Channelopathies in Autism - Treating Nav1.1 with Clonazepan

In this post we look at another existing drug that research shows may be effective in treating core symptoms of autism.  The drug, Clonazepam, is inexpensive and is already used in larger doses to treat anxiety in autism.

 

You make have seen this Venn diagram before, it is one of those graphics I like to produce to make things easier to understand, both for you and for me.

In our quest to treat autism we first need to understand the disease as much as possible.  By far the most complex of the four main areas is the dysfunction of the ion channels and transporters in the brain, the so-called channelopathies.  Ion channels were only discovered relatively recently and science's understanding of them is still evolving.

Here is very useful layperson’s summary:- 

Autism-Linked Variations in Ion Channel Genes Increase Brain Excitability

 

"Neuronal communication guides virtually all aspects of brain development. To better understand Autism Spectrum Disorders (ASD), scientists are searching for autism-linked genes that regulate neuronal activity. Some of these genes encode ion channels, whose activation determines whether a neuron will fire a signal. Variations in ion channels influence neuronal survival, differentiation, migration, outgrowth, and synapse formation.

Ion channels are critical for shaping neuronal excitability. Neurons encode information using electrical signals derived from ion channels. At rest, each neuron has a negative charge. When a neuron receives signals from other neurons via synapses, ion channels open and the neuronal charge becomes either more positive or negative, depending on the type of ion. Once the charge of a neuron rises to a certain threshold, the neuron “fires” a signal to other neurons in a process called emitting an “action potential.”

Think of this process like the boiling of a teapot. The bottom of the teapot receives heat from the burners of the stove, much like how dendrites of a neuron receive synaptic signals. This heat boils the water in the teapot, converting it into steam, just as neurons convert synaptic signals into electrical charges. As the pressure builds, steam escapes through the spout, letting off a loud whistle. Likewise, once a neuron builds up enough positive charge, it sends a fast action potential down its axon to the next neuron.

Positive ion channels boost neuronal excitability by creating a more positive charge. However, the balance of neuronal excitability is crucial. Too much excitation leads to seizures and epilepsy, whereas too little prevents circuits from firing. Individuals with autism frequently also have epilepsy, suggesting that their brains are overexcited.

ASD-linked mutations in genes for calcium (Ca2+), sodium (Na+), and potassium (K+) ion channels enhance brain excitability, although the exact mechanisms are not well understood. Known ASD-associated mutations occur in the genes CACNA1C, CACNA1F, CACNA1G, and CACNA1H, which encode the L-type calcium channels Cav1.2 and Cav1.4 and the T-type calcium channels Cav3.1 and Cav3.2, respectively; the sodium channel genes SCN1A and SCN2A, which encode the channels Nav1.1 and Nav1.2, respectively; and the potassium channel genes KCNMA1 and KCNJ10, which encode the channels BKCa and Kir4.1, respectively.

Variations in ion channel genes are likely to affect a myriad of brain functions. Ion channels may even provide a link between genetics and the environment because environmental factors like mercury increase calcium signaling. The broad role of ion channels may help explain why ASD is so often accompanied by other neurological complications like sleep problems and epilepsy."

Catherine Croft Swanwick, Ph.D.

In this blog I have so far covered a potassium channelopathy and a chloride channelopathy.  From my own research, I already know there are more.

In today’s post we will look at some very extensive research by  Dr Catterall, who seems to be the world’s expert on a specific sodium ion channel called Na_V1.1.  Catterall has shown how it is implicated in two models of autism and it can be effectively treated/reversed using existing drugs.

Dravet’s syndrome

Dravet’s syndrome is a childhood neuropsychiatric disorder including recurrent intractable seizures, cognitive deficit and autism-spectrum behaviours. The neural mechanisms responsible for cognitive deficit and autism-spectrum behaviours in Dravet’s syndrome are poorly understood.  It is known that a dysfunction of the gene, SCN1A,  that encodes encoding voltage-gated sodium channel Na_V1.1 causes Dravet’s syndrome. 

Experiment Number One

In the first paper, Catterall used mice with a deficiency of the SCN1A gene to become his Dravets/autistic test examples.

The mice exhibited hyperactivity, stereotyped behaviours, social interaction deficits and impaired context-dependent spatial memory. Olfactory sensitivity is retained, but novel food odours and social odours are aversive.  In effect he made autistic mice.

He goes on to explain that the behavioral deficit is mediated via impairments in GABAergic neurotransmission.  He tell us that treatment with low-dose clonazepam, a positive allosteric modulator of GABA_A receptors, completely rescued the abnormal social behaviours and deficits in fear memory in the mouse model.  

Autistic-like behaviour in Scn1a+/−mice and rescue by enhanced GABA-mediated neurotransmission

"Remarkably, treatment with low-dose clonazepam, a positive allosteric modulator of GABA_A receptors, completely rescued the abnormal social behaviours and deficits in fear memory in the mouse model of Dravet’s syndrome, demonstrating that they are caused by impaired GABAergic neurotransmission and not by neuronal damage from recurrent seizures. These results demonstrate a critical role for Na_V1.1 channels in neuropsychiatric functions and provide a potential therapeutic strategy for cognitive deficit and autism-spectrum behaviours in Dravet’s syndrome."

Experiment number two

In a recent experiment, Catterall used a standard mouse model of autism called the BTBR mouse.  This is essential a specially bred mouse that exhibits very many traits of autism.  Nobody has purposefully interfered with its SCN1A genes or Na_V1.1 ion channels.

Enhancement of Inhibitory Neurotransmission by GABAA Receptors Having a2,3-Subunits ameliorates Behavioral Deficits in a Mouse Model of Autism

 

The dramatic behavioral improvement after low-dose benzodiazepine treatment was subunit specific—the α_2,3-subunit-selective positive allosteric modulator L-838,417 was effective, but the α₁-subunit-selective drug zolpidem exacerbated social deficits. Impaired GABAergic neurotransmission may contribute to ASD, and α_2,3-subunit-selective positive GABA_A receptor modulation may be an effective treatment

In this study, Catterall repeated his use of low-dose clonazepam to try to “cure” the autistic mouse.  He not only was able to reduce the autistic deficits, but he was able to make cognitive improvements.  In effect he made the mice less autistic and smarter.

The following excepts from his paper are quite technical and you may wish to skip past them.

Increased GABAergic Inhibitory Neurotransmission in Response to Benzodiazepines

 

"Attempts to reverse autistic-like traits by rebalancing the ratio of excitatory to inhibitory neurotransmission through pharmacological treatments that reduce excitatory neurotransmission have met with only partial success because of their limited efficacy and unwanted side effects in control groups. 

The increased GABAergic signaling after treatment with clonazepam led to a decrease in frequency of spontaneous EPSCs (Figures 1G and 1H), without change in amplitude in BTBR hippocampal slices (Figure S1D). Interestingly, the frequency of spontaneous EPSC was also decreased by clonazepam (Figure S1K), without change in amplitude (Figure S1L) in C57BL/6J slices. 

These data support the idea that low-dose clonazepam can reverse the underlying deficit in spontaneous GABAergic inhibitory neurotransmission in BTBR mice."

 

Improvement of Social Interaction by Treatment with Clonazepam

 

"To test the behavioral effects of enhancing inhibitory neurotransmission in BTBR mice, we injected low nonsedating/nonanxiolytic doses of clonazepam intraperitoneally 30 min prior to behavioral tests. In the three-chamber social interaction test, acute clonazepam treatment had no effect on social  interactions of C57BL/6J mice (Figures 2A and S2A) but increased social interactions in BTBR, with a maximal effect at 0.05 mg/kg (Figures 2B and S2B) and no sedation (Figure S2H). Measurements of the time of interaction of the test mouse with a stranger mouse versus a novel object during three-chamber tests showed that the C57BL/6J mice are unaffected by any of the test doses (Figure 2C), whereas improvement of the social deficit in BTBR mice by clonazepam is strikingly dose dependent (Figure 2D). Interestingly, the improved social interactions in BTBR mice were lost at higher doses of clonazepam (Figures 2B and 2D). Other behaviors in BTBR mice were also rescued by low-dose clonazepam. In the open-field test, a single injection of 0.05 mg/kg clonazepam significantly reduced hyperactivity, measured as the total distance moved (Figure 2E), and stereotyped circling behavior, measured as the number of 360_ rotations (Figure 2F).

In contrast, these behaviors in C57BL/6J mice were unaffected by low-dose clonazepam. These low doses of clonazepam had little effect on anxiety-like behaviors of C57BL/6J mice, such as avoidance of the center of an open field or the open arms of an elevated plus maze (Figures 2G and 2H). However, compared to C57BL/6J, BTBR mice visited the center in the open field significantly more frequently and spent more time in open arms during the elevated plus-maze test under control conditions, as if they were less anxious than C57BL/6J mice, and these indicators of abnormally low anxiety in BTBR mice were changed toward the values for C57BL/6J mice after treatment with 0.05 mg/kg clonazepam (Figures 2G and 2H) without sedation (Figure S2I).

 

Amelioration of Cognitive Deficits by Treatment with Clonazepam

 

 

 

"Cognitive problems are often associated with ASD and BTBR mice are known to have impaired fear memory. To test the effects of low dose clonazepam on cognitive deficits, we performed context dependent fear conditioning after treatment with increasing doses of clonazepam in both BTBR and C57BL/6J mice (Figures 3A and 3B). Short-term (30 min) and long-term (24 hr) memory performance in fear conditioning to the spatial context in BTBR mice were improved by treatment with 0.05 mg/kg clonazepam, but no significant effects were observed after treatment with 0.0125 mg/kg or 0.1 mg/kg clonazepam (Figures 3B and S3B). In contrast, no cognitive changes were observed in C57BL/6J mice at any dose (Figures 3A and S3A)."

 

Rescue by a2,a3-Specific Positive Allosteric Modulators of GABAA Receptors

 

"Diversity of GABA receptor function is conferred by more than 20 different subunits, and receptors with different a subunits play distinct roles in the physiological and pharmacological actions of GABA and benzodiazepines."

"These results indicate that different subtypes of GABAA receptors may have opposite roles in social behavior, with activation of GABAA receptors containing a2,3 subunits favoring and activation of GABAA receptors with a1 subunits reducing social interaction, respectively."

"Altogether, these experiments show that treatment with an a2,3-selective positive allosteric modulator of GABAA receptors is sufficient to rescue autistic-like behaviors and cognitive deficit in both a monogenic model of autism-spectrum disorder and the BTBR mouse model of idiopathic autism." 

"Subunit-selective GABAA receptor modulators may also have an important effect on cognitive behaviors."

"The bell-shaped dose-response curves observed for both L-838,417 and clonazepam may explain why high-dose benzodiazepine treatment for prevention of anxiety and seizures has not been reported to improve autistic traits in ASD patients."

 

Discussion

"Our results on mouse models of autism support the hypothesis that social and cognitive deficits in ASDs may be caused by an increased ratio of excitatory to inhibitory synaptic transmission." 

"Therapeutic approaches to treat autistic traits in animal studies or in clinical trials have primarily focused on reducing excitatory neurotransmission in glutamatergic synapses to rebalance E/I ratio in autistic brain.  However, autistic-like behaviors in ASD mouse models are only partially reversed by drugs that inhibit excitatory neurotransmission, and these drugs also have unwanted side effects on wild type mice. To overcome these drawbacks, we focused on the opposing side, the GABAergic inhibitory transmission in autistic brain. Our results highlight the potential for therapy of autistic like behaviors and cognitive deficit in ASD by low-dose treatment with subunit-selective benzodiazepines and other positive allosteric modulators of GABAA receptors. At low doses that do not induce sedative or anxiolytic effects, we found that clonazepam, clobazam, and L-838,417 all improved autistic-like behaviors and cognitive deficit in BTBR mice, supporting the hypothesis that a2,3-subunit-selective up regulation of GABAergic neurotransmission could be an effective treatment for these core features of autism."

"Consistent with this view, Astra-Zeneca and the National Institutes of Health have initiated clinical trials of the a2,3-selective positive allosteric modulator of GABAA receptors, AZD7325, for efficacy in autism."

 

Experiment number three

Experiment number three is of course to test Dr Catterall’s idea about Clonazepam on humans.  This has not yet been done, although a trial is planned with a similar drug AZD7325.

He suggests trialing a low dose of clonazepam, but it is not clear exactly how low. There is mention of 10% of the normal dose. In large doses, clonazepam is already prescribed in autism to reduce anxiety, particularly in the US.  At even larger doses, clonazepam is used to treat seizures; given about 30% of people with autism also have seizures, it would be fair to assume that some of those are also prescribed clonazepam.

The downside is that clonazepam is a benzodiazepine, and this class of drug is habit forming.  In extremely low doses, perhaps this will not be a problem.  For anxiety, plenty of people have been prescribed it for 10+ years; the problem is they cannot stop taking it.

The pharmacological property of clonazepam is modulation of the GABA_A receptor; based on the mice, the effect is extremely dose dependent.  The wrong dose gives no beneficial effect.  Bumetanide, which is affecting GABA in a very similar way to make it inhibitory rather than excitory, seems to work like an on/off switch.  A low dose is ineffective, the correct dose works and a larger dose works just the same.

The optimal dose of clonazepam will be hard to find, too little does not work and neither does too much.  So for the time being it is rather trial and error.

By my calculations, a good place to start would be 0.8 Mcg (micrograms) per Kg per day and then titrate upwards gradually increasing the frequency and size of the doses.

The drug has a half-life that varies from person to person; the average is 30 hours but can vary between 18 and 50 hours.  This means that one child might need nearly 3 times as much as another, of similar weight.

To be an effective treatment the concentration of clonazepam would have to be maintained within the effective range.  This would need some clever maths, and might result in 3 unequal daily doses, and that during sleep the concentration  might be above range, and during daytime it be held in range with one or two smaller top-up doses.  

If you get the maths wrong, the drug would not work.

Conclusion

The jury is out until we see the results of experiment three, or anecdotal evidence of some home trials. One question I have is how this relates to the  Na_V1.1 ion channels referred to at the beginning of this post.  We know that a defect in this ion channel will produce autism-like symptoms and that these can be reversed (in mice) using the correct type of benzodiazepine, such as clonazepam.  If we find that in a particular child with autism, clonazepam reduces their symptoms and increases cognitive performance, can we claim the route cause was a dysfunction with Na_V1.1 ion channels?  It is a bit of a leap of faith, but I think it is a fair conclusion.  In which case of course, the logical next step would be to look at the underlying gene, SCN1A; that I will leave to people much cleverer than me.

The next question is whether this therapy, which is reducing excitability of the neurotransmitter GABA, is alternative or complementary to bumetanide which is, in effect, doing exactly the same thing.  For that we would need Dr Catterall to talk to Dr Ben-Ari.  

In case you are wondering if there is another connection between Dr Catterall (Clonazepam) and Dr Ben-Ari (Bumetanide), there is.  The same man is part-funding both of these research efforts – Jim Simons, via his Simons Foundation.  As a former hedge fund manager, his is very cleverly hedging his bets. 

 

Clonazepam dosage and effectiveness in Autism

 

 

 

How is Monty these days?

Some readers are more interested in how Monty, aged 10 with ASD, is doing these days, rather than in all the scientific research.  This is a post for them.

At school things are moving ahead both academically and socially.  In September our American/Greek ABA consultant visited us; one important point she made was that we should get him to interact more concretely with the other kids at school, and not just superficially. 

He has made great strides forward in this area and now greets all his classmates and the staff members by name.  In the playground he is trying hard to join in the soccer games and the other activities.  This works well, the more he engages with the other kids, the more they want to engage with him. 

When a group of girls were having a problem with a particular boy, one girl went over to fetch Monty to help them; and he did, he made the other boy go away.  This is quite a change - to be giving help, rather than receiving it.

We started with cursive (joined-up) handwriting. This actually went much better than anyone expected, and he now even does his school spelling tests in cursive.  It all looks amazingly neat.  Handwriting is a pretty good indicator of how well under control (or not) autism is.  When Monty had problems a couple of years ago, his writing became terrible.

We had a nice surprise letter from school, telling us how happy they are with his progress and how happy he is; this from the same teacher who first noticed how his behaviour changed when he started Bumetanide.  That was the first ingredient of what became his Polypill.

My favourite benchmark is his piano playing.  Here again things are progressing nicely, the special needs piano teacher is now getting me to photocopy the music used by Monty’s NT 13 year old brother, since we have moved to a more advanced level. When we started with this teacher only 18 months ago, Monty was sometimes screaming and even hitting her; completing the 40 minute lesson was a struggle.   Back then the music was very basic; it no longer is.  As for behaviour, he is now a model student and walks his teacher to the front door at the end of the class.

We are still using a scooter rather than a bicycle.  At the weekend, Monty managed to scoot 5 miles/8km around a lake overtaking the walkers and against a constant stream of joggers coming the other way around.  He did it all again three days later.  This is quite an achievement; kids with ASD appear to lack many natural instincts, which we usually take for granted. Whether this will eventually lead to being able to drive a car remains to be seen.

Yesterday I finally had my teleconference with the European Medicines Agency (EMA) regarding Monty’s Polypill.  Rather as expected, we are worlds apart.  In essence, I should do some further observational trials on other kids with ASD.  This is rational, but where are the ASD doctors to do a trial with?  As for the blog readers who now want to trial the prescription-only-medicines in the Polypill, they should apply to the “compassionate use program” of their national drug regulator, to access the drugs their local doctor refuses to prescribe.  This sounds great in principle, but in practice?

All is not lost, elsewhere on this blog we have already identified a handful of clinicians, who could genuinely count as an “ASD Doctor”.  So let’s see if any of them want to put the Polypill to the test, using my provided biomarkers, to identify the target sub-type of autism.  I will refer to my Dean's List.

As I said to the EMA, I am not so concerned since I already have access to the Polypill and, in Monty’s sub-type of autism, it works a treat. So whereas they think I am at the start of the journey (to produce a drug), I feel that I have already arrived.  It would be nice if some people from the public sector would now take some initiative.

 

 

 

Summertime Raging in Autism – H1 Anti-histamine Effect on Histamine Levels and IL-6

Last summer, I wrote a lot about autism getting much worse in that time of the year and how I found that common “24 hour” anti-histamine drugs seemed to have a magical effect; but one that lasted only 2-3 hours. There were only visible signs of a mild allergy, which could indeed easily be overlooked.

I did later receive a message from a reader who noticed his child’s ASD behaviours were greatly improved by Zrtec and his doctor agreed to prescribe this H1 antihistamine all year round.

Recently, I stumbled upon a blog, rich with many comments of parents of kids with severer types of autism.  Here I noted some parents referring to “summertime raging”, and I thought to myself, I know what they mean.  Fortunately, I found out how to make it go away.

Ant-histamine drugs

The two most common antihistamine drugs are Claritin (Loratadine), its active derivative Aerius (Desloratadine) and Zrtec (Ceterizine) and its active derivative Xyzal (levocetirizine).

The main action of an antihistamine is not actually to reduce the amount of histamine in your blood, rather it is to block the effect of histamine on the H1 receptors.

An H2 antihistamine blocks H2 receptors that are mainly in your intestines, and is used to reduce the amount of acid in the stomach.

This led me on a quest for substances that actually stop the increase in histamine, rather than just blocking some effects.  The only thing that does this is something that can stop so-called mast cells from degranulating and spilling their load of histamine, serotonin, nerve growth factor and cytokines, including IL-6, into the blood; from where, all except serotonin, are free to travel to the brain, across the blood brain barrier (BBB).  Serotonin cannot cross the BBB.

According to the mast cell specialist Theoharides, conventional drugs are not genuine mast cell stabilizers.  There are some partial ones, like Ketotifen, Cromalin, Rupatadine and Azelastine, but Theoharides thinks naturally occurring flavonoids like Luteolin and Quercetin work best.

Last summer in this blog I looked at newly discovered histamine receptors types H3 and H4 which are known to be present in the brain.

So how is it that Claritin and Zrtec can reduce autistic behaviours ?

I did note that both the above drugs did reduce summertime raging and also the Theoharides' research that showed they probably should not, since they are not mast cell stabilizers. 

Since my blog reader also found Zrtec helpful, so much so he gives it to his kid year round and it now seems summertime raging is not an unusual phenomenon in autism, I did some more checking.

In spite of what Theoharides tells us, it turns out that both Claritin and Zrtec do indeed reduce the amount of histamine in the blood.

Also, it turns out that not only is the pro-inflammatory cytokine IL-6 released from mast cells but it is also released from another type of cell, called the endothelial cell.

The endothelium is the thin layer of cells that lines the interior surface of blood vessels and lymphatic vessels, forming an interface between circulating blood or lymph in the lumen and the rest of the vessel wall. The cells that form the endothelium are called endothelial cells. Endothelial cells in direct contact with blood are called vascular endothelial cells, whereas those in direct contact with lymph are known as lymphatic endothelial cells.

And what prompts endothelial cells to release IL-6? Histamine does.

Indeed we have studies showing how Claritin (loratadine) and  Zrtec (Ceterizine) reduce histamine and IL-6; it is the IL-6 from the endothelial cells.

Inhibitory activity of loratadine and descarboxyethoxyloratadine on histamine-induced activation of endothelial cells.

"CONCLUSION:

These results demonstrate that both L and DCL are active to reduce the histamine-induced activation of EC. Interestingly, DCL seems to be effective at lesser concentrations especially to inhibit cytokine secretion."

The above study would suggest that Aerius (DCL) should be more effective than Claritin (L) its predecessor.

Human Mast Cells(HMC-1 5C6) Enhance Interleukin-6 Production by Quiescent and Lipopolysaccharide-Stimulated Human Coronary Artery Endothelial Cells

"Histamine is a major constituent of the mast cell. The effect of histamine on endothelial cells is primarily mediated through H1R

Collectively, our results suggest that mast cell-derived histamine and proteases play an important role in vascular inflammation and calcification in addition to their well-recognized participation in allergic diseases."

This study, and others like it, show how mast cell degranulation contributes to heart disease.  This would suggest that mast cell stabilizers have a much wider role in human health than is realized.  Another example of how a red apple a day (with the skin) may indeed help keep the doctor away and a glass of red wine will do the same.  Both are rich sources of the mast stabilizer Quercetin.  The alcohol increases the bio-availability.

Cetirizinea histamine H1 receptor antagonist improves viral myocarditis

"Conclusion

These results suggest that cetirizine exerts its beneficial effects on viral myocarditis by suppressing expression of pro-inflammatory cytokines, genes related to cardiac remodeling in the hearts of mice."

So how do Claritin and Zrtec reduce summertime/year round raging in autism?  Well it could be histamine or it could be IL-6, we cannot know for sure.  The science tells us that the brain has many H3 and H4 receptors, so they are possibly to be implicated.  Or, it may just be IL-6;  histamine’s involvement could be just provoking the endothelial cells to release more IL-6.

Conclusion

Claritin/Zrtec/Xyzal are relatively cheap, in theory they are long lasting drugs.  In Monty, aged 10 with ASD, they all work for summertime time raging, but not for long.  Adults should take one per 24 hours.  Monty would need one every 3 hours.

The, supposedly better, mast cell stabilizers like Ketotifen and Rupatadine take a few days before they have any effect at all.  Azelastin is available as a nasal spray and is supposed to be effective quickly as an allergy treatment.

My preferred mast cell stabilizing, IL-6 inhibiting, strategy is to combine PEA (palmitoylethanolamide) which is already naturally in your body, with the flavonoid quercetin, which is found in the skin of red apples and red grapes.  In theory, according to the research, this is both a potent combination and should be free of harmful side effects.

Very frequent doses of Claritin/Zrtec/Xyzal are not going to be good.

Links

Blog with 1000s of parent comments, some are very insightful

  

Theoharides on mast cells

On this blog:-

http://epiphanyasd.blogspot.com/2014/02/is-subtype-of-autism-allergy-of-brain.html

http://epiphanyasd.blogspot.com/2014/03/palmitoylethanolamide-pea-vs-flavonoids.html

http://epiphanyasd.blogspot.com/2013/07/histamine-allergies-and-reducing.html

http://epiphanyasd.blogspot.com/2013/11/seasonal-autistic-mastocytosis.html

Dr Chez’s Trial of Lenalidomide, a TNF- α and IL-6 Inhibitor in Autism

 

An interesting trial of a TNF- α and IL-6 inhibitor in autism has been brought to my attention.  It was by Michael Chez, the neurologist from Sacramento, who has made several appearances on this blog.

By coincidence, a copy of his book arrived this week.  The book is called “Autism and its Medical Management”, Chez is one of the few mainstream doctors who does try and treat autism.  The book is rational, readable and in no way radical, so you could show it to your family doctor without upsetting him/her.  Chez does particularly focus on distinguishing regressive from non-regressive autism, as do I. His view is that it is regressive autism, even if it was regression from slightly abnormal.  The important part is that some learned skills, like language, were lost sometime after 12 months of age.  He believes that regressive autism has a different basis to non-regressive autism; he has his own ideas about this, but he admits there is no concrete proof.

The book is a few years old and Chez has published much work in the intervening few years.    

The paper I was referred to is:-

Safety and Observations in a Pilot Study of Lenalidomide for Treatment in Autism

Lenalidomide, an analogue of thalidomide, has the potential to invoke significant changes in TNF-α and other immunomodulatory cytokines.  If thalidomide sounds familiar, it is the drug from the 1950s, that turned out to be very unsafe for use in pregnant women and around the world 10,000 babies were born with malformation of the limbs.

Lenalidomide has been used to successfully treat both inflammatory disorders and cancers in the past 10 years. There are multiple mechanisms of action.  It is extremely expensive, according to NICE:-

“Lenalidomide 25 mg capsules cost £4368 per 21 capsules (excluding VAT; ‘British national formulary’ [BNF] edition 55). Dosage is continued or modified based upon clinical and laboratory findings. For example, if lenalidomide is continued for ten 28-day cycles without dose reduction, the cost would be £43,680.”

 

Dr Chez does not mention the cost of Lenalidomide, but he uses a tiny dose of 2.5 mg; This would cost £20, or $30, a day.  This might also explain the small number (7) of participants in the trial.

 

“2.2. Drug and Dosing. Lenalidomide 2.5mgs was given daily

for 12 weeks. This low dose was selected to minimize the risk

of adverse effects. In addition, because this was a pilot study,

the goal was to test the lowest dose that could potentially lead to improvements.”

 

The drug did reduce TNF-α levels and there were some behavioral improvements, but nothing dramatic.  Perhaps a higher dosage would have had a greater effect?

 

There were only seven participants and the data on the seven is not complete; also the dose of Lenalidomide was very low.  I think it is really only fair to conclude that the trial is interesting but that a much cheaper drug would need to be found and tested on a much larger number of participants.

“Despite the limitations, to our knowledge, this open-label study represents the first attempt to treat autism by specifically targeting elevated innate inflammatory cytokine levels. Safety monitoring and pharmacokinetic data were successfully completed during this pilot study and exploratory observations of clinical and cytokine changes suggest a trend towards improvement. Correlating treatment outcomes with cytokine level changes may be a target in future autism spectrum treatment, especially in those with known maternal or postnatal immunological risk factors. Larger blinded and placebo-controlled studies assessing cytokine measurement and cytokine-targeted treatment in autism patients with TNF-α or other inflammatory cytokine elevation are warranted.”

To his credit, unlike the researchers in Athens who trialed Neuroprotek in a recent post, Chez went about his pilot study in a scientific manner and collected both the biological and the behavioral data.  In other words, he measured the before and after levels of the inflammatory cytokines and the before and after behavioral rating scales.  Well done Dr Chez.

 

 

Let’s be Serious about the Data - Flavonoids, Cytokines & Autism

You may be wondering why, with so many research papers written about autism, so little progress has been made.  It is a very complex task, but nobody is coordinating it.

How do you find a Boeing 777 missing somewhere in Asia?  Another daunting challenge, but with the right people and resources it can be done.  With the wrong people, it will prove to be impossible.

Ashwood et al have documented the level of various inflammatory markers in autism.  Very helpfully, they created three groups: typical children, children with non-regressive autism, and children with regressive autism.

Elevated plasma cytokines in autism spectrum disorders provide evidence of immune dysfunction and are associated with impaired behavioral outcome

Table 2, on the third page, tells us what we need to know.  Certain cytokine levels are markedly elevated in regressive autism, including IL-6 and TNF-alpha.  Furthermore, the difference between the two types of autism is dramatic; rather implying the existence of two distinct conditions.

 

So now, I move on to what could have been an amazingly helpful study, had they spent 1% more time on it and collected some blood samples and split the kids into regressive and non-regressive groups.

Last year in Athens, a study was done using Theoharides’ mix of luteolin and quercetin flavonoids to look at the effect of mast cell stabilization on behaviour in autism.  From recent posts, you will recall that these flavonoids reduce the level of inflammatory cytokines, histamine and nerve growth factor, by stabilizing so called mast cells.  In effect, the study was looking at the impact of inhibiting certain cytokines on behaviour in autism.

An Open-Label Pilot Study of a Formulation Containing the Anti-Inflammatory Flavonoid Luteolin and Its Effects on Behavior in Children With Autism Spectrum Disorders

This sounds great and just what I wanted to find.  Get 40 kids with ASD measure their level of these cytokines/histamine and assess their behaviour.  Give them the cytokine inhibitor/mast cell stabilizer for six months, measure the levels in their blood and assess the behaviour again.

Sadly, they did not bother to take the before and after blood samples and send them downstairs to the hospital’s laboratory.

So we have a paper that took years of planning that tells us that the flavonoids do seem to help; but we do not know exactly why and we cannot correlate improvement in behaviour with change in cytokine levels.

What a pity.