Treated ID and CBS/DYRK1A in Autism and Down Syndrome

One of the most interesting concepts I have come across writing this blog is the idea of treating people with mental retardation (MR) / intellectual disability (ID). I do keep using the term MR, because 90% of the world has no idea what ID means. MR is a very precise description, which is increasingly rare these days.

I still recall several years ago going to a French-speaking neighbour’s barbecue. The French are generally very family-oriented, but quite traditional when it comes to parenting, (hence their low rates of ADHD diagnosis). At that time, Monty aged around 8, could act strangely and was rather obsessed with fire, matches and cigarette lighters. Our neighbour introduced us to his French friends and explained Monty with a brief use of the word “retardé”, which did not prompt any comments or requests for clarification. In the English language this might have been regarded as a big faux-pas; it did not bother me.  It seemed to work very well to forewarn people not to over-react to any unexpected behaviours. 

In the English language, autism has become a nice word and seems the new ADHD, with people even wanting to be diagnosed with it.  MR/ID is still something reserved for other people; it is not something most people want to be associated with. I do use the term cognitive dysfunction, which is just as explicit as MR but does not seem to upset people.

Cognitive dysfunction (MR/ID) is an inevitable consequence of more severe autism and it is just a question of degree. It is not a comorbidity, it is all part of the same package.

In Down Syndrome (DS) IQ is usually between 45 and 71 and worsens with age. MR/ID is defined as an IQ less than 70 and accounts for 2.3% of the general population. An IQ of 100 would put you in the middle of the IQ bell curve. People with DS tend to be very happy and contented, without the problematic behaviors that can occur in autism. 

The good news is that cognitive dysfunction (MR/ID) is likely to be treatable, as some readers of this blog have discovered. You just need to figure out how, which in itself is more about your perseverance than your IQ. You do not need to be an Einstein (IQ > 160), rather a marathon runner.

I just had the uncanny experience at school during the parent-teacher meetings, to be told that other class members could learn from my younger son Monty, aged 14 with autism; that he has the neatest handwriting in class, his essay had the best structure and that when his geography teacher told his assistant to skip the final question in the test (using longitude and latitude) because it was hard, the assistant said just let him try it; he was the only one to get it right. 

So from aged 8 to 14 he has gone from “retardé” to being something quite different.  The teachers do love his assistants, who are great; but he has had an assistant from the age of 4 and back then things moved forward extremely slowly. He learnt to read and write the very hard way, with a vast amount of 1:1 instruction and the school was amazed when his then assistant taught him to read; I don’t think they expected it ever to happen. By treating cognitive dysfunction pharmacologically for five years normal learning became possible and remains a big surprise to everyone.  His new English teacher knows him from back in the darker old days and seemed more shocked than surprised, after a month of teaching him. "Is this the same boy?"

For the first time at school I am being told to be proud of my younger son’s academic achievements, rather than how talented my older son is. Big brother certainly did not expect such a day and his response was along the lines of “well the others in his class must be really thick then” (like it or not, this is a typical teenage male comment). Little brother still has autism, but it is much less disabling. Big brother is currently teaching him to fence (sword fighting), which he would not have bothered to try doing until recently, because it would not have ended well. Years ago Monty did learn to ski, play basketball and soccer, but that all took a lot of effort with very patient (mostly female) instruction; he initially had no idea what to do if a ball was rolled towards him.  Last week he happily sat through the new Blade Runner film, which is nearly three hours long with the trailers. 

Perhaps there is no need for further “breakthroughs” with my Polypill therapy.  It may be good enough already.

It just seems a pity that more people with cognitive dysfunctions are not treated. There are some extremely intelligent parents with children who have severe autism, indeed an ironic twist of genetics. Some even write autism research, or indeed fund it. Even these people are not treating it.   Their fear of quackery blinds them. There certainly are quacks and there are also those who straddle the line, some of what they say is nonsense, but other ideas may not be.

Imagine having a conversation with Bill Gates, who is using his billions to use vaccines to save millions of lives in poor countries, about the possibility that in some people vaccines might trigger mitochondrial disease and autism.  Any organization talking about autism in relation to vaccines, chelation, aluminium, heavy metals etc and anyone who associates with them are in effect blacklisted.

Why does the global head of neuroscience at Novartis not attend the Autism One or TACA conferences? He does have a son with severe autism. It would be very difficult for him to apply any therapy promoted by anyone who attends these events.

Why does a Professor of Medicine from the US Ivy League apply ideas from this blog to his son, but never leave a comment? It is very clear to me why.

As our reader Roger has commented, why do some leading autism researchers still go on about vaccines? It does their interests much more harm than good. 

I think Roger could teach Dr Naviaux a thing or two about getting his Suramin research funded.  

Enhancing Cognition

The first area I came across where serious research is underway to treat MR/ID concerns RASopathies, a group of disorders that share disturbed levels of a protein called RAS. It was actually French research.

In Down Syndrome (DS) I highlighted research that aims to increase cognitive function by targeting the alpha 5 subunit of the GABA_A receptor. We also saw that the same abnormal level of chloride within in cells that exists in much autism also occurs in Down Syndrome (DS); this is why the Frenchman Ben Ari has patented Bumetanide as a therapy for DS. 

In schizophrenia and bipolar there is also reduced cognitive function, but only in schizophrenia has there been much research and clinical trials to improve it. Histamine receptors were one target of this research. 

Too much or too little CBS (Cystathionine-β-synthase )

One known cause of cognitive dysfunction that has not been mentioned in my posts is CBS and since it was raised in a comment I thought it should be included.

All you need to know if you want to rule out a CBS problem is your level of homocysteine. If it is normal you do not have a problem with CBS. If homocysteine is high you have a case of Hyper-homocystinuria, which may be caused by too little CBS, or for a different reason. If you have very low levels of homocysteine (Hypo-homocystinuria) that may be caused by too much CBS and if you have Down Syndrome elevated CBS is inevitable.

Normalizing CBS is very likely to help cognition.

Cystathionine-β-synthase, also known as CBS, is an enzyme that in humans is encoded by the CBS gene. It catalyzes the first step of the transsulfuration pathway, from homocysteine to cystathionine:

L-serine + L-homocysteine    <------>     L-cystathionine + H₂O

Down syndrome is a medical condition characterized by an overexpression of cystathionine beta synthase (CBS) and so a low level of homocysteine in the blood. It has been speculated that cystathionine beta synthase overexpression could be the major culprit in this disease (along with dysfunctioning of GABA_A and Dyrk1a). The phenotype of down syndrome is the opposite of Hyperhomocysteinemia (described below). Pharmacological inhibitors of CBS have been patented by the Jerome Lejeune Foundation and trials are planned.

Cystathionine beta-synthase is enriched in the brains of Down's patients.

Down's syndrome (DS) or trisomy 21 is the most common genetic cause of mental retardation, and adults with DS develop Alzheimer type of disease (AD). Cystathionine beta-synthase (CBS) is encoded on chromosome 21 and deficiency in its activity causes homocystinuria, the most common inborn error of sulfur amino acid metabolism and characterized by mental retardation and vascular disease. Here, we show that the levels of CBS in DS brains are approximately three times greater than those in the normal individuals. CBS is localized to astrocytes and those surrounding senile plaques in the brains of DS patients with AD. The over-expression of CBS may cause the developmental abnormality in cognition in DS children and that may lead to AD in DS

It is a French foundation that is funding research is develop CBS inhibitors to improve cognition in Down Syndrome.

NovAliX To Collaborate With The Fondation Jérôme Lejeune On Down Syndrome (Trisomy 21)

NovAliX will use its expertise and capabilities in medicinal chemistry and structural biology to develop small molecule lead candidates targeting the cystathionine-beta-synthase (CBS). Indeed inhibition of CBS over-expression has been associated with restoration of cognitive impairment in animal models afflicted with trisomy. 

People with DS have a low incidence of coronary atherosclerotic disease (CAD), which would seem to be linked to their low level of homocysteine (high CBS), but their high level of DYRK1A (see later) may be the cause of their early onset Alzheimer’s. 

Some background on homocystinuria, courtesy of Wikipedia:- 

Classical homocystinuria, also known as cystathionine beta synthase deficiency or CBS deficiency, is an inherited disorder of the metabolism of the amino acid methionine, often involving cystathionine beta synthase.

Homocystinuria represents a group of hereditary metabolic disorders characterized by an accumulation of the amino acid homocysteine in the serum and an increased excretion of homocysteine in the urine.

Signs and symptoms of homocystinuria that may be seen include the following:

• A family history of homocystinuria
• Flush across the cheeks
• Musculoskeletal
• Tall, thin build resembling Marfanoid habitus
• Long limbs (dolichostenomelia)
• High-arched feet (pes cavus)
• Knock knees (genu valgum)
• Pectus excavatum and Pectus carinatum
• Intellectual disability
• Seizures
• Psychiatric disease

The term homocystinuria describes an increased excretion of homocysteine in urine (and incidentally, also an increased concentration in plasma). The source of this increase may be one of many metabolic factors, only one of which is CBS deficiency. Others include the re-methylation defects (cobalamin defects, methionine sythase deficiency, MTHFR) and vitamin deficiencies (cobalamin (vitamin B12) deficiency, folate (vitamin B9) deficiency, riboflavin deficiency (vitamin B2), pyridoxal phosphate deficiency (vitamin B6)). In light of this information, a combined approach to laboratory diagnosis is required to reach a differential diagnosis.  

DYRK1A

You may have noticed that DYRK1A was mentioned as another cause of cognitive loss in Down Syndrome.  DYRK1A is yet another autism gene; it encodes an enzyme that is important in how the brain develops. Too much DYRK1A also leads to reduced levels of homocysteine. 

An OTC DYRK1A inhibitor exists today, epigallocatechin gallate (EGCG).

Targeting trisomic treatments: optimizing Dyrk1a inhibition to improve Down syndrome deficits

A chemical with proven clinical safety rescues Down-syndrome-related phenotypes in through DYRK1A inhibition.

DYRK1A is important in neuronal development and function, and its excessive activity is considered a significant pathogenic factor in Down syndrome and Alzheimer's disease. Thus, inhibition of DYRK1A has been suggested to be a new strategy to modify the disease. Very few compounds, however, have been reported to act as inhibitors, and their potential clinical uses require further evaluation. Here, we newly identify CX-4945, the safety of which has been already proven in the clinical setting, as a potent inhibitor of DYRK1A that acts in an ATP-competitive manner. The inhibitory potency of CX-4945 on DYRK1A (IC50=6.8 nM) in vitro was higher than that of harmine, INDY or proINDY, which are well-known potent inhibitors of DYRK1A. CX-4945 effectively reverses the aberrant phosphorylation of Tau, amyloid precursor protein (APP) and presenilin 1 (PS1) in mammalian cells. To our surprise, feeding with CX-4945 significantly restored the neurological and phenotypic defects induced by the overexpression of minibrain, an ortholog of human DYRK1A, in the Drosophila model. Moreover, oral administration of CX-4945 acutely suppressed Tau hyperphosphorylation in the hippocampus of DYRK1A-overexpressing mice. Our research results demonstrate that CX-4945 is a potent DYRK1A inhibitor and also suggest that it has therapeutic potential for DYRK1A-associated diseases

Epigallocatechin gallate: A useful therapy for cognitive disability in Down syndrome?

Neurodevelopmental alterations and cognitive disability are constant features of Down syndrome (DS), a genetic condition due to triplication of chromosome 21. DYRK1A is one of the triplicated genes that is thought to be strongly involved in brain alterations. Treatment of Dyrk1A transgenic mice with epigallocatechin gallate (EGCG), an inhibitor of DYRK1A, improves cognitive performance, suggesting that EGCG may represent a suitable treatment of DS. Evidence in the Ts65Dn mouse model of DS shows that EGCG restores hippocampal development, although this effect is ephemeral. Other studies, however, show no effects of treatment on hippocampus-dependent memory. On the other hand, a pilot study in young adults with DS shows that EGCG transiently improves some aspects of memory. Interestingly, EGCG plus cognitive training engenders effects that are more prolonged. Studies in various rodent models show a positive impact of EGCG on brain and behavior, but other studies show no effect. In spite of these discrepancies, possibly due to heterogeneity of protocols/timing/species, EGCG seems to exert some beneficial effects on the brain. It is possible that protocols of periodic EGCG administration to individuals with DS (alone or in conjunction with other treatments) may prevent the disappearance of its effects.

Conclusion

Understanding emerging therapies that treat various types of MR/ID, and also the various types of dementia, should unlock interesting avenues to raise cognitive function in many types of autism.

Homocysteine levels are very easy to measure. 

Because the gene miss-expression in Down Syndrome (DS) is fully understood, it makes sense that treatment is more advanced than in autism, which is so heterogenous. There are a lot of people in the world with DS and so there is a big market for drug makers.

The potential drug therapies to improve cognition in Down Syndrome (DS) appear to be:- 

·        Basmisanil, a negative allosteric modulator of α₅ subunit-containing GABA_A receptors. It appears that sodium benzoate may have a similar effect.

·        Bumetanide, an NKCC1 inhibitor

·        Potassium bromide, Br^- displaces Cl^- to lower intracellular Cl^-

·        CBS inhibitor

·        DYRK1A inhibitor, like Epigallocatechin gallate (EGCG), but a more potent inhibitor like CX-4945 (Silmitasertib) might be better.

There is mouse model research to show that a single dose just after birth of a drug that stimulates the sonic hedgehog signaling pathway results in a "normal" adult brain.

The risk of Down Syndrome (DS), caused by a third copy of chromosome 21 (trisomy 21), rises rapidly with increasing maternal age, nonetheless the number of births is stable to falling in most developed countries, due to increased prenatal testing and termination of pregnancy for fetal anomaly (TOPFA). TOPFA is not practiced in countries like Poland and Ireland. In Denmark screening has long been free and TOPFA has risen to 98%. In the UK two thirds of mothers opt for their free DS screening and 90% of those who test positive, opt for their free TOPFA. The one third letting nature take its course are probably mainly younger mothers.

In Catholic countries you have both extremes - in Cork, Ireland DS is present 30 times per 10,000 births, but in Zagreb Croatia it is just 6 per 10,000. In the US the CDC say it 14, while in the UK it is 10.  In South Africa 20 cases of DS occur per 10,000 births; mothers are younger than in Ireland.

In developed countries, the natural prevalence of DS looks to be 0.3%, which is the same as the incidence of strictly defined autism (SDA), which I estimated in an earlier post to be 0.3%. It is just that in developed countries most people with DS are never born. 

I would have thought CX-4945 should be trialed by some clever Alzheimer's researcher and indeed for any Tauopathy. In the meantime perhaps Grandad should drink a lot of green tea to get his dose of EGCG.

Unstable Blood Flow in Autistic Brains?

Source: https://images.nature.com/full/nature-assets/nrd/journal/v15/n6/images/nrd.2015.17-f2.jpg

Today’s post is complicated, but may be of interest to those people interested in Nitric Oxide therapies (Agmatine, Cocoa Flavanols, Beetroot, Taurine, Citrulline etc) and those who think they are treating earlier hypoxia/ischemia.

As usual, I am making simplifications, but the science behind the general ideas already exists. When it comes to the details regarding VEGF and autism, there are big gaps in the science. 

We have already seen that something as simple as improving blood flow appears to be therapeutic in some people with autism. Perhaps there should even be a post called “cold feet and autism”. 

One reader of this blog, Seth, has commented before that he sees autism as essentially vascular in nature.  Today’s research suggests it does indeed include microvascular abnormalities.

Rather than simply reduced blood flow, the problem, in at least some autism, appears to be unstable blood flow, which is much more complex.

I do take a leap in logic to suggest that this is likely linked to the known abnormalities in Vascular Endothelial Growth Factor (VEGF) and in VEGF receptor 1 (VEGFR-1).  It also appears that the VEGF anomalies that lead to angiogenesis may be part of the reason for the increased prevalence of chronic inflammatory diseases including asthma, atopic dermatitis, psoriasis, and rheumatoid arthritis.

Ideally you might want to normalize VEGF, even later in life. The use of anti-angiogenic drugs has been suggested.  Angiogenesis inhibitors were once seen as potential wonder drugs to treat cancer.

It does seem that just simply targeting vascular resistance is helpful for some people with autism.   

VEGF is regulated by many things, some are highly complex and are usually studied with regard to cancer, like Wnt signaling and Ras. Recall that both Wnt and Ras are relevant to autism. One simple thing that influences VEGF is nitric oxide (NO), but it is not a simple relationship. As highlighted by our reader Tyler, intermittent fasting (IF) can also be used to increase VEGF. Research suggests that intermittent fasting (IF) is actually a simple but potent tool to both prevent and treat metabolic disorders, including but not limited to type 2 diabetes.

Intermittent fasting promotes adipose thermogenesis and metabolic homeostasis via VEGF-mediated alternative activation of macrophage

In the case of autism, where both VEGF and NO are likely to be low, it does seem quite likely that by increasing the production of NO you will increase the expression of VEGF. So the amino acid L-citrulline is likely to increase VEGF.

In the rat study below, L-citrulline increased eNOS and VEGF; we presume NO also increased. 

L-citrulline Prevents Alveolar and Vascular Derangement in a Rat Model of Moderate Hyperoxia-induced Lung Injury

Blood Flow in Autistic Brains

Now we get to the autism-specific research.

Evidence of Unstable Blood Flow in Autistic Brains

A team of scientists has found evidence that people with autism have unstable vessels in the brain which prevents the proper delivery of blood flow, according to research published in the Journal of Autism and Developmental Disorders. 

“In a typical brain, blood vessels are stable, thereby ensuring a stable distribution of blood,” said Patricia Whitaker-Azmitia, PhD, professor in the Department of Psychology and director of the Graduate Program in Integrative Neurosciences at Stony Brook University, N.Y.,  in a statement. “Whereas in the autism brain, the cellular structure of blood vessels continually fluctuates, which results in circulation that is fluctuating and, ultimately, neurologically limiting.”

Blood vessels may grow unchecked in autism

Persistent Angiogenesis in the Autism Brain: An Immunocytochemical Study of Postmortem Cortex, Brainstem and Cerebellum.

Sustained angiogenesis may contribute to prolonged neuroplasticity in the ASD brain. We propose the sustained splitting angiogenesis is a necessary component to maintain the heightened neuronal activity reported in ASD patients. Many biological and functional indicators are increased in ASD including cerebral metabolic rate, regional synchronous electrical activity sensitivity to sound; cortical activity in deactivation centers at rest, low-level visuospatial processing, visual-tactile interactions; attention to low-level perceptual information and over-connected, redundant cortical networks. It can be suggested that sustained rearrangement of microvasculature permits excessive shorter and local connections to be maintained and prevents the growth of longer and more complex brain connections required for language and social interactions. Use of anti-angiogenic drugs may provide a novel treatment strategy for reducing neuronal activity in ASD patients by inhibiting vascular plasticity.

Brain tissue from children (left) and adults (right) with autism (top) but not controls (bottom) shows dividing cells lining blood vessels.

Angiogenesis and Lymphangiogenesis

It looks like, at least in today’s subgroup of autism, we want less angiogenesis but more lymphangiogenesis.  The ideal way to do this is via VEGF/VEGFRs.

Here it may be helpful to explain the meaning of some new terminology.

“Angiogenesis is the physiological process through which new blood vessels form from pre-existing vessels

Angiogenesis is a normal and vital process in growth and development, as well as in wound healing and in the formation of granulation tissue. However, it is also a fundamental step in the transition of tumors from a benign state to a malignant one, leading to the use of angiogenesis inhibitors in the treatment of cancer.”

“Lymphangiogenesis is the formation of lymphatic vessels from pre-existing lymphatic vessels in a method believed to be similar to angiogenesis (blood vessel development).

Lymphangiogenesis plays an important physiological role in homeostasis, metabolism and immunity. Impaired or excessive lymphatic vessel formation has been implicated in a number of pathological conditions including neoplasm metastasis, oedema, rheumatoid arthritis, psoriasis, lymphangiomatosis and impaired wound healing.”

Lymphatic system and the Brain 

As highlighted recently by our reader Tanya, a pretty basic gap in science’s understanding of how the brain works has just been addressed. It is all about where do the waste products produced in the brain go to.

Scientists have found evidence that the brain is connected to body’s central lymphatic system.

This then begs the question of what happens when this system does not work well. Is this a feature of some neurological disease? If that were the case, it would likely be associated with reduced lymphangiogenesis.

Scientists Have Finally Discovered Proof That Our Brains Have a Waste Drainage System

Running through your body is a network of channels and junctions called the lymphatic system, which siphons off waste and fluids like a biological sewer.

It was long thought the brain was excluded from this web of anatomical plumbing. After being spotted in mice brains two years ago, researchers have now confirmed the presence of lymphatic vessels in human brains, fueling speculation over the kinds of diseases they might be responsible for.

Human and nonhuman primate meninges harbor lymphatic vessels that can be visualized noninvasively by MRI

VEGF and VEGF receptors 

There are four types of VEGF and they act through three types of receptors. Confusingly, the receptors have been given multiple names.

In severe autism there is reduced VEGF, but we do not know which type(s) but there is increased expression of the receptor  VEGFR-1 also known as Flt-1. VEGFR-2 expression is normal, this is the best understood receptor.

This receptor VEGFR-1 is activated by VEGF-A and VEGF-B.  

Serum levels of vascular endothelial growth factor and its receptors in patients with severe autism

Objective:

To study vascular endothelial growth factor (VEGF) and its soluble receptors sVEGFR-1 and -2 in autism.

Design and methods:

We measured serum levels of angiogenic molecules in 22 patients with severe autism and 28 controls.

Results:

Patients and controls had similar sVEGFR-2 levels, but VEGF levels were lower and sVEGFR-1 higher in patients with autism.

Conclusion:

The imbalance between VEGF and its receptor sVEGFR-1 may be involved in the pathophysiology of autism.

Hypoxia related autism 

It is well known that hypoxia-ischemia insults early in life can cause cognitive dysfunction and likely autism.  In the very recent paper below, it is suggested that altered VEGF signaling is the mechanism that causes the damage to the brain. 

Vascular Endothelial Growth Factor (VEGF) in Neurodevelopmental Disorders

Neurovascular dysfunction and the role of vascular endothelial growth factor (VEGF) have been explored in neurodevelopmental disorders including schizophrenia, bipolar disorder, major depressive and mood disorders, and autism. These disorders are correlated with hypoxia-ischemia insults during early life and are strongly associated with cognitive dysfunction. This review focuses on the hypoxia-regulated protein, VEGF, to discuss its crucial roles in brain development and function. These data implicate that alterations to VEGF signaling during early life can impair neural development, underlying the severe cognitive deficits observed in neurodevelopmental disorders.

Recent Findings

VEGF has been linked to neurological processes that influence learning and memory. VEGF is advancing towards being a novel biomarker and possible therapeutic for neurological disorders. Prenatal environmental enrichment positively impacted neurotrophic factors, brain structure, and memory in rodent models.

Summary

Understanding the molecular mechanisms of VEGF in neurodevelopment will create intervention strategies for at-risk children born to adverse early-life events. By proactively working with those in a pliable neurodevelopmental state, we hope to ameliorate cognitive deficits to increase their chance to develop into high-functioning adults with disabilities. 

Hypoxia-Induced Angiogenesis - Good and Evil

Hypoxia promotes vessel growth by upregulating multiple pro-angiogenic pathways that mediate key aspects of endothelial, stromal, and vascular support cell biology. Interestingly, recent studies show that hypoxia influences additional aspects of angiogenesis, including vessel patterning, maturation, and function.

VEGF, considered a master regulator of angiogenesis in its own right, causes endothelial cells to detach from the parent vessel and migrate into the neighboring stroma. Hypoxia is the principal regulator of VEGF expression, as it is a direct transcriptional target of both HIF-1α and HIF-2α.

Allergy and inflammation resulting from angiogenesis 

It appears that in some people another consequence of too much angiogenesis is allergy and other inflammatory disease; these are of course often comorbid with autism.  This suggests anti-angiogenic and pro-lymphangiogenic therapies.

An Important Role of Blood and Lymphatic Vessels in Inflammation and Allergy

Angiogenesis and lymphangiogenesis, the growth of new vessels from preexisting ones, have received increasing interest due to their role in tumor growth and metastatic spread. However, vascular remodeling, associated with vascular hyperpermeability, is also a key feature of many chronic inflammatory diseases including asthma, atopic dermatitis, psoriasis, and rheumatoid arthritis. The major drivers of angiogenesis and lymphangiogenesis are vascular endothelial growth factor- (VEGF-)A and VEGF-C, activating specific VEGF receptors on the lymphatic and blood vascular endothelium. Recent experimental studies found potent anti-inflammatory responses after targeted inhibition of activated blood vessels in models of chronic inflammatory diseases. Importantly, our recent results indicate that specific activation of lymphatic vessels reduces both acute and chronic skin inflammation. Thus, antiangiogenic and prolymphangiogenic therapies might represent a new approach to treat chronic inflammatory disorders, including those due to chronic allergic inflammation.

Figure 1: VEGF-binding properties and distinct VEGF receptor expression on lymphatic and blood vascular endothelium. VEGFs bind to the three VEGF receptor tyrosine kinases, leading to the formation of VEGFR dimers. Blood vascular endothelial cells express VEGFR-1 and VEGFR-2, whereas lymphatic endothelial cells express VEGFR-2 and VEGFR-3. VEGF-A—which binds both VEGFR-1 and VEGFR-2—can directly induce blood and lymphatic vascular remodeling. VEGF-C and -D bind VEGFR-3 and, after proteolytic processing, also VEGFR-2, thus inducing angiogenesis and lymphangiogenesis.

There is clear evidence that in humans, vascular remodeling occurs in many chronic inflammatory disorders. Even though different anti-inflammatory drugs are on the market, there is no specific therapy that interferes with the pathological vascular changes that occur during inflammation. Angiogenesis and lymphangiogenesis are tightly linked to chronic inflammation, and targeting the blood vessels and lymphatic vessels has been shown to be an effective strategy in different experimental mouse models of chronic inflammation. One has to keep in mind, however, that in most conditions the vascular activation likely represents a downstream event that maintains the inflammatory process, but not the pathogenetic cause of the respective disease, which often has remained unknown. Nonetheless, antiangiogenic and prolymphangiogenic therapies might represent new approaches to treat chronic inflammatory disorders, including those due to chronic allergic inflammation.

Conclusion

I did start this post by saying this subject is complicated.

From the previous post on nitric oxide, it looked like L-citrulline, L-norvaline, Agmatine and other NO increasing substances could be therapeutic. Cold hands and feet seem to be very common in autism.

It seems likely that the NO increasing therapies will likely also increase VEGF, which I think is a good thing.

From today’s post we see that rather than just a single VEGF we have five broad types (A,B,C, D and PIGF), but even just VEGF-A has various different forms. We do not have detailed research on autism and specific subtypes of VEGF. 

We have the four different VEGF receptors and we know VEGFR-1 is over expressed. We do not have a clever way to counter this. More VEGFR-3 expression would be helpful and that is again a case of changing the balance between inflammatory cytokines, which as we know is usually disturbed in autism.

The inflammatory cytokine IL-6 induces VEGF-C production which leads to both angiogenesis and lymphangiogenesis; this is why people with cancer and high IL-6 may have a poor prognosis.

Regarding VEGF and autism we clearly lack 95% of the science. Strange things are afoot and we are just guessing.

For the time being, I see increasing vascular permeability via eNOS as therapeutic, even though today’s post suggests that antiangiogenic therapies could be helpful, which may seem contradictory.

The kind of drugs that would reduce the activity of VEGFR-1/Flt-1 would be very expensive cancer drugs.  Hypoxia also downregulates VEGFR-1/Flt-1.

Inflammatory cytokines regulate VEGFR-3/Flt-4 and hence control of lymphangiogenesis.  Interferon gamma (IFNγ) upregulates VEGFR-3/Flt-4, while Interleukin 1 beta (IL1β) down regulates it. 

So more IFNγ and less IL1β might help.

Although expensive, interferon gamma (IFNγ) has been shown to be effective in treating severe atopic dermatitis. This would make sense since it induces lymphangiogenesis and the research suggests this should improve inflammatory disease.

Inflammatory Cytokines Regulate VEGFR-3/Flt-4 Expression in Lymphatic Endothelial Cells

Long-term therapy with recombinant interferon-gamma (rIFN-gamma) for atopic dermatitis.

CONCLUSIONS:

We conclude that rIFN-gamma appears to be a safe long-term therapy for patients with severe atopic dermatitis.

So perhaps interferon-gamma (IFNγ) for some autism? Quite possibly, just look for the ones with asthma, atopic dermatitis, psoriasis or juvenile arthritis.

Nitric Oxide (NO), Arginase and Endothelial Dysfunction in Autism

Endothelial dysfunction is not something people associate with autism. It is something I have covered previously in this blog and if you search on Google my post is about all you will find.

Endothelial dysfunction is acknowledged to be very important in diabetes, which is characterized by ROS (reactive oxygen species), reduced NO (nitric oxide) , reduced eNOS (endothelial nitric oxide synthase) and too much Arginase. There is also Peroxynitrite (ONOO⁻), an ion we have encountered before.

In autism we do already know from the research that VEGF (Vascular endothelial growth factor) is disturbed and there will be a post on that.

So when you put it all this together, it is odd that nobody has researched endothelial dysfunction and autism.  When I find something like this, my fallback is always schizophrenia. What about Endothelial Dysfunction and Schizophrenia? Sure enough, there is plenty of research on the subject, like this paper.

Microvascular dysfunction in schizophrenia: a case–control study

We tested the hypothesis that subjects with schizophrenia have impaired endothelial function.

Our findings suggest that a diagnosis of schizophrenia is associated with impaired microvascular function as indicated by lower values of VTI, irrespective of many other clinical characteristics. It might be an early indicator of cardiovascular risk in schizophrenia, and might help to identify high-risk individuals.

Endothelial Dysfunction does ultimately cause all kinds of problems in later life.  What is relevant to this blog is the potential neurological benefit of improving endothelial function in younger people, if any.

We need to recall that historically there have been very few older people with more severe autism; they did not live to the age when typical problems caused by endothelial dysfunction become apparent. 

Overlapping causes of Endothelial Dysfunction

The interesting question is just how many of the possible causes of endothelial dysfunction occur in autism. 

So far the following factors seem to apply to autism:-

·        Oxidative stress (ROS)

·        Reduced eNOS and nitic oxide (NO)    

·         VEGF (Vascular endothelial growth factor) is disturbed

·         Even estrogen deficiency can play a role and this is reduced in autism

People with autism who use calcium folinate (Leucoverin) are already quenching  Peroxynitrite (ONOO⁻) another factor in Endothelial Dysfunction.                                                               

Is Arginine/Arginase disturbed in Autism?

One well known anomaly in diabetes is a high level of an enzyme called Arginase, resulting in reduced production of nitric oxide (NO) in endothelial cells.

Here again we have to revert to looking at schizophrenia, as the closest thing to autism. Here there are no surprises. 

Altered brain arginine metabolism in schizophrenia.

Previous research implicates altered metabolism of l-arginine, a versatile amino acid with a number of bioactive metabolites, in the pathogenesis of schizophrenia. The present study, for we believe the first time, systematically compared the metabolic profile of l-arginine in the frontal cortex (Brodmann's area 8) obtained post-mortem from schizophrenic individuals and age- and gender-matched non-psychiatric controls (n=20 per group). The enzyme assays revealed no change in total nitric oxide synthase (NOS) activity, but significantly increased arginase activity in the schizophrenia group. Western blot showed reduced endothelial NOS protein expression and increased arginase II protein level in the disease group. High-performance liquid chromatography and liquid chromatography/mass spectrometric assays confirmed significantly reduced levels of γ-aminobutyric acid (GABA), but increased agmatine concentration and glutamate/GABA ratio in the schizophrenia cases. Regression analysis indicated positive correlations between arginase activity and the age of disease onset and between l-ornithine level and the duration of illness. Moreover, cluster analyses revealed that l-arginine and its main metabolites l-citrulline, l-ornithine and agmatine formed distinct groups, which were altered in the schizophrenia group. The present study provides further evidence of altered brain arginine metabolism in schizophrenia, which enhances our understanding of the pathogenesis of schizophrenia and may lead to the future development of novel preventions and/or therapeutics for the disease

Arginine metabolic pathways. l-arginine can be metabolized by NOS, arginase and ADC to form a number of bioactive molecules (see the Introduction for detailed description). We found increased levels of arginase activity, arginase II protein expression and agmatine tissue concentration (indicated by the red letters and arrows), and reduced eNOS protein expression and GABA level (indicated by the green letters and arrows) in the schizophrenia cases. ADC, arginine decarboxylase; BA8, Brodmann's area 8; eNOS, endothelial NOS; GABA, γ-aminobutyric acid; iNOS, inducible NOS; NO, nitric oxide; NOS, nitric oxide synthase; nNOS, neuronal NOS.  

It is of interest to note that the plasma agmatine level was increased over threefold in schizophrenic patients relative to healthy controls

The present study, interestingly, found an over 50% increase in arginase activity in BA8 accompanied by a significant upregulation of arginase II in the schizophrenia group. It is currently unclear how arginase changes in blood correlate with those in the brain tissue

Polyamines and agmatine have also been implicated in psychiatric disorders

L-Norvaline for Aspie1983?

One reader has raised issue of whether L-Norvaline would be a good idea.

L-Norvaline is an arginase inhibitor, used by body builders to increase nitric oxide.

L-arginine is used as a substrate by both nitric oxide synthase (NOS) and arginase to produce nitric oxide (NO) and urea, respectively.

If you inhibit arginase you shift the L-arginine over towards nitric oxide production.

People with diabetes and, as we saw above schizophrenia, have elevated levels of arginase. This will cause them to have a reduced level of nitric oxide. Reduced nitric oxide will contribute to Endothelial Dysfunction.

So it looks like L-Norvaline might well be beneficial in diabetes and schizophrenia.

L-Norvaline  might slow the conversion of ammonia to urea, if arginase was low to start with.  If arginase was elevated to start with you might expect no impact on the conversion of ammonia to urea.

Agmatine, Polyamines & L-citrulline 

Agmatine may already be elevated in schizophrenia, but it looks like a little extra can be beneficial in autism.

Polyamines can also be good for you if they increase autophagy. Which specific polyamine you want is an open question.

In the schizophrenia study L-citrulline is reduced. This makes sense because L-arginine has been shifted over towards  urea by elevated arginase. L-citrulline is a byproduct when nitric oxide (NO) is produced.

Perhaps unexpectedly, l-Citrulline is also a potent endogenous precursor of l-arginine. In a recent clinical study, l-citrulline supplementation dose-dependently increases plasma l-arginine levels in healthy human volunteers more effectively than equivalent doses of l-arginine itself.

Aspie1983 might not need to supplement L-citrulline, if he used L-Norvaline .

Altered brain arginine metabolism in autism?

I suspect Aspie1983 is not the only one with an altered brain arginine metabolism.

There appear to be many therapeutic options and they are all body building supplements because they will all increase nitric oxide (NO).

They will all improve Endothelial Dysfunction, which was the original subject of this post.

Conclusion

It certainly seems like Endothelial Dysfunction is present in some autism and that numerous established therapies should help.

We are already targeting oxidative stress with antioxidants and some people use calcium folinate that will target nitrosative stress.

The therapies that increase NO and/or eNOS include:-

·        Agmatine

·        L-arginine

·        L-citrulline

·        L- norvaline

·        Cocoa flavanols

·        Beetroot juice

·        L-taurine does increase eNOS and NO, but it is not clear how

There are products sold to body builders that include several of these and some clever additional ones.

Like this one, 12 grams made up of:-

1.   L-Citrulline

2.   L-Taurine

3.   Agmatine Sulfate 

4.   Glycerol Monostearate

5.   Dan-Shen, a Chinese cardio-protective herb that increases NO and also behaves like low dose aspirin

6.   Beetroot Powder

7.   L-Norvaline

8.   Hesperidin, a citrus flavonoid that increases NO

9.   Black pepper extract; piperine is known to affect NO release

Dan-Shen :- there are numerous clinical trials on Dan-Shen and its active ingredient. It has even been suggested to treat PANS/PANDAS.

These clinical trials include treating altitude sickness.

Hesperiden is found in oranges and indeed peppermint, but in oranges it is most abundant in the white inner part of the peel. Orange peel is a home remedy to lower cholesterol. Research shows that Hesperiden (and naringin) is a potent cholesterol lowering substance.

You would think that you can have too much of a good thing, that is too much endothelial nitric oxide; ask a body builder.

There is more to this subject, beyond the body builder’s science; the related areas to look at are angiogenesis and lymphangiogenesis. These are very much influenced by VEGF (Vascular Endothelial Growth Factor). In the next post we will see that there is evidence suggesting blood vessel growth can be unchecked in some autism resulting in unstable blood flow, not simply reduced flow.

So while the view from today’s post is that in autism there may be restricted blood flow, rather like in vascular dementia, the real situation is likely more complex.

We also have the issue of how the lymphatic system, that collects waste materials from the body (including the brain), may also be affected. With blood vessels there may be “too much growth” but in the case of lymphatic system there may be too little. This is all governed by VEGF.

We have already seen that autophagy and mitophagy are reduced in some autism and are a defining feature of Huntingdon’s Disease. Accumulation of waste products in the brain has consequences. Improved autophagy, possible via the same polyamines referred to in the earlier graphic, and improved lymphangiogenesis could be therapeutic. It appears that the brain flushes out waste products to the lymphatic system while you sleep; Alzheimer's is most prevalent in people who sleep very little.

Back to School (again)

Another September passes and another school year is underway. For Monty, aged 14 with ASD, he moved up to the secondary/high school building with his 12 year old classmates.  He has attended the same small international school for ten years.

The experience autism parents have with schools varies widely, both from country to country and within the same country.

This blog is mainly read by people in North America, where autism is generally much better treated than in the rest of the world.  Publicly funded early intervention in the US is available from birth to three; it actually finishes before most people in the rest of the world even get a diagnosis.

While many people complain about the services they receive, it is ultimately up to the parents to make the best of it, using whatever means they have at their disposal.  The results appear to be extremely varied.

Our method was to go part time to school to the age of twelve, leaving plenty of time to have a home-based learning program.  Up to the age of eight almost all learning actually took place at home; school was more for “socialization”.  Then there was a big behavioral regression for almost a year; school continued but skills were lost. Then I started my Polypill interventions and in that September agreed Monty move back two years at school.

For the last five years Monty has stayed with the same NT peer group who are two years his junior.  Much to everyone’s surprise, he participates in the same assessments as his classmates, something inconceivable up to the age of eight. Moreover he does not get the lowest grades in class, which would have been the case up to the age of 8 had the teacher used the same tests as the rest of the class.

At some point, I assume he will not be able to move forward, but that point has not yet come.  This year we have already had tests in all subjects and the average grade has been “B”, which has surprised everyone. If you treat classic autism you will still have autism, but normal learning becomes possible. 

Progress to date

There is much in previous posts about how people with classic autism start to acquire skills long after their peers, and that even then their rate of acquisition of new skills is much slower. The end result is that the learning gap between people with autism and their NT peers starts out wide and then grows. Many people with classic autism leave high school with a skill level ten years lower.

NT kids start acquiring skills from an earlier age and at a faster rate than those with Classic autism. Adjust for this and “catch up”.

The idea of this blog is to use science to close the gap as much as possible, so rather than being left totally behind, aim to leave school with much more than just a very minimal education.

People with Asperger’s clearly do not have these problems and most people diagnosed today with autism have this kind of mild autism.   

One good thing about not being in a selective school is that you have a wide range of intelligence and indeed motivation among the class. If you have a selective school with hard working intelligent kids, you clearly could not include someone with classic autism, but you should be able to have people with Asperger’s.  They were there long before Asperger’s was a diagnosis. 

As I have pointed out in previous back-to-school posts, there may well come a September when moving forward a year may not happen, but for the last five years it has been possible.

The idea of explaining concepts such as elements, compounds, atoms and molecules really would have seemed absurd, just a few years ago. I may even be putting up a poster of the periodic table in Monty’s room.  It is of course just a very basic understanding; so H₂O is water where H is hydrogen, O is oxygen.  It was not so long ago that it was proving impossible to teach the concept of bigger and smaller with single digit numbers or the meaning of basic prepositions.

The biggest issue currently involves history, where rather than just learning what happened and when, it is already more about your opinions about why something happened. So the problem is more one of language and I would myself struggle to understand and explain the causes of World War 1 in my second language. People with classic autism really do not have a mother tongue, their first language is silence and so language will remain limited and be matter of fact and literal.

So we will focus on numeracy/math, literacy (English), a second language, science, geography (which is surprisingly teachable) and make something of history. The non-academic subjects, music and physical education/PE work very well and autism is not a limiting factor.  

Because the class is of mixed abilities and perhaps more importantly varying motivations, in spite of his obvious disadvantages, Monty does not come bottom. I think if you come bottom in every subject, then inclusion may not be appropriate.

There is a view that you should give different tasks and simpler assessments to special needs kids included in mainstream classrooms. This is like the old village school where one teacher is teaching different age groups at the same time. This does put a burden on the class teacher and you can see why it does not happen, unless the teacher is very motivated and well supported. I do not see how classes in public schools with 30 kids and two of those have special needs and assistants can function well. The risk is you end up failing the 28 NT kids.

The key to successful inclusion of someone with classic autism seems to be pharmacologically raising their cognitive function (IQ) as much possible, having good one to one classroom assistants and having a smaller class size.

These days most people diagnosed with autism are more likely to have Asperger’s, so they did not have a speech delay and all the biological consequences of that. People with Asperger’s face very different issues at school. In theory these issues are much easier to deal with, but because they appear minor they may get ignored. Issues include sensory gating, sensory overload and bullying; none of which affect my son at school.  Selective schools would seem a good choice for those with Asperger’s, since they will have more in common with at least some of those clever hard working types.  I continue to be surprised that special schools for Asperger’s exist in some countries.  They may be a refuge from bullying, but cannot be a good preparation for future life and employment.

Special schools for more severe autism vary widely.  In some countries there are some very good ones, but this kind of provision is extremely expensive and so is often not available.

I think if you are behaviourally and academically “includable”, mainstreaming is the ideal option. If inclusion is just a class within a class, with the assistant teaching the child in a corner of the mainstream classroom, then it is not going to be a success.  

You have to be behaviourally and academically includable.  If you are just behaviourally includable but understand nothing from the teacher, there is not much point being there.  If you are not behaviourally includable it is not fair on all the NT kids.

In kindergarten and the next couple of years the fact someone has autism does not stand out so much, because many kids behave badly. So you have till the age of 7 to get things in as good a shape as you can.

Treating autism pharmacologically makes learners much more includable and hopefully one day will be available on demand. It can reduce negative behaviors like aggression and anxiety, while raising cognitive functioning.   

Conclusion

The US system is based on the idea of making a huge effort before the age of four in the hope that things will get very much better and fast.  There is indeed evidence that in about 10-15% of people with autism, by the age of five things have pretty much fixed themselves, regardless of intervention.

Few people will be able to keep up the pace of this early intervention for the next ten or more years. It is too expensive and just too labour intensive. In the US there are some publicly funded special schools that do have this level of provision, but not in most countries.

Having been very focused on behavioral intervention until my son was eight, it is clear that the optimal solution is to start pharmacological intervention in parallel, meaning from diagnosis.  Some people in the UK wait for years just for a diagnosis, which is absurd. I think an astute observer can diagnose more severe autism at 18 months of age, with 90% accuracy.  In some countries they wait till five years old before diagnosing autism, preferring to use words like apraxia instead. Outside the US there is no rush to diagnose autism, because there are no services.  If there are no services, nor interventions, there is little point having a diagnosis, it is just a label.

Pharmacological intervention is going to be rather hit and miss, but this is also true in many other medical conditions (dementia, multiple sclerosis, epilepsy, depression …).  For the 85% that are not going to magically recover, pharmacological intervention combined with 1:1 teaching/support is the way to go.  It is the 1:1 part that is expensive, but for many people that is already available in many countries, meaning a teaching assistant in a mainstream classroom.  All the 1:1 therapy is much more effective, when you improve some of biological dysfunctions.

Why more people cannot have a one or two year “catch-up” adjustment in mainstream school is not clear to me. It is a very simple strategy that does not cost anything, since in many countries people with special needs get free education beyond 18 years of age. There is a rigid belief that you must educate a 9 year old with other 9 year olds, rather than matching people by their stage of cognitive development. In my world no NT kid would leave primary/junior school until he had mastered basic numeracy and literacy, which often is not the case, even in developed countries.