Why Low Doses can work differently, or “Biphasic, U-shaped actions at the GABAa receptor”

This post does get a little complicated, so here is a summary.

Key points

·        High doses of oral Pregnenolone are shown to help Schizophrenia, particularly in females.  (these are all adults)

·        High dose oral Pregnenolone has also been shown to help adults with autism.

·        Low doses of transdermal progesterone (and likely Pregnenolone), anecdotally, reduce anxiety in Asperger’s and ADHD

·        Unusual levels of various hormones are a hallmark of autism, this can directly affect neurotransmitters like GABA

·        Hormones are produced in the brain as well as elsewhere in the body and so supplementing them may have unintended side effects.  Some hormones do not cross the blood brain barrier.

·        Side effects should be less likely after puberty, so research is done on adults

·        Some people regularly give very young children hormones, like melatonin

·        It may be possible to get the benefit of the hormones affecting GABA_A at low doses

·        Changes in certain hormone levels actually change the structure (and hence the effect) of the GABA_A receptor

·        Modulating the GABA_A receptor via the neurosteroid site then changes how the Benzo site of the same receptor responds to modulation (hence changes the effect, and side effects of Benzodiazepines)

Today’s post has a very odd tittle.

It will explain some of the odd things that we have been seeing in seizure drugs having potent effects at tiny doses.  It really is a case where “less is more”.

We will see that modulating the GABA_A receptor using the neurosteroid binding site (not the usual Benzo site) has potential for many neurological conditions.  There are some interesting interventions possible today and some are OTC.  We will also see that the structure of the GABA_A receptor is itself dynamic and some drugs affecting it are actually changing it.

This is all very relevant because it appears that GABA_A dysfunction is at the very core of the common autism variants and a key factor in schizophrenia.

   

I did say in a recent post that  GABA_A receptor is rather complicated and best left to Professors Sigel and Catterall and their mice, but then I came across the explanation myself.  As usual, the answer is there in the science, you just have to know where to look for it; or just stumble upon it.

It also appears that the recent autism trial at Stanford of pregnenolone, may have left untold part of the story.  They gave increasing high doses of pregnenolone, which is converted in the body into allopregnanolone, a positive allosteric modulator of GABA_A receptors. 

At tiny doses, allopregnanolone stimulates GABA_A, at higher doses it inhibits it and then at very high doses again it stimulates it.  So the precise dosage of Pregnenolone, or indeed progesterone, which also produces allopregnanolone, would be critical in achieving the desired modulation of GABA.  The Stanford researcher is a psychiatrist, by the way, not a biochemist; he did not investigate the effect of small doses.

Brief report: an open-label study of the neurosteroid pregnenolone in adults with autism spectrum disorder.

There are a whole raft of similar studies in the works, trialing Pregnenolone in Schizophrenia, Bipolar, TBI and even Gulf War Illnesses.

Proof-of-concept randomized controlled trial of pregnenolone in schizophrenia

   

Allopregnanolone

As usual the most up-to-date source is Wikipedia:-

Function

Allopregnanolone possesses a wide variety of effects, including, in no particular order, antidepressant, anxiolytic, stress-reducing, rewarding, prosocial, antiaggressive, prosexual, sedative, pro-sleep, cognitive and memory-impairing, analgesic, anesthetic, anticonvulsant, neuroprotective, and neurogenic effects.

Fluctuations in the levels of allopregnanolone and the other neurosteroids seem to play an important role in the pathophysiology of mood, anxiety, premenstrual syndrome, catamenial epilepsy, and various other neuropsychiatric conditions.

Increased levels of allopregnanolone can produce paradoxical effects, including negative mood, anxiety, irritability, and aggression. This appears to be because allopregnanolone possesses biphasic, U-shaped actions at the GABA_A receptor – moderate level increases (in the range of 1.5–2 nM/L total allopregnanolone, which are approximately equivalent to luteal phase levels) inhibit the activity of the receptor, while lower and higher concentration increases stimulate it. This seems to be a common effect of many GABA_A receptor positive allosteric modulators. In accordance, acute administration of low doses of micronized progesterone (which reliably elevates allopregnanolone levels), have been found to have negative effects on mood, while higher doses have a neutral effect.

Neurosteroids and GABA-A receptor function

Possible Explanations for the Paradoxical Effect of GABA-Steroids

In this section, possible mechanisms of the biphasic response curve of allopregnanolone on behavioral parameters are discussed. The basic idea of so called paradoxical effect where neurosteroids show one type of effect at low concentrations and another type at high concentrations is that an enhanced GABA_A-receptor activity may give an excitatory net effect in certain situations, instead of the usual inhibitory effect. The following hypotheses suggest several possible mechanisms how this can be achieved. In addition, there are no contradictions between the different hypothesis and they may very well act in parallel.

The Effect of Neurosteroids on the GABA_A-Receptor

The GABA_A-receptor can be modulated by a number of therapeutic agents, including benzodiazepines , barbiturates , anesthetics, ethanol , zinc , and neurosteroids . The effect of neurosteroids on the GABA_A-receptor depends on the type of steroids (agonist or antagonist), the type of receptors (synaptic of extrasynaptic), the subunit compositions, and the intrinsic structure of the steroid. Recent studies indicate that the existence of at least two neurosteroid actions on the GABA_A-receptor, namely an agonistic action and an antagonistic action by the sulfated and 3β-OH steroids. The agonistic action can further be divided into an allosteric enhancement of GABA-evoked Cl⁻ current and a direct activation of the GABA_A-receptor.

It is puzzling why an increase in allopregnanolone during the menstrual cycle is related to development of negative mood as allopregnanolone should be anxiolytic agent like benzodiazepines. The answer depends on the fact that all GABA_A-receptor agonists such as benzodiazepines, barbiturates, alcohol, and allopregnanolone have paradoxical anxiogenic effects in certain individuals. At low concentrations or doses they give severe adverse emotional reactions in a subset of individuals (3–6%) and moderate reactions in up to 20–30% of individuals. This paradoxical effect is induced by allopregnanolone  benzodiazepines , barbiturates , and ethanol . Symptoms induced by these GABA_A-receptor active drugs are depressive mood, irritability, aggression, and other symptoms known to occur during the luteal phase in women with PMS/PMDD. A biphasic effect was also observed for medroxyprogesterone (MPA) and natural progesterone in postmenopausal women taking hormone therapy. These women felt worse on a lower dosage of MPA or progesterone than on a higher dosage or placebo.

Thus allopregnanolone seems to have a biphasic effect on mood with an inverted U-shaped relationship between concentration and effect. In postmenopausal women receiving progesterone, a biphasic relation between the negative mood symptoms and the plasma concentrations of allopregnanolone was observed. The negative mood increased with the elevating serum concentration of allopregnanolone up to the maximum concentration seen at the luteal phase. With further increase in allopregnanolone concentration there was a decrease in symptom severity  An inverted U-shaped relation between allopregnanolone dosage and irritability/aggression has also been noted in rats 

Antagonist Neurosteroids on the GABA_A-Receptor

Neurosteroids may both enhance and inhibit GABAergic neurotransmission

Paradoxical effects of GABA-A modulators may explain sex steroid induced negative mood symptoms in some persons.

Abstract

Some women have negative mood symptoms, caused by progestagens in hormonal contraceptives or sequential hormone therapy or by progesterone in the luteal phase of the menstrual cycle, which may be attributed to metabolites acting on the GABA-A receptor. The GABA system is the major inhibitory system in the adult CNS and most positive modulators of the GABA-A receptor (benzodiazepines, barbiturates, alcohol, GABA steroids), induce inhibitory (e.g. anesthetic, sedative, anticonvulsant, anxiolytic) effects. However, some individuals have adverse effects (seizures, increased pain, anxiety, irritability, aggression) upon exposure. Positive GABA-A receptor modulators induce strong paradoxical effects including negative mood in 3%-8% of those exposed, while up to 25% have moderate symptoms. The effect is biphasic: low concentrations induce an adverse anxiogenic effect while higher concentrations decrease this effect and show inhibitory, calming properties. The prevalence of premenstrual dysphoric disorder (PMDD) is also 3%-8% among women in fertile ages, and up to 25% have more moderate symptoms of premenstrual syndrome (PMS). Patients with PMDD have severe luteal phase-related symptoms and show changes in GABA-A receptor sensitivity and GABA concentrations. Findings suggest that negative mood symptoms in women with PMDD are caused by the paradoxical effect of allopregnanolone mediated via the GABA-A receptor, which may be explained by one or more of three hypotheses regarding the paradoxical effect of GABA steroids on behavior: (1) under certain conditions, such as puberty, the relative fraction of certain GABA-A receptor subtypes may be altered, and at those subtypes the GABA steroids may act as negative modulators in contrast to their usual role as positive modulators; (2) in certain brain areas of vulnerable women the transmembrane Cl(-) gradient may be altered by factors such as estrogens that favor excitability; (3) inhibition of inhibitory neurons may promote disinhibition, and hence excitability.

Allopregnanolone and mood disorders.

Abstract

Certain women experience negative mood symptoms during the menstrual cycle and progesterone addition in estrogen treatments. In women with PMDD increased negative mood symptoms related to allopregnanolone increase during the luteal phase of ovulatory menstrual cycles. In anovulatory cycles no symptom or sex steroid increase occurs. This is unexpected as positive modulators of the GABA-A receptor are generally increasing mood. This paradoxical effect has brought forward a hypothesis that the symptoms are provoked by allopregnanolone the GABA-A receptor system. GABA-A is the major inhibitory system in the brain. Positive modulators of the GABA-A receptor include the progesterone metabolites allopregnanolone and pregnanolone, benzodiazepines, barbiturates, and alcohol. GABA-A receptor modulators are known, in low concentrations to induce adverse, anxiogenic effects whereas in higher concentrations show beneficial, calming properties. Positive GABA-A receptor modulators induce strong paradoxical effects e.g. negative mood in 3-8% of those exposed, while up to 25% have moderate symptoms thus similar as the prevalence of PMDD, 3-8% among women in fertile ages, and up to 25% have moderate symptoms of premenstrual syndrome (PMS). The mechanism behind paradoxical reaction might be similar among them who react on positive GABA-A receptor modulators and in women with PMDD. In women the severity of these mood symptoms are related to the allopregnanolone serum concentrations in an inverted U-shaped curve. Negative mood symptoms occur when the serum concentration of allopregnanolone is similar to endogenous luteal phase levels, while low and high concentrations have less effect on mood. Low to moderate progesterone/allopregnanolone concentrations in women increases the activity in the amygdala (measured with fMRI) similar to the changes seen during anxiety reactions. Higher concentrations give decreased amygdala activity similar as seen during benzodiazepine treatment with calming anxiolytic effects. Patients with PMDD show decreased sensitivity in GABA-A receptor sensitivity to diazepam and pregnanolone while increased sensitivity to allopregnanolone. This agrees with findings in animals showing a relation between changes in alpha4 and delta subunits of the GABA-A receptor and anxiogenic effects of allopregnanolone.

CONCLUSION:

These findings suggest that negative mood symptoms in women with PMDD are caused by the paradoxical effect of allopregnanolone mediated via the GABA-A receptor.

Neurosteroids, GABAA receptors, and escalated aggressive behavior.

Abstract

Aggressive behavior can serve important adaptive functions in social species. However, if it exceeds the species-typical pattern, it may become maladaptive. Very high or escalated levels of aggressive behavior can be induced in laboratory rodents by pharmacological (alcohol-heightened aggression), environmental (social instigation), or behavioral (frustration-induced aggression) means. These various forms of escalated aggressive behavior may be useful in further elucidating the neurochemical control over aggression and violence. One neurochemical system most consistently linked with escalated aggression is the GABAergic system, in conjunction with other amines and peptides. Although direct stimulation of GABA receptors generally suppresses aggression, a number of studies have found that positive allosteric modulators of GABAA receptors can cause increases in aggressive behavior. For example, alcohol, benzodiazepines, and many neurosteroids are all positive modulators of the GABAA receptor and all can cause increased levels of aggressive behavior. These effects are dose-dependent and higher doses of these compounds generally shift from heightening aggressive behavior to being sedative and anti-aggressive. In addition, these modulators interact with each other and can have additive effects on the GABAA receptor and on behavior, including aggression. The GABAA receptor is a heteropentameric protein that can be constituted from various subunits. It has been shown that subunit composition can affect sensitivity of the receptor to some modulators and that subunit composition differentially affects the sedative vs anxiolytic actions of benzodiazepines. Initial studies targeting alpha subunits of the GABAA receptor point to their significant role in the aggression-heightening effects of alcohol, benzodiazepines, and neurosteroids.

The Do No Harm Principle (Primum non nocere)

A guiding principle in this blog is not to do any harm, while trying to do some good.

When I read that Hardan was trialing Pregnenolone at Stanford, I thought it was very interesting, but I thought his doses were very high and did not pass the above “first, no harm” principle.  Our pediatric endocrinologist thought the dose rising to 500mg was very unwise.

When I looked into this hormone precursor a year ago I remember thinking it odd that some people were saying 5mg was a big dose, while others were using 50mg and Hardan was going up to 500mg.

Now that I have understood about the mode of action is likely GABA_A, and that allopregnanolone possesses “biphasic, U-shaped actions at the GABA_A receptor”, I understand what may be going on.  The tiny dose might be as effective as the huge dose, but without the side effects caused by all the other accompanying hormonal changes.

The endocrinologist would likely not worry about 5mg of Pregnenolone.  Unlike most other known PAMs of GABA_A, pregnenolone does not need a prescription.

I did look for reports of people trying it themselves for schizophrenia/autism, but did not find anything useful.

Depression and  anxiety, and are frequently-seen side effects of 5α-reductase inhibitors such as finasteride, and are thought to be caused, in part, by interfering with the normal production of allopregnanolone.

Experiments in Humans

The doctors/scientist amongst you will have realized the potential therapeutic value of these paradoxical behaviors at GABA_A receptors.

Instead of using the usual right hand side of the curve, where high doses are effective but may risk tolerance and side effects, we may in some cases be able to use the left hand side.  This means low doses and far less chance of any side effects.

You do of course need some data on the U curve itself and the existing levels, if any, of the chosen GABAA modulator.

In the case of pregnenolone/ allopregnanolone/progesterone this seems to exist at a constant low level in males, but in cyclical low to high levels in females.

You would need to locate where you are on the curve, or perhaps to the left of the entire curve.  By adding a positive allosteric modulator (PAM) can only move to the right.  We know that 500mg of  pregnenolone in adults move to a “better” position on the allopregnanolone curve.

Circulating Levels of Allopregnanolone in Humans:

Gender, Age, and Endocrine Influences

In males 19-39 years old the level of Allopregnanolone is 0.8 nmol/l.

In Women  it varies from from 0.6 to 4.5 nmol/l during the month.

  

Allopregnanolone Elevations Following Pregnenolone Administration are Associated with Enhanced Activation of Emotion Regulation Neurocircuits

These results demonstrate that in response to emotional stimuli, allopregnanolone reduces activity in regions associated with generation of negative emotion. Furthermore, allopregnanolone may enhance activity in regions linked to regulatory processes. Aberrant activity in these regions has been linked to anxiety psychopathology. These results thus provide initial neuroimaging evidence that allopregnanolone may be a target for pharmacological intervention in the treatment of anxiety disorders, and suggest potential future directions for research into neurosteroid effects on emotion regulation neurocircuitry.

Pregnenolone is lipophilic and readily crosses the blood brain barrier. We have previously found that pregnenolone is preferentially metabolized to allopregnanolone, rather than other compounds such as cortisol or DHEA (43, 44); however these metabolites were also assayed. Allopregnanolone serum levels have been reported to triple two hours after oral administration of 400 mg pregnenolone (45). Thus, drug administration occurred two hours before neuroimaging to ensure elevated levels during the scan.

Pregnenolone administration reduced activity in neural circuits associated with the generation of negative emotions. Across all conditions and all face types, pregnenolone administration decreased right amygdala and right insula activity, and serum levels of pregnenolone and allopregnanolone were negatively correlated with amygdala and insula activation levels. The amygdala is a key region in threat detection (52), fear conditioning (53), and emotional salience (54). The insula is responsible for interoception (55), disgust (56), emotion processing (57), emotional recall (36), and anticipation of aversive stimuli (58). Both regions are associated with negative emotional response (57), and greater amygdala activation in response to the presentation of facial expressions is associated with greater magnitude of emotional response (59–63). Additionally, activation reductions in amygdala and insula are associated with down-regulation of negative emotions (64). Thus, allopregnanolone’s reduction of activity in amygdala and insula suggests that allopregnanolone may reduce emotional reactivity to aversive stimuli.

Allopregnanolone likely impacts emotion regulation neurocircuitry through GABAergic mechanisms, though it may also impact this circuitry through its enhancement of neurogenesis (78) myelination (79) or neuroprotection (80–83). Amygdala and mPFC are rich in GABA(A) receptors (28) and endogenous allopregnanolone (48), suggesting that allopregnanolone could feasibly have a direct impact on activity in these regions. Indeed, in our sample, allopregnanolone serum level was more strongly correlated to amygdala activity than activity in any other brain region. Preclinical research suggests that the amygdala may be a particular target of allopregnanolone’s anxiolytic effects (30). In rats, microinfusions of allopregnanolone directly into the amygdala produce anxiolytic (30) antidepressant (31) and anti-aggressive (32) effects. In previous neuroimaging studies, greater endogenous allopregnanolone has been reported to be associated with lower amygdala reactivity (33, 41) and greater coupling between amygdala and dmPFC (34). Though we did not directly test the GABAergic effect of our intervention, our findings illuminate potential neural pathways through which pregnenolone administration and resulting increases in allopregnanolone levels could feasibly impact GABAergic transmission in a manner that is relevant to pathological anxiety.

In conclusion, we demonstrate that pregnenolone administration (leading to increased downstream allopregnanolone levels) reduces activity in regions associated with the generation of negative emotion and enhances activity in regions linked to regulatory control over emotion, as well as increasing connectivity between two of these regions (dmPFC and amygdala). Considering the wealth of evidence that neurocircuits involving these regions are altered in anxiety disorders, our results invite further investigation into the brain basis for allopregnanolone’s use as an anxiolytic pharmacological intervention.

  

There is plenty of research into mood changes in females linked to the GABAA receptor.  So you could figure out what happens at what concentration of Allopregnanolone, in females.

The “problem” here is that plot thickens even further, in females it has been shown that the structure of the GABAA receptor actually changes.  When estrogen levels are higher than progesterone levels, the number of delta receptors decrease, increasing nerve cell activity, in turn increasing anxiety.

http://www.ncbi.nlm.nih.gov/pubmed/15895085

Here we demonstrate periodic alterations in specific GABA(A)R subunits during the estrous cycle in mice, causing cyclic changes of tonic inhibition in hippocampal neurons. In late diestrus (high-progesterone phase), enhanced expression of deltaGABA(A)Rs increases tonic inhibition, and a reduced neuronal excitability is reflected by diminished seizure susceptibility and anxiety. Eliminating cycling of deltaGABA(A)Rs by antisense RNA treatment or gene knockout prevents the lowering of excitability during diestrus

Since it appears the other GABAA receptors also exhibit the same U-shaped responses, there will be a choice.

I think a little experiment with very low doses of pregnenolone is worthwhile.

You may recall earlier mention in this blog of people with Asperger’s using a topical progesterone cream.  That would likely have exactly the same effect.  

There are other theories as to why progesterone cream might reduce anxiety, but it does seem to help some people.   Here is a comment on an Amazon forum:-

“My 9-year-old son is slightly autistic, suffers from severe anxiety as well as ADD, and although the medicine he takes works wonders for him, he still has residual anxiety. I rubbed 50 mg of natural progesterone cream into his chest every night for about three weeks and noticed unbelievable results. He just blossomed emotionally. We went in for his regular neuro checkup and even the neurologist immediately noticed a difference in my son, commenting on how happy and relaxed he seemed.”

There is also a pregnenolone cream.

It should be cautioned that these are all hormones and they do other things than modulate GABA_A receptors.  The effect/dosage will vary between males/females and with age.

  

Effects of modulating multiple binding sites of GABA_A

We did learn in an earlier post that the GABAA receptors have numerous different binding sites.  Since modulating some of these sites produces paradoxical results, you might wonder what happens if you really mix things up.  For example what happens if you modulate the benzo site and the neurosteroid site at the same time.

Neurosteroid coadministration prevents development of tolerance and augments recovery from benzodiazepine withdrawal anxiety and hyperactivity in mice

or

Mechanisms Underlying Tolerance after Long-Term Benzodiazepine Use: A Future for Subtype-Selective Receptor GABA_A Modulators?

4.4.3. Mechanism 6: Neurosteroids

There is ample and convincing evidence that neurosteroids are endogenous allosteric regulators that interact with GABA_A receptors to modulate both tonic (extrasynaptic) and phasic (synaptic) inhibition (for reviews, see [150, 151]). Also, acute or chronic neurosteroid treatment may change GABA_A receptor subunit expression, especially extrasynaptic α₄ and δ subunits [151]. In light of the plasticity-inducing actions of neurosteroids on inhibitory signaling, long-term enhancement of the GABA system with benzodiazepines may in turn evoke changes in the neurosteroids system such as changes in neurosteroid synthesis and metabolism, although classical benzodiazepines may differ in their potency to cause such changes [152]. In support, ovariectomy attenuated the development of tolerance to the anticonvulsant actions of diazepam [153]. Moreover, co-administration of the neurosteroids allopregnanolone or pregnenolone (but not dehydroepiandrosterone) prevented the development of tolerance after chronic treatment with either triazolam and diazepam [154]. Adding to the complexity of the putative involvement of neurosteroids in benzodiazepine tolerance, factors such as GABA_A receptor subunit composition, phosphorylation mechanisms, and ((extra)synaptic) localization—which are all factors that were already found to be involved in tolerance development—influence the specific dynamics of neurosteroid activity.

Ganaxolone – an altogether better Neurosteroid ?

Ganaxolone has the same chemical structure as allopregnanolone, with the addition of a methyl group designed to prevent conversion back to an active steroid, thereby eliminating the opportunity for unwanted hormonal effects while preserving its desired CNS activity.

We came across Ganaxolone in an earlier post, which looked at drugs being trialed in Fragile X.

I thought it was interesting that it is also being trialed in epilepsy and indeed PTSD (post-traumatic stress disorder)

I think that PTSD and TBI (Traumatic Brain Injury) can provide insights for understanding autism.

It is odd that nobody has trialed Ganaxolone for schizophrenia, to see if it shares the positive effects of Pregnenolone.  Then you might expect someone to think of trialing it in autism.

Conclusion

It would seem that, depending on your own natural level of allopregnanolone, supplementing it with pregnenolone or progesterone could have very different effects, depending on the dosage.

In addition, we have the fact that in autism the GABA_A receptor is dysfunctional and some aspects may work in reverse.

Having established that very large doses of Pregnenolone (which produces allopregnanolone) seems to be helpful in autism and schizophrenia, it would be well worth measuring the level of allopregnanolone, produced by different doses and of course investigating the effect of tiny doses of Pregnenolone.

Anecdotally, in typical people, tiny doses of Pregnenolone do have an effect.

It might turn out that because of where you are actually on the curve, you might actually need a low dose Negative Allosteric Modulator (NAM), to make you move to the left.  Interestingly there is such a NAM, Pregnenolone Sulfate.

Pregnenolone sulfate  is an endogenous excitatory neurosteroid that is synthesized from pregnenolone. It is known to have cognitive and memory-enhancing, antidepressant, anxiogenic, and proconvulsant effects.^[2]

Mechanism

Pregnenolone sulfate is a neurosteroid with excitatory effects in the brain, acting as a potent negative allosteric modulator of the GABA_A receptor and a weak positive allosteric modulator of the NMDA receptor.^] To a lesser extent, it also acts as a negative allosteric modulator of the AMPA, kainate, and glycine receptors, and may interact with the nACh receptors as well. In addition to its effects on ligand-gated ion channels, pregnenolone sulfate is an agonist of the sigma receptor, as well as an activator of the TRPM1 and TRPM3 channels. It may also interact with potassium channels and voltage-gated sodium channels.

Pregnenolone and its sulfate, like DHEA and its sulfate and progesterone, belong to the group of neurosteroids that are found in high concentrations in certain areas of the brain, and are synthesized there. Neurosteroids affect synaptic functioning, are neuroprotective, and enhance myelinization. Pregnenolone and its sulfate ester are under investigation for their potential to improve cognitive and memory functioning.^[3] Pregnenolone is also being considered as a potential treatment for schizophrenia.^[1]

Role of pregnenolone, dehydroepiandrosterone and their sulfate esters on learning and memory in cognitive aging

“Studies in animals demonstrated that the neurosteroids pregnenolone (PREG) and dehydroepiandrosterone (DHEA), as sulfate derivatives (PREGS and DHEAS, respectively), display memory-enhancing properties in aged rodents. Moreover, it was recently shown that memory performance was correlated with PREGS levels in the hippocampus of 24-month-old rats. Human studies, however, have reported contradictory results. First, improvement of learning and memory dysfunction was found after DHEA administration to individuals with low DHEAS levels, but other studies failed to detect significant cognitive effects after DHEA administration. Second, cognitive dysfunctions have been associated with low DHEAS levels, high DHEAS levels, or high DHEA levels; while in other studies, no relationship was found.”

Another NAM at the GABAA receptor is DHEA, a steroid hormone produced in the body.  Regular exercise stimulates the production of DHEA.

Lowered DHEA-S plasma levels in adult individuals with autistic disorder

Faulty serotonin--DHEA interactions in autism: results of the 5-hydroxytryptophan challenge test.

We also learnt that structure of the GABA_A receptor can be modified.  It happens continuously in females.  So as well as clever ways to use allosteric modulators, you could also copy nature and change the structure of the GABA_A receptors themselves.  In fact the genetic research does suggest this structure has been disturbed in autism; you would just be correcting a defect.

It does look like high dose Pregnenolone really is effective in reducing the symptoms in schizophrenia.  Here is yet another study showing this:-

Proof-of-Concept Trial with the Neurosteroid Pregnenolone Targeting Cognitive and Negative Symptoms in Schizophrenia

Biotin & Triglycerides - why perhaps Fish Oil and Niacin may actually help a little in Autism & Schizophrenia

Far back in this blog, I wrote a post about fish oil.  Omega 3 oils are definitely good for your general health, but do they help with autism?  They are also claimed to help with ADHD and improve your NT child’s cognitive performance.

On critical review of the evidence, it seemed that the benefit was far from conclusive.  There was one very positive study, that neither the authors nor anyone else could repeat.

The following review of the literature by the University of Maryland show that, as with autism, studies on fish oil in depression, ADHD, bipolar and schizophrenia show conflicting results.

Omega-3 fatty acids

Some of the “cognitive enhancing” fish oil products are extremely expensive and I showed that regular fish consumption was far cheaper and likely to be as effective.

There is an issue of just how big an effect you are looking for.  We can all imagine tiny effects, but you really want an effect that everyone else notices.

Monty, aged 11 with ASD, eats lots of fish, mainly because he loves it.  He is not at all put off by those little bones.

The effect of fish oil on Monty was not noticeable.

Biotin

A recent post contained a study from Greece, where they found a remarkably high proportion of kids with ASD with a biotin deficiency.  This had not shown up on the standard test, because the standard test is strangely not for biotin at all; it tests for biotinidase, a related enzyme.

Identifying a biotin deficiency is not easy, blood tests are not helpful and you have to look at certain compounds found in urine.  As a result your local laboratory may not offer a useful test for biotin.

Since supplementation with pharmacological doses of biotin is known to be harmless, the practical way forward is to try it.

In the midst of looking at the relative effect of different primary antioxidants, I was substituting one thiol antioxidant (ALA) for another (NAC) to see if there was any obvious difference.  I could give lots of reasons, with scientific papers to back them up, as to why 0.6g of ALA plus 1.8g of NAC might be “better” than 2.4g of NAC, but it is not.  If anything, it might be worse.

Then I tried Carnosine in combination with NAC and again I could see absolutely no effect.

Then I decided to go back to my original NAC regime and add the biotin that had been on the shelf since Christmas. Very surprisingly, the effect that I thought might show up with ALA, showed up with biotin.  

It was not a huge effect, but a small step forward, that Monty’s assistant at school also noticed.  He was more calm and altogether more "normal". 

Does this mean Monty has a biotin deficiency?  It is of course possible.  In the Greek study 4% of the kids were thought to have such a deficiency, far more than expected, and most did respond, in varying degrees, to biotin supplements.  Unfortunately they only gave the biotin to the 4%; I would like to know what would have happened to the remaining 96%.

Biotin lowers Triglycerides and Elevated Triglycerides are associated with Mood Disorders   

Biotin is a B vitamin, but very little is actually known about it.

Then I found the link I was looking for.

Biotin does not lower cholesterol, but it does reduce (in a big way) your Triglycerides.

Several studies have shown that elevated Triglycerides are associated with all kinds of disorders: bipolar, depression and schizophrenia.  These studies suggested a causal link between the mood disorder and the elevated triglyerides.

Other Effects on Mood

          Besides depression, high levels of triglycerides are also correlated with other affective disorders including bipolar disorder (manic depression), schizoaffective disorders, aggression and hostility. In fact, the poor nutritional status of many depressed persons, who often have diets high in fats, can be improved to lessen the depression, according to Charles Glueck, MD, medical director of the Cholesterol Center of Jewish Hospital in Cincinnati.

"We have shown that in patients with high triglycerides who were in a depressive state, the more you lower the triglycerides, the more you alleviate the depression," Glueck wrote in a 1993 article in Biological Psychiatry.

According to the U.S. Centers for Disease Control and Prevention (CDC), most Americans aren't aware of the role triglycerides play in physical and mental health. A five-year study of more than 5,000 Americans found that 33 percent of them had borderline high triglyceride levels.

Improvement in symptoms of depression and in an index of life stressors accompany treatment of severe hypertriglyceridemia.

In 14 men and nine women referred because of severe primary hypertriglyceridemia, our specific aim in a 54-week single-blind treatment (Rx) period was to determine whether triglyceride (TG) lowering with a Type V diet and Lopid would lead to improvement in symptoms of depression, improvement in an index of life stressors, change in locus of control index, and improved cognition, as serially tested by Beck (BDI), Hassles (HAS) and HAS intensity indices, Locus of Control index, and the Folstein Mini-Mental status exam. On Rx, median TG fell 47%, total cholesterol (TC) fell 15%, and HDLC rose 19% (all p < or = 0.001). BDI fell at all nine Rx visits (p < or = 0.001), a major reduction in a test of depressive symptoms. The HAS score also fell at all nine visits (p < or = 0.05 - < or = 0.001). Comparing pre-Rx baseline BDI vs BDI at 30 and 54 weeks on Rx, there was a major shift towards absence or amelioration of depressive symptoms (chi 2= 5.9, p = 0.016). On Rx, the greater the percent reduction in TG, the greater the percent fall in BDI (r = 0.47, p < or = 0.05); the greater the percent reduction in TC, the greater the percent fall in HAS (r = 0.41, p < or = 0.05). Improvement in the BDI and HAS accompanied treatment of severe hypertriglyceridemia, possibly by virtue of improved cerebral perfusion and oxygenation. There may be a reversible causal relationship between high TG and symptoms of depression.

Mood symptoms and serum lipids in acute phase of bipolar disorder inTaiwan.

 

Abstract

Serum lipids have been found to play important roles in the pathophysiology of mood disorders. The aim of the present study was therefore to investigate the relationship between symptom dimensions and serum cholesterol and triglyceride levels, and to explore correlates of lipid levels during acute mood episodes of bipolar I disorder in Taiwan. Measurements were taken of the serum cholesterol and triglyceride levels in patients with bipolar I disorder hospitalized for acute mood episodes (68 manic, eight depressive, and six mixed). The relationships between serum lipids levels and various clinical variables were examined. The mean serum levels of cholesterol (4.54 mmol/L) and triglycerides (1.16 mmol/L) of sampled patients were comparable to those of the general population in the same age segment. Severe depressive symptoms and comorbid atopic diseases were associated with higher serum cholesterol levels. A negative association was noted between serum triglyceride levels and overall psychiatric symptoms. Compared with previous studies on Western populations, racial differences may exist in lipids profiles of bipolar disorder patients during acute mood episodes. Increased serum cholesterol levels may have greater relevance to immunomodulatory system and depressive symptoms, in comparison with manic symptoms.

Biotin supplementation reduces plasma triacylglycerol and VLDL in type 2 diabetic patients and in non-diabetic subjects with hypertriglyceridemia.

Abstract

Biotin is a water-soluble vitamin that acts as a prosthetic group of carboxylases. Besides its role as carboxylase prosthetic group, biotin regulates gene expression and has a wide repertoire of effects on systemic processes. The vitamin regulates genes that are critical in the regulation of intermediary metabolism. Several studies have reported a relationship between biotin and blood lipids. In the present work we investigated the effect of biotin administration on the concentration of plasma lipids, as well as glucose and insulin in type 2 diabetic and nondiabetic subjects. Eighteen diabetic and 15 nondiabetic subjects aged 30-65 were randomized into two groups and received either 61.4 micromol/day of biotin or placebo for 28 days. Plasma samples obtained at baseline and after treatment were analyzed for total triglyceride, cholesterol, very low density lipoprotein (VLDL), glucose and insulin. We found that the vitamin significantly reduced (P=0.005) plasma triacylglycerol and VLDL concentrations. Biotin produced the following changes (mean of absolute differences between 0 and 28 day treatment+/-S.E.M.): a) triacylglycerol -0.55+/-0.2 in the diabetic group and -0.92+/-0.36 in the nondiabetic group; b) VLDL: -0.11+/-0.04 in the diabetic group and -0.18+/-0.07 in the nondiabetic group. Biotin treatment had no significant effects on cholesterol, glucose and insulin in either the diabetic or nondiabetic subjects. We conclude that pharmacological doses of biotin decrease hypertriglyceridemia. The triglyceride-lowering effect of biotin suggests that biotin could be used in the treatment of hypertriglyceridemia.

The hypotriglyceridemic effect of biotin supplementation involves increased levels of cGMP and AMPK activation

Abstract

In addition to its role as a carboxylase cofactor, biotin modifies gene expression and has manifold effects on systemic processes. Several studies have shown that biotin supplementation reduces hypertriglyceridemia. We have previously reported that this effect is related to decreased expression of lipogenic genes. In the present work, we analyzed signaling pathways and posttranscriptional mechanisms involved in the hypotriglyceridemic effects of biotin. Male BALB/cAnN Hsd mice were fed a control or a biotin-supplemented diet (1.76 or 97.7 mg of free biotin/kg diet, respectively for 8 weeks after weaning. The abundance of mature sterol regulatory element-binding protein (SREBP-1c), fatty-acid synthase (FAS), total acetyl-CoA carboxylase-1 (ACC-1) and its phosphorylated form, and AMP-activated protein kinase (AMPK) were evaluated in the liver. We also determined the serum triglyceride concentrations and the hepatic levels of triglycerides and cyclic GMP (cGMP). Compared to the control group, biotin-supplemented mice had lower serum and hepatic triglyceride concentrations. Biotin supplementation increased the levels of cGMP and the phosphorylated forms of AMPK and ACC-1 and decreased the abundance of the mature form of SREBP-1c and FAS. These data provide evidence that the mechanisms by which biotin supplementation reduces lipogenesis involve increased cGMP content and AMPK activation. In turn, these changes lead to augmented ACC-1 phosphorylation and decreased expression of both the mature form of SREBP-1c and FAS. Our results demonstrate for the first time that AMPK is involved in the effects of biotin supplementation and offer new insights into the mechanisms of biotin-mediated hypotriglyceridemic effects.

Triglycerides are also elevated in autism:-

Alterations in lipid profile of autistic boys: a case control study.

Abstract

We hypothesize that autism is associated with alterations in the plasma lipid profile and that some lipid fractions in autistic boys may be significantly different than those of healthy boys. A matched case control study was conducted with 29 autistic boys (mean age, 10.1 +/- 1.3 years) recruited from a school for disabled children and 29 comparable healthy boys from a neighboring elementary school in South Korea. Fasting plasma total cholesterol (T-Chol), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), the LDL/HDL ratio, and 1-day food intakes were measured. Multiple regression analyses were performed to assess the association between autism and various lipid fractions. The mean TG level (102.4 +/- 52.4 vs 70.6 +/- 36.3; P = .01) was significantly higher, whereas the mean HDL-C level (48.8 +/- 11.9 vs 60.5 +/- 10.9 mg/dL; P = .003) was significantly lower in cases as compared to controls. There was no significant difference in T-Chol and LDL-C levels between cases and controls. The LDL/HDL ratio was significantly higher in cases as compared to controls. Multiple regression analyses indicated that autism was significantly associated with plasma TG (beta = 31.7 +/- 11.9; P = .01), HDL (beta = -11.6 +/- 2.1; P = .0003), and the LDL/HDL ratio (beta = 0.40 +/- 0.18; P = .04). There was a significant interaction between autism and TG level in relation to plasma HDL level (P = .02). Fifty-three percent of variation in the plasma HDL was explained by autism, plasma TG, LDL/HDL ratio, and the interaction between autism and plasma TG level. These results indicate the presence of dyslipidemia in boys with autism and suggest a possibility that dyslipidemia might be a marker of association between lipid metabolism and autism.

Omega-3 Oil and Niacin in Schizophrenia

Like Autism, Schizophrenia is another observational diagnosis, with many different underlying genetic and environmental causes.  I keep referring to it as adult-onset autism.  It is also characterized by oxidative stress.

I found it interesting that two very widely used therapies for schizophrenia are omega-3 fish oil and high doses of niacin.  2 g a day of NAC is another common therapy in schizophrenia.

The clinical trials of omega-3 oil in schizophrenia, are just like the ones in autism, far from conclusive.  Yet people with schizophrenia continue to buy the expensive EPA fish oils, just like many parents of children with autism.

Another very popular treatment is Niacin.

Niacin does many things but these include increasing your HDL (good) cholesterol, reduce LDL (bad) cholesterol and, importantly, can reduce triglycerides by up to 50%.

Management of Hypertriglyceridemia

Niacin in Anxiety

Supplemental Niacinamide Mitigates Anxiety Symptoms: Three Case Reports

Niacin in autism

People do use high dose niacin and niacinamide in autism, but in general niacin levels are totally normal in people with autism, according to this study:-

Nutritional and metabolic status of children with autism vs. neurotypical children, and the association with autism severity

For the vitamins, the only significant difference was a 20% lower biotin (p < 0.001) in the children with autism. There were possibly significant (p < 0.05) lower levels of vitamin B5, vitamin E, and total carotenoids. Vitamin C was possibly slightly higher in the children with autism. Vitamin B6 (measured as the active form, P5P, in the RBC) had an unusually broad distribution in children with autism compared to controls (see Figure ​Figure1),1), with the levels in the children with autism having 3 times the standard deviation of the neurotypical children.

Niacin was very similar in the autism group (7.00 μg/l and the control group (7.07 μg/l)

Other interesting findings highlighted the usual metabolic differences:-

·        ATP, NADH, and NAHPH were significantly different between the autism and neurotypical groups

·        Sulfation, methylation, glutathione, and oxidative stress biomarkers which were significantly different between the autism and neurotypical groups

·        Amino Acids which were significantly different between the autism and neurotypical groups, rescaled to the average neurotypical value

Peter Triglyceride Hypothesis in Autism & Schizophrenia

Elevated triglycerides in autism/schizophrenia may contribute to behavioral/mood problems.  The lipid contribution to the dysfunction may be correlated to elevation of triglycerides.  In other words triglycerides aggravate the existing disorder.

Some CAM treatments currently used in autism/schizophrenia, including high dose niacin, high dose biotin and high dose omega 3 oils may be effective due to their ability to lower triglycerides.

Biotin may be the safest, cheapest and most effective option to reduce triglycerides and improve mood/behavior.

The underlying cause of lipid dysfunction in autism/schizophrenia is the ongoing oxidative stress.

Fish oil is claimed to be good for your heart, but it has been shown not to affect cholesterol levels.  In some studies it did lower triglycerides.  In some countries doctors prescribe omega-3 oil to patients with stubbornly high triglycerides.  Perhaps they should read the research and try biotin?

  

Other functions of biotin

Biotin does have other more complex functions and the triglycerides may, so to speak, be a red herring.

Regulation of gene expression by biotin (review).

Abstract

In mammals, biotin serves as coenzyme for four carboxylases, which play essential roles in the metabolism of glucose, amino acids, and fatty acids. Biotin deficiency causes decreased rates of cell proliferation, impaired immune function, and abnormal fetal development. Evidence is accumulating that biotin also plays an important role in regulating gene expression, mediating some of the effects of biotin in cell biology and fetal development. DNA microarray studies and other gene expression studies have suggested that biotin affects transcription of genes encoding cytokines and their receptors, oncogenes, genes involved in glucose metabolism, and genes that play a role in cellular biotin homeostasis. In addition, evidence has been provided that biotin affects expression of the asialoglycoprotein receptor and propionyl-CoA carboxylase at the post-transcriptional level. Various pathways have been identified by which biotin might affect gene expression: activation of soluble guanylate cyclase by biotinyl-AMP, nuclear translocation of NF-kappaB (in response to biotin deficiency), and remodeling of chromatin by biotinylation of histones. Some biotin metabolites that cannot serve as coenzymes for carboxylases can mimic biotin with regard to its effects on gene expression. This observation suggests that biotin metabolites that have been considered "metabolic waste" in previous studies might have biotin-like activities. These new insights into biotin-dependent gene expression are likely to lead to a better understanding of roles for biotin in cell biology and fetal development.

It does appear that biotin is more important than generally appreciated. 

Conclusion

In earlier posts I highlighted that elevated cholesterol is a bio-marker for inflammation.  In a large sub-group in autism, cholesterol is elevated.

In today’s post we looked at  a different type of lipid, triglycerides, they have a different role to cholesterol.  Not surprisingly the lipid profile is dysfunction, since it is closely linked to oxidative stress, which appears to be at the root of many problems in autism.

It is extremely easy and inexpensive to check your lipid profile (LDL, HDL and triglycerides); if elevated, there are safe established ways to bring things back to “normal”.

Parents seeing a small positive effect with their fish oil supplements might consider saving a lot of money and seeing if an extremely inexpensive biotin (5mg) supplement has an equal or greater effect.  The cost of biotin would be $2 a month.  The cost of fish oil with anything like the concentration used in the more effective trials (0.84g EPA and 0.7g DHA) will cost around $50 a month and may not lower triglycerides by as much as the cheap biotin.

By measuring the lipid profile before and after, you will be able to determine for yourself the relative merits.

Niacin also has been shown to improve mood/anxiety.  It is used by people with autism and schizophrenia.  Niacin is also extremely effective at reducing triglycerides.  High doses of Niacin can be accompanied by side effects and so use is discouraged.

Biotin levels do seem to be slightly low in autism.  Effective methods of accurately diagnosing deficiency are disputed.  Biotin is very effective at reducing triglycerides.

Elevated triglycerides have been associated with mood disorders and depression.

It seems plausible that the benefits from Omega-3 , niacin and biotin stem from their effectiveness in reducing triglycerides.

Biotin would seem to be a very cost effective and safe way to achieve this, without the side effects of niacin.  

Biotin also appears to have other key functions, including transcription of cytokine genes. Over expression of pro-inflammatory cytokines is a common feature of autism.

Broccoli soup at school – washed down with a little grapefruit juice

A growing number of readers have discovered the remarkable effects of a specific preparation of broccoli sprout powder.  It was my suggested method to match the Sulforaphane, made in the lab at Johns Hopkins, and recently trialed with great results in young adults with autism.

I did mention to therapists working with Monty, aged 11 with ASD, what a surprise there would be at the local special school if they served up some extra-potent broccoli soup for lunch one day.  There would be some very bemused teachers and parents.  It would also be the world's cheapest randomized trial on 100 people and the fastest. (you would just have to note down who actually ate the soup, but I think it would be obvious later)

Since another reader stumbled upon the anti-oxidant capability of grapefruit juice the other day, I would add some of that to the school lunch.  Preferably pink grapefruit, since they also would have a dose of lycopene, another potent antioxidant.

As fate would have it, a trial is underway with a jar of the aforementioned broccoli powder.  It is not at the local special school, but at a private center for speech & behavioral therapy.  

A reader of this blog has told someone else, who then tried it on their child and now someone else has bought a jar to try on the children at the center.

Of course, in a litigious country, nobody would dream of doing this; but in some countries, common sense still prevails.

I do hope the center keeps a note of who tried it and what the effects were, so we can have some statistics.  The good thing is that because it is so fast-acting, the therapist will observe the effects unfolding within the very same session.

Since the main effects are on mood and speech, a speech therapist is probably the best person to observe and quantify the effect.

In the kind of children who attend such centers, where autism is a disability rather than a difference, I think the response rate with be really high.  I would guess 70+%.  If they want to write up a report, I will be delighted to post it on this blog.

Anyway, I give them 10 out of 10 for initiative.

Targeted pharmacological treatment of autism spectrum disorders: fragile X and Rett syndrome

Today’s post is to refer the scientists among you to a very thorough paper looking at possible drug therapies for two specific variants of autism, Fragile X and Rett Syndrome.

Targeted pharmacological treatment of autism spectrum disorders: fragile X and Rett syndromes

  

These are single gene autisms and, as such, it is very much easier to study them than classic autism(s) or regressive autism(s).

We have already seen that much can be learnt from Fragile X and Retts.  What helps treat these disorders may give useful pointers to treat other types of autism and some therapies may be directly transferable, in some cases.

Note the use of baclofen, memantine, lovastatin, rapamycin, a PAK inhibitor, two potassium channel drugs, oxytocin, and even lithium.

Ganaxalone is a positive allosteric modulator of the GABA_A receptor, probably affects the neurosteroid site.  It does not have the drawbacks of benzodiazepines.  I wonder whether it exhibits interesting effects at tiny doses? 

Tuning GABAa receptors

Treatment of Autism with low dose Phenytoin

Acamprosate appears to be neuro-protective, but the mechanism of action is unknown and controversial.  It is a drug a drug used for treating alcohol and benzodiazepine dependence.  A surprising number of off-label autism drugs are used for to treat substance abuse.

The paper is well worth a read for those who are heavily into the subject.