, and serum electrolytes were measured before, during, and after the administration period. Six of the eight patients responded with an increase in urine output and improvement of the other variables ; the other two did not. We conclude that the combination of dopamine and high-dose bumetanide is effective in increasing diuresis in critically ill patients in the early stages of oliguria

How does dopamine interact with NKCC1/2?

This is a very logical question, but there is something in the literature on this subject.  It does come from frogs, but it was all I could find.

Functional expression of the murine D₂, D₃ and D₄ dopamine receptors in Xenopus laevis oocytes

The different murine D2-type dopamine receptors (D_2L, D_2S, D_3L, D_3S, and D₄) were expressed in Xenopus laevis oocytes. The D2-type receptors were all similarly and efficiently expressed in Xenopus oocytes and were shown to bind the D2 antagonist [¹²⁵I]sulpride. They were all shown to activate Cl⁻ influx upon agonist stimulation. Using the diagnostic inhibitor bumetanide, we were able to separate the Na⁺/K⁺/2Cl⁻ cotransporter component of the Cl⁻ influx from the total unidirectional Cl⁻ influx. The D_3L subtype was found to operate exclusively through the bumetanide-insensitive Cl⁻ influx whereas the other D2-type receptors acted on the Na⁺/K⁺/2Cl⁻ cotransporter as well. The pertussis toxin sensitivity of the receptor-activated chloride influx via the Na⁺/K⁺/2Cl⁻ cotransporter varied between the various D2-type receptors showing that they may couple to different G proteins, and activate different second messenger systems.

In contrast to the D2 and D3 receptor subtypes, D4 receptor activity was not significantly altered by the presence of PTX, suggesting that in Xenopus oocytes it may couple with one or more PTX-insensitive G proteins to cause changes in Cl3 influx. By contrast, in the case of the D2 receptor, PTX reduced the total Cl3 influx mediated by the D2S isoform by approximately 67%, and that mediated by the D2L isoform by approximately 40% (Fig. 2A). However, the activities of the two components of this ion influx, namely the bumetanide sensitive Na/K/2Cl- cotransporter and the bumetanide-insensitive Cl- influx, differed between these two isoforms. While the bumetanide-insensitive Cl3 influx was reduced by approximately 60% by PTX for the D2L isoform, it was only slightly reduced for the D2S isoform (Fig. 2C). Thus, the majority of the inhibitory effect of PTX on the D2S-induced influx was caused by uncoupling from the signalling cascade that activates the Na/K/2Cl- cotransporter. On the other hand, the signal transduction pathway that activates the cotransporter after stimulation of the D2L receptor remained relatively unaffected by PTX (Fig. 2B), indicating that D2S and D2L couple to different G proteins when expressed in Xenopus oocytes. For the D3 receptor, both long and short isoforms showed a reduction (50^60%) in the presence of PTX, at the bumetanide-insensitive Cl- influx (Fig. 2C), whereas for both D3 receptor isoforms, PTX had little or no effect on the Na/K/2Cl- cotransporter, indicated by the bumetanide-sensitive component of the Cl3 influx (Fig. 2B).  

PTX = pertussis toxin

  

Caffeine among its many effects is effectively a dopamine D2/3 receptor agonist.

Caffeine mimics the effect of a dopamine D2/3 receptor agonist onthe expression of immediate early genes in globus pallidus.

Conclusion

As I understand from the large scale trial use of bumetanide use in autism, there is indeed an issue with hypokalemia (loss of potassium).  

I would think that this should be solvable using a supplement and dietary potassium.  Agnieszka pointed out that kiwis have the advantage of potassium with little carbohydrate, as do avocados. Bananas and orange juice are the traditional potassium-rich foods for people on diuretics. 

This is a case where the care giver has to play an active role, it is not just about the doctor prescribing a pill.  The care giver has to manage the process to minimize the side effects.  So potassium needs to be managed, as does fluid intake. 

For people who struggle with hypokalemia, the idea of a lower dose of bumetanide, but with dopamine, could be interesting.  The other method is to add a potassium sparing diuretic like spironolactone. 

For my son, the dietary option, plus 250mg of potassium twice a day, is very effective.  Now I just have to persuade him to take a Greek coffee with his breakfast. 

For people whose autism responds to penicillin type antibiotics and who take bumetanide then Bromocriptine might be interesting as a caffeine alternative.

Biomarkers in Autism : The Cholinergic system – In need of caffeine & nicotine or maybe just choline

Strange as it may sound, but if you have ASD a strong cup of coffee and a cigarette may actually do you some good.  Following on from my earlier post about Serotonin, showing that LSD was seen as an effective therapy in the 1960s, you might be wondering where my blog is taking us.  I just follow the science, wherever it takes us.

First of all what is the Cholinergeric system.

Cholinergic system (a summary from Wikipedia)

Cholinergic typically refers to acetylcholine in the neurological sense.  The parasympathetic nervous system, which uses acetylcholine almost exclusively to send its messages, is said to be almost entirely cholinergic. Neuromuscular junctions, preganglionic neurons of the sympathetic nervous system, the basal forebrain, and brain stem complexes are also cholinergic

In neuroscience and related fields, the term cholinergic is used in the following related contexts:

• A substance (or ligand) is cholinergic if it is capable of producing, altering, or releasing acetylcholine ("indirect-acting") or mimicking its behaviour at one or more of the body's acetylcholine receptor types ("direct-acting").
• A receptor is cholinergic if it uses acetylcholine as its neurotransmitter.^[2]
• A synapse is cholinergic if it uses acetylcholine as its neurotransmitter.

Acetylcholine is one of many neurotransmitters in the autonomic nervous system (ANS). It acts on both the peripheral nervous system (PNS) and central nervous system (CNS) and is the only neurotransmitter used in the motor division of the somatic nervous system.

In the central nervous system, acetylcholine and the associated neurons form a neurotransmitter system, the cholinergic system, which tends to cause anti-excitatory actions.

Damage to the cholinergic (acetylcholine-producing) system in the brain has been shown to be plausibly associated with the memory deficits associated with Alzheimer's disease.

Synthesis and degradation

Acetylcholine is synthesized in certain neurons by the enzyme choline acetyltransferase from the compounds choline and acetyl-CoA. Cholinergic neurons are capable of producing Ach.

Receptors

There are two main classes of acetylcholine receptor (AChR), nicotinic acetylcholine receptors (nAChR) and muscarinic acetylcholine receptors (mAChR). They are named for the ligands used to activate the receptors.

Nicotinic

Nicotinic AChRs are ionotropic receptors permeable to sodium, potassium, and calcium ions. They are stimulated by nicotine and acetylcholine. They are of two main types, muscle-type and neuronal-type. The former can be selectively blocked by curare and the latter by hexamethonium. The main location of nicotinic AChRs is on muscle end plates, on autonomic ganglia (both sympathetic and parasympathetic), and in the CNS.^[32]

Muscarinic

Muscarinic receptors are metabotropic, and affect neurons over a longer time frame. They are stimulated by muscarine and acetylcholine, and blocked by atropine. Muscarinic receptors are found in both the central nervous system and the peripheral nervous system, in heart, lungs, upper GI tract and sweat glands. Extracts from the plant Deadly night shade included this compound (atropine), and the blocking of the muscarinic AChRs increases pupil size as used for attractiveness in many European cultures in the past

--- end of wikipedia ---

 

The Research Showing Abnormality in ASD

The following study was carried out in the UK in 2002 on post mortem brain tissue from “Brain banks” in the US.  It is extensively referred to in the later research.

Nicotinicreceptor abnormalities in the cerebellar cortex in autism

 

An earlier paper on the same subject:-

Cholinergic Activity in Autism: Abnormalities in the Cerebral Cortex and Basal Forebrain

CONCLUSIONS: These neurochemical abnormalities implicate the cholinergic system in developmental disorders such as autism and suggest the potential for intervention based on cholinergic receptor modulation.

If the low level of cortical nicotinic receptors is consistently observed and clinically relevant, therapeutic strategies could include receptor agonists, such as nicotine, which has already been applied in Tourette’s disorder with amelioration of symptoms. Such treatment could also be disease modifying.

 

Other studies on autistic brain samples have shown diminished acetylcholine and nicotinic receptor activity.

Implications 10 years on remain the same

A recent study by neuroscientists at Ohio State University, concludes that neuronal nicotinic acetylcholine receptor (nAChR) alterations are biomarkers for ASD and that specific nAChRs subtypes are likely to be useful therapeutic targets for the treatment of core deficits. They claim a case can be made for the use of  α7 nAChRs to reduce neuroinflammation in the brain in those ASD individuals with such clinical pathology. The ultimate hope is that these agents, when administered early in development, by their presumed ability to modulate a number of different neurotransmitter systems and associated signaling pathways, could help correct core deficits associated with ASD.

Interventions

Just by spending 5 minutes on Wikipedia, you can find logical interventions that could have been tested since 2002.  Some have indeed been tested, others have not.  Here below is a copy-paste from Wikipedia, with interesting drugs highlighted.

 

Reversibel acetylcholinesterase inhibitor (often abbreviated AChEI)

Compounds which function as reversible competitive or noncompetitive inhibitors of cholinesterase are those most likely to have therapeutic uses. These include:

• Some organophosphates not listed under "Irreversible" below
• Delta9-tetrahydrocannabinol (THC)
• Carbamates
• Physostigmine
• Neostigmine
• Pyridostigmine
• Ambenonium
• Demarcarium
• Rivastigmine
• Phenanthrene derivatives
• Galantamine
• Caffeine – noncompetitive (also an Adenosine receptor antagonist)^[8]
• Piperidines
• Donepezil, also known as E2020
• Tacrine, also known as tetrahydroaminoacridine (THA')
• Edrophonium
• Huperzine A^[9][10]
• Ladostigil
• Ungeremine^[11]
• Lactucopicrin

Natural Compounds

• Huperzine A
• Galantamine
• Onchidal
• Coumarins
• Celastrus paniculatus

ACh receptor agonists/antagonists

Acetylcholine receptor agonists and antagonists can either have an effect directly on the receptors or exert their effects indirectly, e.g., by affecting the enzyme acetylcholinesterase, which degrades the receptor ligand. Agonists increase the level of receptor activation, antagonists reduce it.

Drugs acting on the cholinergic system

Blocking, hindering or mimicking the action of acetylcholine has many uses in medicine. Drugs acting on the acetylcholine system are either agonists to the receptors, stimulating the system, or antagonists, inhibiting it.

ACh and its receptors
Drug	Nm	Nn	M1	M2	M3
ACh, Charbacol, AChEi (Physostigmine, Galantamine, Neostigmine, Pyridostigmine)	+	+	+	+	+
Nicotine, Varenicline, Cotinine	+	+
Succinylcholine	+/-
Tubocurarine, Atracurium, Cisatracurium, Rocuronium, Vecuronium, Pancuronium	-
Epibatidine, DMPP, Decamethonium		+
Trimethaphan, Mecamylamine, Bupropion, Dextromethorphan, Hexamethonium		-
Muscarine, Methacholine, Oxotremorine, Bethanechol, Pilocarpine			+	+	+
Atropine, Tolterodine, Oxybutynin			-	-	-
Vedaclidine, Talsaclidine, Xanomeline, Ipratropium			+
Pirenzepine, Telenzepine			-
Methoctramin				-
Darifenacin, 4-DAMP, Darifenacin, Solifenacin					-

Direct acting

These are drugs that mimic acetylcholine on the receptor. In low doses, they stimulate the receptors, in high doses they numb them due to depolarisation block.

Acetyl l-carnitine[33] Acetylcholine itself Bethanechol Carbachol

Cevimeline Muscarine Nicotine

Pilocarpine Suberylcholine Suxamethonium

------- end of Wikipedia ---------

 

Evidence based approach

The web is full of commentators telling you to only pay attention to evidence-based treatments.  This sound great in principle, but it assumes there are copious amounts of well-constructed clinical trials.  Moreover, is assumes that there is just one type of autism, or that clinical trials are sophisticatedly constructed to test individual sub-types, one at a time (which they are not).

So, in reality, the evidence is generally poor quality and so applying a pure evidence-based approach will leave you exactly back where you started.

I have gathered together what I think is a remarkable amount of evidence from multiple imperfect trials and anecdotal case studies.

Use Of Donepzil

Following on two earlier trials, Chez et Al carried out a double-blind study  of Donepezil hydrochloride, an acetylcholinesterase inhibitor  to confirm those findings. 

 

Donepezil hydrochloride: a double-blind study in autistic children

 The trial concluded:-

Expressive and receptive speech gains, as well as decreases in severity of overall autistic behavior, were documented after 6-weeks for the treatment group. These improvements were statistically significant when compared to placebo, and were clinically meaningful as assessed over time. Donepezil hydrochloride appears to improve expressive and receptive language as well as overall autistic features, consistent with the hypothesis of acetylcholinergic enhancement

 Here is a more recent case study from India

Role of Donepezil in Autism: Its conduciveness in Psychopharmacotherapy

A woman consulted psychiatric Out-Patient Department (OPD) for her 5-year and 2-month-old son presenting with typical autistic symptoms like social, behavioural, and communicational ineptitudeness. Subsequent treatment with Donepezil resulted in marked improvement in the aforementioned symptomatology. Recent studies in autistic child have shown diminished acetylcholine and nicotinic receptor activity, thus an acetylcholinergic enhancer, Donepezil, likely accounts for improvement in autistic symptoms. Evidently, the case report consolidates Donepezil role as a potentially useful agent in the treatment of cognitive and behavioural symptoms observed in this disorder.

 Mecamylamine

There was a recent trial of Mecamylamine, with mixed results, but the researcher is already planning a follow trial of a similar drug called varenicline, that was previously suggested by other researchers.

Placebo-controlled pilot trial of mecamylamine for treatment of autism spectrum disorders.

RESULTS:

Eighteen participants (10 mecamylamine, 8 placebo) completed the study. All doses were well tolerated; the only side effect of note was constipation (50% compared with 25% of placebo group). Three children had clinically nonsignificant electrocardiographic QT prolongation. Both groups showed modest to moderate improvement, but differences between groups were negligible. On the primary outcome measure, the Ohio Autism Clinical Impressions Scale, 90% of the active treatment group showed improvement at some point (but only 40% sustained it), compared with 62% on placebo. Of the four in active treatment that sustained improvement, three had a maximum dose of 0.13-0.15 mg/kg/day, while those who regressed had doses ≥0.18 mg/kg/day. Graphed means suggested better outcome with lower mg/kg and longer medication duration. Four parents spontaneously reported reduced hyperactivity and irritability and better verbalization and continued mecamylamine at their own expense.

CONCLUSION:

Mecamylamine appeared to be safe, but not very effective in autism. The suggestion of better results at lower doses and longer exposure warrants consideration for future trials. The next step would be exploration of a more specific α4β2 nAChR agonist, such as varenicline.

Varenicline

Varenicline is a drug developed to help people to stop smoking.  It is widely used and looks set to be trialed in autism

Varenicline in Autistic Disorder: Hypothesis and Case Report of Single-Patient Crossover

Galantamine

Galantamine was successfully trialed and I am surprised we do not hear more about it.  In fact, it was developed in the Soviet Union in the 1950s and is now used for Alzheimer's.  It is based on snowdrop flowers.  It is available as a drug and as a supplement, depending on where you live.

A prospective, open-label trial of galantamine in autistic disorder.

RESULTS:

Patients showed a significant reduction in parent-rated irritability and social withdrawal on the ABC as well as significant improvements in emotional lability and inattention on the Conners' Parent Rating Scale--Revised. Similarly, clinician ratings showed reductions in the anger subscale of the Children's Psychiatric Rating Scale. Eight of 13 participants were rated as responders on the basis of their improvement scores on the Clinical Global Impressions scale. Overall, galantamine was well-tolerated, with no significant adverse effects apart from headaches in one patient.

CONCLUSION:

In this open trial, galantamine was well-tolerated and appeared to be beneficial for the treatment of interfering behaviors in children with autism, particularly aggression, behavioral dyscontrol, and inattention. Further controlled trials are warranted

The missing evidence

You will have noticed caffeine and nicotine in the title of this post.  You may have noted that back in 2001/2 the original researchers suggested the logical next step was to trial nicotine patches.

All I can find is one case report in ADHD, which to me is just ASD-lite.

Transdermal Nicotine in Adult ADHD With Depression and Anxiety

If you look in internet forums you will see that DAN doctors in the US are using nicotine patches.  You will also find people giving small doses of caffeine.

Having reviewed “the evidence” I think it is entirely logical to trial SMALL doses of nicotine and caffeine.  The research indeed tells us that only SMALL does may have the desired effect.

One report I read was a DAN Doctor giving her own child a quarter of 7mg nicotine patch.  By my research, that equals the nicotine of a single cigarette.

You will also see older kids with HFA (high functioning autism) writing on the web how they feel it easier to (pretend to) be more NT (neuro-typical) after drinking coffee and/or smoking. (Maybe they just look more NT, or maybe there is some truth in it).  They do not talk about alcohol.

The other “obvious” thing that has not been trialed is acetylcholine or choline itself.  It is known to be deficient in autism.  It is sometimes included in multivitamin pills in small amounts. Choline is widely available as a supplement.  It is also used for its nootropic properties and there are claims it reduces neuroinflammation.  It is used in depression, memory loss, Alzheimer’s and schizophrenia  It also lower cholesterol. Most surprisingly, choline is prescribed to control asthma, a comorbidity of ASD.  

Choline is used by people trying to boost their brainpower by combining it with other nootropic drugs.  Their favourite drug appear to be Piracetam, which is the same drug used for ASD in Ukraine and subject of a clinical trial in Iran, that I wrote about recently.

It is remarkable how many drugs I am writing about are either (ab)used by body builders or now IQ builders.

Conclusion

This post has really surprised me.  Firstly, there more drugs that look like they actually do work in autism (Donepezil and Galantamine).  There is an interesting phase 4 trial underway using Donepzil + Choline. Phase 4 is the final phase.

Nicotine may set alarm bells ringing, but if you check it out, you will see that very small amounts are apparently harmless.  Thanks to smokers, there exists a perfect transdermal delivery system.  Just why nobody trials it in autism (Glaxo produce Nicorette patches) is inexplicable.

Small amounts of coffee are given to even young children in many strong coffee drinking countries (like the Balkans). Coca Cola and even Ice Tea are caffeine-rich.

Choline is probably the simplest, cheapest and safest intervention;  but that does not mean it is will be effective.  Nobody has made a controlled trial with it, probably because there is no money in it.

For a change in my posts, it looks like there is something for everyone.