More on Treatable ID Masquerading as Autism

I did write a post a while back highlighting an excellent on line resource that gives clinicians data on 81 treatable forms of Intellectual Disability, ID (formerly known as mental retardation, MR).

Treatable ID/MR

There is a big overlap between the causes of some ID and causes of some autism.

If you have a case of autism, it is worth reviewing the 81 treatable forms of ID, just in case you have one, even a mild version causing minimal ID.  Partial dysfunctions certainly are possible, as we saw with biotin. 

It is also very interesting to look through the therapies used and see how they overlap with those used by people in their n=1 case of autism.

For example the therapy for SLOS (Smith–Lemli–Opitz syndrome) which is related to very low cholesterol is to give cholesterol and Simvastatin.  Simvastatin is widely used in older people to LOWER cholesterol.  Statins have several other known modes of action. We use Atorvastatin.

Note all the vitamin related syndromes etc.

The data is all on the online resource that is highlighted at the top of every page in this blog, but as one regular reader from Hong Kong pointed out, it is better to actually read it in table form.  

He recommended the two papers below.  I reproduced some of the tables, but I suggest you click the link to read the papers. 

The formatting is not so good, since I have cut and paste from the papers.

You have the syndromes, their therapies and their diagnostic tests.

Complicated questions should be addressed to the authors of the papers or your doctor.

Treatable inborn errors of metabolism causing intellectual disability: A systematic literature review

Table 2Overview of all 81 treatable IDs.In this table, the IEMs are grouped according to the biochemical phenotype as presented in standard textbooks, and alphabetically. Of note, primary CoQ deficiency was considered as one single IEM even though more though 6 genes have been described; this is true as well for MELAS and Pyruvate Dehydrogenase Complex deficiency.
Biochemical category	Disease name	OMIM#	Biochemical deficiency	Gene(s)
Amino acids	HHH syndrome (hyperornithinemia, hyperammonemia, homocitrullinemia)	238970	Ornithine translocase	SLC25A15 (AR)
	l.o. Non-ketotic hyperglycinemia	605899	Aminomethyltransferase/glycine decarboxylase/glycine cleavage system H protein	AMT/GLDC/GCSH (AR)
	Phenylketonuria	261600	Phenylalanine hydroxylase	PAH (AR)
	PHGDH deficiency(Serine deficiency)	601815	Phosphoglycerate dehydrogenase	PHGDH (AR)
	PSAT deficiency(Serine deficiency)	610992	Phosphoserine aminotransferase	PSAT1 (AR)
	PSPH deficiency(Serine deficiency)	614023	Phosphoserine phosphatase	PSPH (AR)
	Tyrosinemia type II	276600	Cytosolic tyrosine aminotransferase	TAT (AR)
Cholesterol & bile acids	Cerebrotendinous xanthomatosis	213700	Sterol-27-hydroxylase	CYP27A1 (AR)
	Smith–Lemli–Opitz Syndrome	270400	7-Dehydroxycholesterol reductase	DHCR7 (AR)
Creatine	AGAT deficiency	612718	Arginine: glycine amidinotransferase	GATM (AR)
	Creatine transporter Defect	300352	Creatine transporter	SLC6A8 (X-linked)
	GAMT deficiency	612736	Guanidino-acetate-N-methyltransferase	GAMT (AR)
Fatty aldehydes	Sjögren–Larsson syndrome	270200	Fatty aldehyde dehydrogenase	ALDH3A2 (AR)
Glucose transport & regulation	GLUT1 deficiency syndrome	606777	Glucose transporter blood–brain barrier	SLC2A1 (AR)
	Hyperinsulinism hyperammonemia syndrome	606762	Glutamate dehydrogenase superactivity	GLUD1 (AR)
Hyperhomocysteinemia	Cobalamin C deficiency	277400	Methylmalonyl-CoA mutase and homocysteine : methyltetrahydrofolate methyltransferase	MMACHC (AR)
	Cobalamin D deficiency	277410	C2ORF25 protein	MMADHC (AR)
	Cobalamin E deficiency	236270	Methionine synthase reductase	MTRR (AR)
	Cobalamin F deficiency	277380	Lysosomal cobalamin exporter	LMBRD1 (AR)
	Cobalamin G deficiency	250940	5-Methyltetrahydrofolate-homocysteine S-methyltransferase	MTR (AR)
	Homocystinuria	236200	Cystathatione β-synthase	CBS (AR)
	l.o. MTHFR deficiency	236250	Methylenetetrahydrofolate reductase deficiency	MTHFR (AR)
Lysosomes	α-Mannosidosis	248500	α-Mannosidase	MAN2B1 (AR)
	Aspartylglucosaminuria	208400	Aspartylglucosaminidase	AGA (AR)
	Gaucher disease type III	231000	ß-Glucosidase	GBA (AR)
	Hunter syndrome (MPS II)	309900	Iduronate-2-sulfatase	IDS (X-linked)
	Hurler syndrome (MPS I)	607014	α-L-iduronidase	IDUA (AR)
	l.o. Metachromatic leukodystrophy	250100	Arylsulfatase A	ARSA (AR)
	Niemann–Pick disease type C	257220	Intracellular transport cholesterol & sphingosines	NPC1 NPC2 (AR)
	Sanfilippo syndrome A (MPS IIIa)	252900	Heparan-N-sulfatase	SGSH (AR)
	Sanfilippo syndrome B (MPS IIIb)	252920	N-acetyl-glucosaminidase	NAGLU (AR)
	Sanfilippo syndrome C (MPS IIIc)	252930	Acetyl-CoA glucosamine-N-acetyl transferase	HGSNAT (AR)
	Sanfilippo syndrome D (MPS IIId)	252940	N-acetyl-glucosamine-6-Sulfatase	GNS (AR)
	Sly syndrome (MPS VII)	253220	β-glucuronidase	GUSB (AR)
Metals	Aceruloplasminemia	604290	Ceruloplasmin (iron homeostasis)	CP (AR)
	Menkes disease/Occipital horn syndrome	304150	Copper transport protein (efflux from cell)	ATP7A (AR)
	Wilson disease	277900	Copper transport protein (liver to bile)	ATP7B (AR)
Mitochondria	Co enzyme Q10 deficiency	607426	Coenzyme Q2 or mitochondrial parahydroxybenzoate-polyprenyltransferase; aprataxin; prenyl diphosphate synthase subunit 1; prenyl diphosphate synthase subunit 2; coenzyme Q8; coenzyme Q9	COQ2, APTX, PDSS1, PDSS2, CABC1, COQ9 (most AR)
	MELAS	540000	Mitochondrial energy deficiency	MTTL1, MTTQ,MTTH, MTTK,MTTC, MTTS1,MTND1, MTND5,MTND6, MTTS2 (Mt)
	PDH complex deficiency	OMIM# according to each enzyme subunit deficiency: 312170; 245348; 245349	Pyruvate dehydrogenase complex (E1α, E2, E3)	PDHA1 (X-linked), DLAT (AR), PDHX (AR)
Neurotransmission	DHPR deficiency (biopterin deficiency)	261630	Dihydropteridine reductase	QDPR (AR)
	GTPCH1 deficiency (biopterin deficiency)	233910	GTP cyclohydrolase	GCH1 (AR)
	PCD deficiency (biopterin deficiency)	264070	Pterin-4α-carbinolamine dehydratase	PCBD1 (AR)
	PTPS deficiency (biopterin deficiency)	261640	6-Pyruvoyltetrahydropterin synthase	PTS (AR)
	SPR deficiency (biopterin deficiency)	612716	Sepiapterin reductase	SPR (AR)
	SSADH deficiency	271980	Succinic semialdehyde dehydrogenase	ALDH5A1 (AR)
	Tyrosine Hydroxylase Deficiency	605407	Tyrosine Hydroxylase	TH (AR)
Organic acids	3-Methylcrotonyl glycinuria	GENE OMIM # 210200; 210210	3-Methylcrotonyl CoA carboxylase (3-MCC)	MCC1/MCC2 (AR)
	3-Methylglutaconic aciduria type I	250950	3-Methylglutaconyl-CoA hydratase	AUH (AR)
	β-Ketothiolase deficiency	203750	Mitochondrial acetoacetyl-CoA thiolase	ACAT1 (AR)
	Cobalamin A deficiency	251100	MMAA protein	MMAA (AR)
	Cobalamin B deficiency	251110	Cob(I)alamin adenosyltransferase	MMAB (AR)
	Ethylmalonic encephalopathy	602473	Mitochondrial sulfur dioxygenase	ETHE1 (AR)
	l.o. Glutaric acidemia I	231670	Glutaryl-CoA dehydrogenase	GCDH (AR)
	Glutaric acidemia II	231680	Multiple acyl-CoA dehydrogenase	ETFA, ETFB,ETFDH (AR)
	HMG-CoA lyase deficiency	246450	3-Hydroxy-3-methylglutaryl-CoA lyase	HMGCL (AR)
	l.o. Isovaleric acidemia	243500	Isovaleryl-CoA dehydrogenase	IVD (AR)
	Maple syrup urine disease (variant)	248600	Branched-chain 2-ketoacid complex	BCKDHA/BCKDHB/ DBT (AR)
	l.o. Methylmalonic acidemia	251000	Methylmalonyl-CoA mutase	MUT (AR)
	MHBD deficiency	300438	2-Methyl-3-hydroxybutyryl-CoA dehydrogenase	HSD17B10 (X-linked recessive)
	mHMG-CoA synthase deficiency	605911	Mitochondrial 3-hydroxy-3-Methylglutaryl-CoA synthase	HMGCS2 (AR)
	l.o. Propionic acidemia	606054	Propionyl-CoA carboxylase	PCCA/PCCB (AR)
	SCOT deficiency	245050	Succinyl-CoA 3-oxoacid CoA transferase	OXCT1 (AR)
Peroxisomes	X-linked adrenoleukodystrophy	300100	Peroxisomal transport membrane protein ALDP	ABCD1 (X-linked)
Pyrimidines	Pyrimidine 5-nucleotidase superactivity	GENE OMIM # 606224	Pyrimidine-5-nucleotidase Superactivity	NT5C3 (AR)
Urea cycle	l.o. Argininemia	207800	Arginase	ARG1 (AR)
	l.o. Argininosuccinic aciduria	207900	Argininosuccinate lyase	ASL (AR)
	l.o. Citrullinemia	215700	Argininosuccinate Synthetase	ASS1 (AR)
	Citrullinemia type II	605814	Citrin (aspartate–glutamate carrier)	SLC25A13
	l.o. CPS deficiency	237300	Carbamoyl phosphate synthetase	CPS1 (AR)
	l.o. NAGS deficiency	237310	N-acetylglutamate synthetase	NAGS (AR)
	l.o. OTC Deficiency	311250	Ornithine transcarbamoylase	OTC (X-linked)
Vitamins/co-factors	Biotinidase deficiency	253260	Biotinidase	BTD (AR)
	Biotin responsive basal ganglia disease	607483	Biotin transport	SLC19A3(AR)
	Cerebral folate receptor-α deficiency	613068	a.o. Cerebral folate transporter	FOLR1 (AR)
	Congenital intrinsic factor deficiency	261000	Intrinsic factor deficiency	GIF (AR)
	Holocarboxylase synthetase deficiency	253270	Holocarboxylase synthetase	HLCS (AR)
	Imerslund Gräsbeck syndrome	261100	IF-Cbl receptor defects (cubulin/amnionless)	CUBN & AMN (AR)
	Molybdenum co-factor deficiency type A	252150	Sulfite oxidase & xanthine dehydrogenase & aldehyde oxidase	MOCS1, MOCS2,(AR)
	Pyridoxine dependent epilepsy	266100	Pyridoxine phosphate oxidase	ALDH7A1 (AR),
	Thiamine responsive encephalopathy	606152	Thiamine transport	SLC19A3 (AR)

Table 5Overview of all causal therapies (n=91).This Table provides an overview of the specific therapy/-ies available for each IEM with relevant level(s) of evidence, therapeutic effect(s) on primary and/or secondary outcomes and use in clinical practice. For 10 IEMs, two therapies are available; these are listed separately (in brackets).
Disease name	Therapeutic modality (−ies)	Level of evidence	Clinical practice	Treatment effect	Literature references
Aceruloplasminemia	Iron chelation	4	Standard of care	D,E	[[45], [46],[47]]
(X-linked)adrenoleukodystrophy	Stemcell transplantation (Gene therapy)	1c (5)	Individual basis (Individual basis)	D,E (D,E)	[[48], [49],[50]]
AGAT deficiency	Creatine supplements	4	Standard of care	A,D	[[51], [52],[53]]
α-Mannosidosis	Haematopoietic stem cell transplantation	4-5	Individual basis	D	[54
l.o. Argininemia	Dietary protein restriction, arginine supplement, sodium benzoate, phenylbutyrate (Liver transplantation)	2b (4)	Standard of care (Individual basis)	B,C,D,E,F,G (C)	[[55], [56],[57], [58],[59], [60],[61]]
l.o. Argininosuccinic aciduria	Dietary protein restriction, arginine supplement, sodium benzoate, phenylbutyrate (liver transplantation)	2b (4)	Standard of care (individual basis)	B,C,D,E,F,G (C)	[[55], [56],[57], [58],[60], [61]]
Aspartylglucosaminuria	Haematopoietic stem cell transplantation	4-5	Individual basis	D	[62
β-Ketothiolase deficiency	Avoid fasting, sickday management, protein restriction	5	Standard of care	C	[[63], [64],[65]]
Biotin responsive basal ganglia disease	Biotin supplement	4	Standard of care	A,E	[66
Biotinidase deficiency	Biotin supplement	2c	Standard of care	A,E,G	[67
Cerebral folate receptor-α deficiency	Folinic acid	4	Standard of care	A,D,E,F	[[68], [69]]
Cerebrotendinous xanthomatosis	Chenodesoxycholic acid, HMG reductase inhibitor	4	Standard of care	B,D,E,G	[[70], [71],[72]]
l.o. Citrullinemia	Dietary protein restriction, arginine supplement, sodium benzoate, phenylbutyrate (Liver transplantation)	2b (4)	Standard of care (Individual basis)	B,C,D,E,F,G (C)	[[55], [56],[57], [60],[61]]
Citrullinemia type II	Dietary protein restriction, arginine supplement, sodium benzoate, phenylbutyrate (Liver transplantation)	2b (4)	Standard of care (Individual basis)	B,C,D,E,F,G (C)	[[50], [51],[52], [73],[55], [56]]
Co enzyme Q10 deficiency	CoQ supplements	4	Standard of care	E,F	[[74], [75]]
Cobalamin A deficiency	Hydroxycobalamin, protein restriction	4	Standard of care	C,G	[[76], [77],[78], [79]]
Cobalamin B deficiency	Hydroxycobalamin, protein restriction	4	Standard of care	C,G	[[76], [77],[78], [79]]
Cobalamin C deficiency	Hydroxycobalamin	4	Standard of care	C,D,G	[[76], [77],[78], [79]]
Cobalamin D deficiency	Hydroxy-/cyanocobalamin	4	Standard of care	C,D,G	[[76], [77],[78], [79]]
Cobalamin E deficiency	Hydroxy-/methylcobalamin, betaine	4	Standard of care	C,D,G	[[76], [77],[78], [79]]
Cobalamin F deficiency	Hydroxycobalamin	4	Standard of care	C,D,G	[[76], [77],[78], [79]]
Cobalamin G deficiency	Hydroxy-/methylcobalamin, betaine	4	Standard of care	C,D,G	[[76], [78],[79]]
Congenital intrinsic factor deficiency	Hydroxycobalamin	4	Standard of care	A,E,G	[80
l.o. CPS deficiency	Dietary protein restriction, arginine supplement, sodium benzoate, phenylbutyrate (Liver transplantation)	2b & 4	Standard of care (Individual basis)	B,C,D,E,F,G (C)	[[55], [56],[57], [60],[61]]
Creatine transporter defect	Creatine, glycine, arginine supplements	4-5	Individual basis	F	[29
DHPR deficiency	BH4,diet, amine replacement, folinic acid	4	Standard of care	A,E	[52
Ethylmalonic encephalopathy	N-acetylcysteine, oral metronidazol	4	Standard of care	E,G	[81
GAMT deficiency	Arginine restriction, creatine & ornithine supplements	4	Standard of care	B,D,E,F	[[48], [52],[82], [83]]
Gaucher disease type III	Haematopoietic stem cell transplantation	4–5	Individual basis	D,G	[[84], [85]]
GLUT1 deficiency syndrome	Ketogenic diet	4	Standard of Care	F	[[19], [86]]
l.o. Glutaric acidemia I	Lysine restriction, carnitine supplements	2c	Standard of care	C,D,E,G	[[87], [88]]
Glutaric acidemia II	Carnitine, riboflavin, β-hydroxybutyrate supplements; sick day management	5	Standard of care	C,G	[[89], [90]]
GTPCH1 deficiency	BH4, amine replacement	4	Standard of care	A,E	[91
HHH syndrome	Dietary protein restriction, ornithine supplement, sodium benzoate, phenylacetate	4	Standard of care	B,C,D,E,F,G	[92
HMG-CoA lyase deficiency	Protein restriction, avoid fasting, sick day management,	5	Standard of care	C	[[58], [59],[60], [93]]
Holocarboxylase synthetase deficiency	Biotin supplement	4	Standard of care	A,E,G	[[94], [95]]
Homocystinuria	Methionine restriction, +/−pyridoxine, +/−betaine	2c	Standard of care	C,D,G	[[96], [76]]
Hunter syndrome (MPS II)	Haematopoietic stem cell transplantation	4–5	Individual basis	D,G	[[24], [85],[97]]
Hurler syndrome (MPS I)	Haematopoietic stem cell transplantation	1c	Standard of care	D,G	[[24], [85],[97]]
Hyperammonemia–Hyperinsulinism syndrome	Diazoxide	4–5	Standard of care	D	[[98], [99]]
Imerslund Gräsbeck syndrome	Hydroxycobalamin	4	Standard of Care	A,E,G	[100
l.o. Isovaleric acidemia	Dietary protein restriction, carnitine supplements, avoid fasting, sick day management	2c	Standard of care	C,G	[[101], [102],[103], [104],[93]]
l.o. NAGS deficiency	Dietary protein restriction, arginine supplement, sodium benzoate, phenylbutyrate (Liver transplantation)	2b & 4	Standard of care (Individual basis)	B,C,D,E,F,G (C)	[[55], [56],[57], [105],[60], [61]]
l.o. Non-ketotic hyperglycinemia	Glycine restriction; +/−sodium benzoate, NMDA receptor antagonists, other neuromodulating agents	4-5	Standard of Care	B,D,E,F	[106
Maple syrup urine disease (variant)	Dietary restriction branched amino-acids, avoid fasting, (Liver transplantation)	4 & 4	Standard of care (Individual basis)	B,C,D (A,C)	[[107], [108],[109], [110]]
MELAS	Arginine supplements	4–5	Standard of Care	C,D,E,F	[26
Menkes disease occipital horn syndrome	Copper histidine	4	Individual basis	D	[[111], [112],[113]]
l.o. Metachromatic leukodystrophy	Haematopoietic stem cell transplantation	4-5	Individual basis	D	[[114], [85]]
3-Methylcrotonyl glycinuria	Dietary protein restriction; carnitine, glycine, biotin supplements; avoid fasting; sick day management	5	Standard of care	C	[[115], [116]]
3-Methylglutaconic aciduria type I	Carnitine Supplements, Avoid Fasting, Sick Day Management	5	Standard of care	C	[117
l.o. Methylmalonic acidemia	Dietary protein restriction, carnitine supplements, avoid fasting, sick day management	2c	Standard of care	C,G	[[101], [102],[103], [104],[93]]
MHBD deficiency	Avoid fasting, sick day management, isoleucine restricted diet	5	Standard of care	C	[[63], [64],[65], [93]]
mHMG-CoA synthase deficiency	Avoid fasting,sick day management, +/−dietary precursor restriction	5	Standard of care	C	[[63], [64],[65], [93]]
Molybdenum co-factor deficiency type A	Precursor Z/cPMP	4	Individual basis	A,F	[25
l.o. MTHFR deficiency	Betaine supplements, +/−folate, carnitine, methionine supplements	4	Standard of care	C,D,G	[[76], [79]]
Niemann–Pick disease type C	Miglustat	1b	Standard of care	D,E	[[118], [119],[120], [121]]
l.o. OTC deficiency	Dietary protein restriction, citrulline supplements, Sodium benzoate/phenylbutyrate (Liver transplantation)	2b & 4	Standard of care (Individual basis)	B,C,D,E,F,G (C)	[[55], [56],[57], [60],[61]]
PCD deficiency	BH4	4	Standard of care	A,E	[91
PDH complex deficiency	Ketogenic diet & thiamine	4	Individual basis	D,E,F	[122
Phenylketonuria	Dietary phenylalanine restriction +/−amino-acid supplements (BH(4) supplement)	2a (4)	Standard of care (Individual basis)	B, D, E (C)	[[123], [23],[124], [143]]
PHGDH deficiency	L-serine & +/−glycine supplements	4	Standard of care	D,F	[[125], [126]]
PSAT deficiency	L-serine & +/−glycine supplements	4	Standard of care	D,F	[[125], [126]]
l.o. Propionic acidemia	Dietary protein restriction, carnitine supplements, avoid fasting, sick day management	2c	Standard of care	C,G	[[101], [102],[103], [104],[93]]
PSPH deficiency	L-serine & +/−glycine supplements	4	Standard of care	D,F	[[125], [126]]
PTPS deficiency	BH4, diet, amine replacement	4	Standard of care	A,E	[91
Pyridoxine dependent epilepsy	Pyridoxine	4	Standard of care	A,F	[[127], [128]]
Pyrimidine 5-nucleotidase superactivity	Uridine supplements	1b	Standard of care	A,B,F,G	[129
Sanfilippo syndrome A (MPS IIIa)	Haematopoietic stem cell transplantation	4–5	Individual basis	D	[[24], [85],[97]]
Sanfilippo syndrome B (MPS IIIb)	Haematopoietic stem cell transplantation	4–5	Individual basis	D	[[24], [85],[97]]
Sanfilippo syndrome C (MPS IIIc)	Haematopoietic Stemcell Transplantation	4–5	Individual Basis	D	[[24], [85],[97]]
Sanfilippo syndrome D (MPS IIId)	Haematopoietic stem cell transplantation	4–5	Individual basis	D	[[24], [85],[97]]
SCOT deficiency	Avoid fasting, protein restriction, sick day management	5	Standard of care	C	[65
Sjögren–Larsson syndrome	Diet: low fat, medium chain & essential fatty acid supplements & Zileuton	5	Individual basis	D,G	[[130], [131]]
Sly syndrome (MPS VII)	Haematopoietic stem cell transplantation	4-5	Individual basis	D	[[24], [85],[97]]
Smith–Lemli–Opitz syndrome	Cholesterol & simvastatin	4–5	Individual basis	B,D	[[27], [132],[133]]
SPR deficiency	Amine replacement	4	Standard of care	A,E	[134
SSADH deficiency	Vigabatrin	4	Individual basis	B,F	[135
Thiamine-responsive encephalopathy	Thiamin supplement	4-5	Standard of care	E	[[136], [137]]
Tyrosine hydroxylase deficiency	L-dopa substitution	4	Standard of care	A,E	[138
Tyrosinemia type II	Dietary phenylalanine & tyrosine restriction	4-5	Standard of care	D,G	[[34], [139],[140]]
Wilson disease	Zinc & tetrathiomolybdate	1b	Standard of care	E,G	[[113], [141],[142]]

The metabolic evaluation of the child with an intellectual 

developmental disorder: Diagnostic algorithm for identification of treatable causes and new digital resource

Table 2aOverview of the first tier metabolic screening tests denoting all diseases (with OMIM# and gene(s)) potentially identified per individual test.
Diagnostic test	Disease	OMIM#	Gene
Blood tests
Plasma amino acids	l.o. Argininemia	207800	ARG1 (AR)
Plasma amino acids	l.o. Argininosuccinic aciduria	207900	ASL (AR)
Plasma amino acids	l.o. Citrullinemia	215700	ASS1 (AR)
Plasma amino acids	Citrullinemia type II	605814	SLC25A13 (AR)
Plasma amino acids	l.o. CPS deficiency	237300	CPS1 (AR)
Plasma amino acids	HHH syndrome (hyperornithinemia, hyperammonemia, homocitrullinuria)	238970	SLC25A15 (AR)
Plasma amino acids	Maple syrup urine disease (variant)	248600	BCKDHA/BCKDHB/DBT(AR)
Plasma amino acids	l.o. NAGS deficiency	237310	NAGS (AR)
Plasma amino acids (& UOA incl orotic acid)	l.o. OTC deficiency	311250	OTC (X-linked)
Plasma amino acids	Phenylketonuria	261600	PAH (AR)
Plasma amino acids (& UOA)	Tyrosinemia type II	276600	TAT (AR)
Plasma amino acids (tHcy)	l.o. MTHFR deficiency	236250	MTHFR (AR)
Plasma total homocysteine	Cobalamin E deficiency	236270	MTRR (AR)
Plasma total homocysteine	Cobalamin G deficiency	250940	MTR (AR)
Plasma total homocysteine (& UOA)	Cobalamin F deficiency	277380	LMBRD1 (AR)
Plasma total homocysteine (& OUA)	Cobalamin C deficiency	277400	MMACHC (AR)
Plasma total homocysteine (& OUA)	Homocystinuria	236200	CBS (AR)
Plasma total homocysteine (& PAA)	l.o. MTHFR deficiency	236250	MTHFR (AR)
Plasma total homocysteine (& UOA)	Cobalamin D deficiency	277410	MMADHC (AR)
Serum ceruloplasmin & copper (& serum iron & ferritin)	Aceruloplasminemia	604290	CP (AR)
Serum copper & ceruloplasmin (& urine copper)	MEDNIK diseases	609313	AP1S1 (AR)
Serum copper & ceruloplasmin (urine deoxypyridonoline)	Menkes disease/occipital horn syndrome	304150	ATP7A (AR)
Serum copper & ceruloplasmin (& urine copper)	Wilson disease	277900	ATP7B (AR)
Urine tests
Urine creatine metabolites	AGAT deficiency	612718	GATM (AR)
Urine creatine metabolites	Creatine transporter defect	300352	SLC6A8 (X-linked)
Urine creatine metabolites	GAMT deficiency	612736	GAMT (AR)
Urine glycosaminoglycans	Hunter syndrome (MPS II)	309900	IDS (X-linked)
Urine glycosaminoglycans	Hurler syndrome (MPS I)	607014	IDUA (AR)
Urine glycosaminoglycans	Sanfilippo syndrome A (MPS IIIa)	252900	SGSH (AR)
Urine glycosaminoglycans	Sanfilippo syndrome B (MPS IIIb)	252920	NAGLU (AR)
Urine glycosaminoglycans	Sanfilippo syndrome C (MPS IIIc)	252930	HGSNAT (AR)
Urine glycosaminoglycans	Sanfilippo syndrome D (MPS IIId)	252940	GNS (AR)
Urine glycosaminoglycans	Sly syndrome (MPS VII)	253220	GUSB (AR)
Urine oligosaccharides	α-Mannosidosis	248500	MAN2B1 (AR)
Urine oligosaccharides	Aspartylglucosaminuria	208400	AGA (AR)
Urine organic acids	β-Ketothiolase deficiency	203750	ACAT1 (AR)
Urine organic acids	Cobalamin A deficiency	251100	MMAA (AR)
Urine organic acids	Cobalamin B deficiency	251110	MMAB (AR)
Urine organic acids	l.o. Glutaric acidemia I	231670	GCDH (AR)
Urine organic acids	Glutaric acidemia II	231680	ETFA, ETFB, ETFDH(AR)
Urine organic acids	HMG-CoA lyase deficiency	246450	HMGCL (AR)
Urine organic acids	Holocarboxylase synthetase deficiency	253270	HLCS (AR)
Urine organic acids	3-Methylglutaconic aciduria type I	250950	AUH (AR)
Urine organic acids	MHBD deficiency	300438	HSD17B10 (X-linked recessive)
Urine organic acids	mHMG-CoA synthase deficiency	605911	HMGCS2 (AR)
Urine organic acids	SCOT deficiency	245050	OXCT1 (AR)
Urine organic acids	SSADH deficiency	271980	ALDH5A1 (AR)
Urine organic acids (& ACP)	Ethylmalonic encephalopathy	602473	ETHE1 (AR)
Urine organic acids (& ACP)	l.o. Isovaleric acidemia	243500	IVD (AR)
Urine organic acids (& ACP)	3-Methylcrotonylglycinuria	210200	MCC1/MCC2 (AR)
Urine organic acids (& ACP)	l.o. Methylmalonic acidemia	251000	MUT (AR)
Urine organic acids (& tHcy)	Cobalamin C deficiency	277400	MMACHC (AR)
Urine organic acids (& tHcy)	Cobalamin D deficiency	277410	MMADHC (AR)
Urine organic acids (& tHcy)	Homocystinuria	236200	CBS (AR)
Urine organic acids incl orotic acid (& PAA)	l.o. OTC deficiency	311250	OTC (X-linked)
Urine organic acids (& PAA)	Tyrosinemia type II	276600	TAT (AR)
Urine organic acids (& ACP)	l.o. Propionic acidemia	606054	PCCA/PCCB (AR)
Urine organic acids (tHcy)	Cobalamin F deficiency	277380	LMBRD1 (AR)
Urine purines & pyrimidines	Lesch–Nyhan syndrome	300322	HPRT (AR)
Urine purines & pyrimidines	Molybdenum cofactor deficiency type A	252150	MOCS1, MOCS2, (AR)
Urine purines & pyrimidines	Pyrimidine 5-nucleotidase superactivity	606224	NT5C3 (AR)

Table 2bOverview of all diseases (in alphabetical order) requiring second tier biochemical testing, i.e. a specific test per disease approach; for each disease the OMIM# and gene(s) are listed.
Disease	OMIM#	Gene(s)	Diagnostic test
(X-linked) Adrenoleukodystrophy	300100	ABCD1 (X-linked)	Plasma very long chain fatty acids
Biotin responsive basal ganglia disease	607483	SLC19A3 (AR)	Gene analysis
Biotinidase deficiency	253260	BTD (AR)	Biotinidase enzyme activity
Cerebral folate receptor-α deficiency	613068	FOLR1 (AR)	CSF 5′-methyltetrahydrofolate
Cerebrotendinous xanthomatosis	213700	CYP27A1 (AR)	Plasma cholestanol
Co-enzyme Q10 deficiency	607426	COQ2, APTX, PDSS1,PDSS2, CABC1, COQ9(most AR)	Co-enzyme Q (fibroblasts) & gene analysis
Congenital intrinsic factor deficiency	261000	GIF (AR)	Plasma vitamin B12 & folate
Dihydrofolate reductase deficiency	613893	DHFR (AR)	CSF 5′-methyltetrahydrofolate
DHPR deficiency (biopterin deficiency)	261630	QDPR (AR)	CSF neurotransmitters & biopterin loading test
Gaucher disease type III	231000	GBA (AR)	Glucocerebrosidase enzyme activity (lymphocytes)
GLUT1 deficiency syndrome	606777	SLC2A1 (AR)	CSF: plasma glucose ratio
GTPCH1 deficiency	233910	GCH1 (AR)	CSF neurotransmitters & biopterin loading test
Hypermanganesemia with dystonia, polycythemia, and cirrhosis (HMDPC)	613280	SLC30A10	Whole blood manganese
Hyperinsulinism hyperammonemia syndrome	606762	GLUD1 (AR)	Gene analysis (& ammonia, glucose, insulin)
Imerslund Gräsbeck syndrome	261100	CUBN & AMN (AR)	Plasma vitamin B12 & folate
MELAS	540000	MTTL1, MTTQ, MTTH,MTTK, MTTC, MTTS1,MTND1, MTND5, MTND6,MTTS2 (Mt)	Mitochondrial DNA mutation testing
l.o. Metachromatic leukodystrophy	250100	ARSA (AR)	Arylsulfatase-α enzyme activity
Niemann–Pick disease type C	257220	NPC1 NPC2 (AR)	Filipin staining test (fibroblasts) & gene analyses
l.o. Non-ketotic hyperglycinemia	605899	AMT/GLDC/GCSH (AR)	CSF amino acids (& PAA)
PCBD deficiency (biopterin deficiency)	264070	PCBD1 (AR)	CSF neurotransmitters & biopterin loading test
PDH complex deficiency	OMIM# according to each enzyme subunit deficiency: 312170;245348; 245349	PDHA1 (X-linked), DLAT(AR), PDHX (AR)	Serum & CSF lactate:pyruvate ratio enzyme activity, gene analysis
PHGDH deficiency (serine deficiency)	601815	PHGDH (AR)	CSF amino acids (& PAA)
PSAT deficiency (serine deficiency)	610992	PSAT1 (AR)	CSF amino acids (& PAA)
PSPH deficiency (serine deficiency)	614023	PSPH (AR)	CSF amino acids (& PAA)
PTS deficiency (biopterin deficiency)	261640	PTS (AR)	CSF neurotransmitters & biopterin loading test
Pyridoxine dependent epilepsy	266100	ALDH7A1 (AR)	Urine α-aminoadipic semialdehyde & plasma pipecolic acid
Sjögren Larsson syndrome	270200	ALDH3A2 (AR)	Fatty aldehyde dehydrogenase enzyme activity
Smith Lemli Opitz syndrome	270400	DHCR7 (AR)	Plasma 7-dehydrocholesterol:cholesterol ratio
SPR deficiency (biopterin deficiency)	612716	SPR (AR)	CSF neurotransmitters, biopterin & Phe loading test (enzyme activity, gene analysis)
Thiamine responsive encephalopathy	606152	SLC19A3 (AR)	Gene analysis
Tyrosine hydroxylase deficiency	605407	TH (AR)	CSF neurotransmitters, gene analysis
VMAT2 deficiency	193001	SLC18A2 (AR)	Urine mono-amine metabolites

Improvement in core ASD symptoms after long-term treatment with probiotics

Another brief post today to draw your attention to a paper highlighted on the Questioning Answers blog.

There are two virtually identically probiotics one called VSL#3 and the other called Viviomixx.  As pointed out in a recent post there is an ongoing clinical trial of Vivomixx.

  

Ongoing Clinical Trial of Vivomixx Probiotic in Children with Autism

Some readers of this blog are trialing VSL#3 or Viviomixx.

The new paper is a case study of a 12 year old boy with severe autism who was given VSL#3 at his residential care home.

He has celiac disease, but his doctors were surprised that when the reduction in severity of abdominal symptoms was accompanied by an improvement in his autism.

This should not come as a surprise to regular readers.  Just recall Kanner’s subject #1, Donald Triplett, who was later diagnosed with juvenile arthritis. When his arthritis was treated his autism improved.  This is exactly what should be expected.

Treat your comorbidities, particularly those of an inflammatory/auto immune nature, and very likely you will improve behavior and even cognition.

Unexpected improvement in core autism spectrum disorder symptoms after long-term treatment with probiotics

Abstract

Objectives: Autism spectrum disorder is a neurodevelopmental condition that typically displays socio-communicative impairment as well as restricted stereotyped interests and activities, in which gastrointestinal disturbances are commonly reported. We report the case of a boy with Autism Spectrum Disorder (ASD) diagnosis, severe cognitive disability and celiac disease in which an unexpected improvement of autistic core symptoms was observed after four months of probiotic treatment.

Method: The case study refers to a 12 years old boy with ASD and severe cognitive disability attending the Villa Santa Maria Institute in resident care since 2009. Diagnosis of ASDs according to DSM-V criteria was confirmed by ADOS-2 assessment (Autism Diagnostic Observation Schedule).

The medication used was VSL#3, a multi-strain mixture of ten probiotics. The treatment lasted 4 weeks followed by a four month follow-up.

The rehabilitation program and the diet was maintained stable in the treatment period and in the follow up. ADOS-2 was assessed six times: two times before starting treatment; two times during the treatment and two times after interruption of the treatment.

Results: The probiotic treatment reduced the severity of abdominal symptoms as expected but an improvement in Autistic core symptoms was unexpectedly clinically evident already after few weeks from probiotic treatment start. The score of Social Affect domain of ADOS improved changing from 20 to 18 after two month’s treatment with a further reduction of 1 point in the following two months. The level 17 of severity remained stable in the follow up period. It is well known that ADOS score does not fluctuate spontaneously along time in ASD and is absolutely stable.

Conclusions: The appropriate use of probiotics deserves further research, which hopefully will open new avenues in the fight against ASD.

Tackling autism, child by child

Today’s post is to highlight an unusually well informed article about autism, pointed out to me by our reader Natasa.  

It is about how autism is treated by Dr Richard Frye at Arkansas Children's Hospital.  If you read the article, you may wonder why your pediatrician is unaware of these methods.

Click the link below to read the article.

Tackling autism, child by child 

Histamine Reaction to Bio Gaia Gastrus

Alli from Switzerland discovered the autism benefits of Bio Gaia Gastrus.

This probiotic contains two different bacteria:-

·        Lactobacillus reuteri 17938 (Lactobacillus reuteri Protectis)

 ·        Lactobacillus reuteri ATCC PTA 6475

These two bacteria have different effects.

The first bacteria is very well researched and recently was shown to increase oxytocin in autism mouse studies.  It is available on its own and this is the product most people I know are using.

The second bacteria is included in Bio Gaia Gastrus specifically for its additional anti-inflammatory effects.

Recent comments on this blog have shown that some people have a negative “histamine-y" reaction to Bio Gaia Gastrus.  This is entirely logical since the mode of action of the second bacteria is to generate histamine to activate H2 receptors in the gut.

This might sound rather odd since histamine is thought of as inflammatory, but the researchers working for Bio Gaia have shown that histamine can produce the opposite effect, suppressing TNF via Modulation of PKA and ERK Signaling.

Histamine Derived from Probiotic Lactobacillus reuteri Suppresses TNF via Modulation of PKA and ERK Signaling

Beneficial microbes and probiotic species, such as Lactobacillus reuteri, produce biologically active compounds that can modulate host mucosal immunity. Previously, immunomodulatory factors secreted by L. reuteri ATCC PTA 6475 were unknown. A combined metabolomics and bacterial genetics strategy was utilized to identify small compound(s) produced by L. reuteri that were TNF-inhibitory. Hydrophilic interaction liquid chromatography-high performance liquid chromatography (HILIC-HPLC) separation isolated TNF-inhibitory compounds, and HILIC-HPLC fraction composition was determined by NMR and mass spectrometry analyses. Histamine was identified and quantified in TNF-inhibitory HILIC-HPLC fractions. Histamine is produced from L-histidine via histidine decarboxylase by some fermentative bacteria including lactobacilli. Targeted mutagenesis of each gene present in the histidine decarboxylase gene cluster in L. reuteri 6475 demonstrated the involvement of histidine decarboxylase pyruvoyl type A (hdcA), histidine/histamine antiporter (hdcP), and hdcB in production of the TNF-inhibitory factor. The mechanism of TNF inhibition by L. reuteri-derived histamine was investigated using Toll-like receptor 2 (TLR2)-activated human monocytoid cells. Bacterial histamine suppressed TNF production via activation of the H₂receptor. Histamine from L. reuteri 6475 stimulated increased levels of cAMP, which inhibited downstream MEK/ERK MAPK signaling via protein kinase A (PKA) and resulted in suppression of TNF production by transcriptional regulation. In summary, a component of the gut microbiome, L. reuteri, is able to convert a dietary component, L-histidine, into an immunoregulatory signal, histamine, which suppresses pro-inflammatory TNF production. The identification of bacterial bioactive metabolites and their corresponding mechanisms of action with respect to immunomodulation may lead to improved anti-inflammatory strategies for chronic immune-mediated diseases.

This may mean that people who respond well to H2 histamine antagonists (Zantac, Tagamet etc) are unlikely to benefit from Lactobacillus. reuteri ATCC PTA 6475.

It might also mean that people who respond negatively to Bio Gaia Gastrus might get benefit from H2 histamine antagonists.

It might be worthwhile people trialing the single bacteria Bio Gaia product (Protectis), if they have a negative reaction to Gastrus.

Autism/ASD is not a valid Biological Diagnosis

It's September again and about time most Autism “Experts”, therapists, advocates, charities and journalists went back to school as well

Today’s post is a brief one to highlight a mainstream scientific paper that highlights what regular readers will have already determined; autism/ASD is not a valid diagnosis.  Hundreds of different biological dysfunctions may lead to behaviors, in some shape or form, that will be diagnosed as autism.

So a behavioral diagnosis of autism is just the start of the process to determine what the biological problem(s) are.

Several readers have already highlighted the paper, but it is important enough for its own post.

This also means that clinical trials that are based on a group of subjects with completely different biological dysfunctions, but vaguely similar behavioral issues, are likely often to be of little value.

Fortunately, there are shared pathways affected by many of these numerous biological dysfunctions, so there will be some therapies that apply to clusters of subjects. 

ASD Validity

ASD research is at an important crossroads. The ASD diagnosis is important for assigning a child to early behavioral intervention and explaining a child’s condition. But ASD research has not provided a diagnosis-specific medical treatment, or a consistent early predictor, or a unified life course. If the ASD diagnosis also lacks biological and construct validity, a shift away from studying ASD-defined samples would be warranted. Consequently, this paper reviews recent findings for the neurobiological validity of ASD, the construct validity of ASD diagnostic criteria, and the construct validity of ASD spectrum features. The findings reviewed indicate that the ASD diagnosis lacks biological and construct validity. The paper concludes with proposals for research going forward.

PAK inhibitors and potentially treating some Autism using Grandpa’s Medicine Cabinet

I wrote several posts about why PAK1 inhibitors should be beneficial in some autism and indeed some schizophrenia.

We also saw that PAK1-blocking drugs could be potentially useful for the treatment of neurofibromatosis type 2, in addition to RAS-induced cancers and neurofibromatosis type 1.

One problem with drugs developed for cancer is that, even if they finally get approved, they tend to be ultra-expensive.  Production volumes are low because even if they “work” they do not prolong life for so long and cancer has numerous sub-types.

Cheap drugs are ones used to treat common chronic conditions like high blood pressure, high cholesterol and indeed treatment of male lower urinary tract symptoms (LUTS), like benign prostatic hyperplasia (BPH).

A small number of readers of this blog have confirmed the beneficial effect of PAK inhibitors in their specific sub-types of autism.  The problem is that there are no potent PAK1 inhibitors suitable for long term use that are readily available.

The anti-parasite drug Ivermectin is an extremely cheap PAK1 inhibitor, but cannot be used long term, due to its other effects.

Propolis containing CAPE (Caffeic Acid Phenethyl Ester) is a natural PAK1 inhibitor, but may not be sufficiently potent as is reported by people with neurofibromatosis.

You would think somebody would just synthesize CAPE (Caffeic Acid Phenethyl Ester) artificially and then higher doses could be achieved.

PAK Inhibitors and Treatment of Prostate Enlargement

I was rather surprised that research has recently been published suggesting that PAK inhibitors could be used to treat the prostate enlargement, common in most older men. 

P21-Activated Kinase Inhibitors FRAX486 and IPA3: Inhibition of Prostate Stromal Cell Growth and Effects on Smooth Muscle Contraction in the Human Prostate

Abstract

Prostate smooth muscle tone and hyperplastic growth are involved in the pathophysiology and treatment of male lower urinary tract symptoms (LUTS). Available drugs are characterized by limited efficacy. Patients’ adherence is particularly low to combination therapies of 5α-reductase inhibitors and α₁-adrenoceptor antagonists, which are supposed to target contraction and growth simultaneously. Consequently, molecular etiology of benign prostatic hyperplasia (BPH) and new compounds interfering with smooth muscle contraction or growth in the prostate are of high interest. Here, we studied effects of p21-activated kinase (PAK) inhibitors (FRAX486, IPA3) in hyperplastic human prostate tissues, and in stromal cells (WPMY-1). In hyperplastic prostate tissues, PAK1, -2, -4, and -6 may be constitutively expressed in catecholaminergic neurons, while PAK1 was detected in smooth muscle and WPMY-1 cells. Neurogenic contractions of prostate strips by electric field stimulation were significantly inhibited by high concentrations of FRAX486 (30 μM) or IPA3 (300 μM), while noradrenaline- and phenylephrine-induced contractions were not affected. FRAX486 (30 μM) inhibited endothelin-1- and -2-induced contractions. In WPMY-1 cells, FRAX486 or IPA3 (24 h) induced concentration-dependent (1–10 μM) degeneration of actin filaments. This was paralleled by attenuation of proliferation rate, being observed from 1 to 10 μM FRAX486 or IPA3. Cytotoxicity of FRAX486 and IPA3 in WPMY-1 cells was time- and concentration-dependent. Stimulation of WPMY-1 cells with endothelin-1 or dihydrotestosterone, but not noradrenaline induced PAK phosphorylation, indicating PAK activation by endothelin-1. Thus, PAK inhibitors may inhibit neurogenic and endothelin-induced smooth muscle contractions in the hyperplastic human prostate, and growth of stromal cells. Targeting prostate smooth muscle contraction and stromal growth at once by a single compound is principally possible, at least under experimental conditions.

It looks like a PAK inhibitor could potentially solve both the key problems in BPH and so replace the current therapies.

Existing Drugs for LUTS/BPH

Undoubtedly someone is going to wonder whether existing drugs for LUTS/BPH might improve autism.  This is actually possible, but totally unrelated to PAK1 inhibition and RASopathies.

Existing drugs are in two classes, 5α-reductase inhibitors and α₁-adrenoceptor antagonists.

α-adrenoceptor antagonists

Alpha blockers relax certain muscles and help small blood vessels remain open. They work by keeping the hormone norepinephrine (noradrenaline) from tightening the muscles in the walls of smaller arteries and veins, which causes the vessels to remain open and relaxed. This improves blood flow and lowers blood pressure.

Because alpha blockers also relax other muscles throughout the body, these medications can help improve urine flow in older men with prostate problems.

Selective α₁-adrenergic receptor antagonists are often used in BPH because it is the α₁-adrenergic receptor that is present in the prostate.

 α ₂-adrenergic receptors are present elsewhere in the body

Alpha-2 blockers are used to treat anxiety and post-traumatic stress disorder (PTSD). They decrease sympathetic outflow from the central nervous system. Post-traumatic stress disorder is an anxiety disorder that is theorized to be related to a hyperactive sympathetic nervous system.

Alpha-2 receptor agonists for the treatment of post-traumatic stress disorder

So a nonselective alpha blocker, like one given to an older man with high blood pressure and BPH, might well have an effect on some kinds of anxiety.

You would think that a selective alpha 2 blocker might be interesting, how about Idazoxan?

Idazoxan is a drug which is used in research. It acts as both a selective α2 adrenergic receptor antagonist, and an antagonist for the imidazoline receptor. Idazoxan has been under investigation as an antidepressant, but it did not reach the market as such. More recently, it is under investigation as an adjunctive treatment in schizophrenia. Due to its alpha-2 receptor antagonism it is capable of enhancing therapeutic effects of antipsychotics, possibly by enhancing dopamine neurotransmission in the prefrontal cortex of the brain, a brain area thought to be involved in the pathogenesis of schizophrenia.

Mirtazapine is a cheap generic drug used at high doses for depression.  It happens to be a selective alpha 2 blocker, but it has numerous other effects as well.  One reader of this blog does respond very well to Mirtazapine.

So realistically in Grandpa’s medicine cabinet there might a selective alpha 1 agonist or a non-selective alpha agonist, it is the latter type that might have an effect on some kinds of autism.

5α-reductase inhibitors

The pharmacology of 5α-reductase inhibition involves the binding of NADPH to the enzyme followed by the substrate. Specific substrates include testosterone, progesterone, androstenedione, epitestosterone, cortisol, aldosterone, and deoxycorticosterone.

Beyond being a catalyst in testosterone reduction, 5α-reductase isoforms I and II reduce progesterone to 5α-dihydroprogesterone (5α-DHP) and deoxycorticosterone to dihydrodeoxycorticosterone (DHDOC).

In vitro and animal models suggest subsequent 3α-reduction of DHT, 5α-DHP and DHDOC lead to neurosteroid metabolites with effect on cerebral function.

These neurosteroids, which include allopregnanolone, tetrahydrodeoxycorticosterone (THDOC), and 5α-androstanediol, act as potent positive allosteric modulators of GABA_A receptors, and have anticonvulsant, antidepressant, anxiolytic, prosexual, and anticonvulsant effects.

Inhibition of 5α-reductase results in decreased conversion of testosterone to DHT.

This, in turn, results in slight elevations in testosterone and estradiol levels. 

In BPH, DHT acts as a potent cellular androgen and promotes prostate growth; therefore, it inhibits and alleviates symptoms of BPH. In alopecia, male and female-pattern baldness is an effect of androgenic receptor activation, so reducing levels of DHT also reduces hair loss.

A new look at the 5alpha-reductase inhibitor finasteride

Finasteride is the first 5alpha-reductase inhibitor that received clinical approval for the treatment of human benign prostatic hyperplasia (BPH) and androgenetic alopecia (male pattern hair loss). These clinical applications are based on the ability of finasteride to inhibit the Type II isoform of the 5alpha-reductase enzyme, which is the predominant form in human prostate and hair follicles, and the concomitant reduction of testosterone to dihydrotestosterone (DHT). In addition to catalyzing the rate-limiting step in the reduction of testosterone, both isoforms of the 5alpha-reductase enzyme are responsible for the reduction of progesterone and deoxycorticosterone to dihydroprogesterone (DHP) and dihydrodeoxycorticosterone (DHDOC), respectively. Recent preclinical data indicate that the subsequent 3alpha-reduction of DHT, DHP and DHDOC produces steroid metabolites with rapid non-genomic effects on brain function and behavior, primarily via an enhancement of gamma-aminobutyric acid (GABA)ergic inhibitory neurotransmission. Consistent with their ability to enhance the action of GABA at GABA(A) receptors, these steroid derivatives (termed neuroactive steroids) possess anticonvulsant, antidepressant and anxiolytic effects in addition to altering aspects of sexual- and alcohol-related behaviors. Thus, finasteride, which inhibits both isoforms of 5alpha-reductase in rodents, has been used as a tool to manipulate neuroactive steroid levels and determine the impact on behavior. Results of some preclinical studies and clinical observations with finasteride are described in this review article. The data suggest that endogenous neuroactive steroid levels may be inversely related to symptoms of premenstrual and postpartum dysphoric disorder, catamenial epilepsy, depression, and alcohol withdrawal.

This would suggest that a 5α-reductase inhibitor, like finasteride, that might be among Grandpa’s tablets might very well have an effect on someone with GABAa dysfunction, this includes very many people with autism, schizophrenia and Down Syndrome.

Whether the effect will be good or bad is hard to say, and may well depend on whether other drugs that target GABA or NMDA receptors are being used. Due to their other effects, 5α-reductase inhibitors are usually only used in adults.

Merck developed a lower dose form of finasteride, called Prospecia to treat baldness, usually in men.  It is 20% the normal potency used for BPH.

Side effects

The current BPH drugs cause side effects in some people.  PAK1 inhibitors may also have some side effects.

Conclusion

Going back in the days of living with your extended family might make treating many people’s autism much simpler.  It looks like many older people’s drugs can be repurposed for some types of autism (ion channel modifying diuretics, calcium channel blockers, statins, even potentially intranasal insulin in some).  Because older people’s drugs are so widely used they are well understood and inexpensive.  

Clearly the research on PAK inhibitors for LUTS/BPH is at an early stage, but there is a huge potential market.   A widely available PAK1 inhibitor might be a big help to some people with autism, neurofibromatosis, other RASopathies, not just Grandpa’s prostate.

In addition to FRAX486 and IPA3, why doesn’t someone try synthetic CAPE, i.e. without the bees, as a PAK inhibitor?

Bioactivity and chemical synthesis of caffeic acid phenethyl ester and its derivatives.

There is far more chance of a PAK1 inhibitor coming to market for LUTS/BPH, or certain cancers than for autism.  That is a fact of life.

As for 5α-reductase inhibitors, like finasteride, we know from Hardan’s study on Pregnenolone at Stanford that this hormone can have a positive effect and we know that various natural steroid metabolites will modulate GABA subunits.  So it is quite likely that finasteride is going have a behavioral effect.  Perhaps Hardan would like to trial finasteride 5mg and 1mg (Prospecia) in some adults with autism. I suspect it will make some people “worse” and others somewhat “better”; so please do not report the “average” response, highlight the nature of the positive responders.

Wandering & Forever Young

Today’s post is rather light on the usual science.

One reader recently suggested a post on wandering. Wandering off and getting lost is a common event for many with more severe autism and while for some it may be an issue only in childhood, for many it will continue to adulthood.  US news reports frequently feature this kind of wandering, but it occurs everywhere.

Minions like to wander too

The broader issue here is that many people with severe autism remain child-like their entire lives.  So they continue to face many of the same risks as a neuro-typical toddler. If you do not pay great attention to your typical two year they also may have all kinds of accidents, but they soon figure out that roads are dangerous and falling from a window is going to hurt.

There are lots of clever high tech tracking solutions to help find your child, but the ideal solution must be not to lose him in the first place.

We have a high fence around our garden; we have a cover on our pool that even an adult cannot fall through and a number coded lock on the way out to the garage. So it would be hard for any toddler to wander off from our house and hard to fall from an upper window.

I think we have reached a developmental age where wandering is not likely, this is likely in part due to pharmacological intervention.

Many years ago I used to travel on business to Warsaw, in Poland, and we were fortunate to stay in a very upmarket hotel in the reconstructed old town called the Bristol.  You would think this would be a very safe place.  Some years later a friend was telling me how our former colleague was staying there over one weekend with his wife and their typical toddler son.  The boy was left unattended and somehow fell to his death from an upper window.

We do not electronically tag all two year olds, the idea is that they are given near constant supervision and hopefully things work out well. 

The big risks for kids with autism are drowning and seizures; in some cases it is a seizure while in the bath unattended that causes drowning.  Drowning should be preventable.  I think that with the appropriate treatment the onset of seizures in many people with autism might be prevented.

In the US on average 10 people drown each day, of whom two will be under 14 years old. Another 10 children receive emergency department care each day for nonfatal submersion injuries.

Life is a risky business.

Tracking Devices

There are numerous types of tracking device, but most have the drawback that they are removable.  To be genuinely effective the device would have to some kind of bracelet that cannot be removed.

In some countries by law all pet dogs have to be microchipped. If the dog gets lost a small inexpensive scanner reads the number on the chip which is looked up on an online database revealing the owner's details.

Our neighbour’s dog wanders off on regular basis, but thanks to his chip he has made it home so far.

It would be possible to microchip non-verbal people.  The problem here is that who would have a scanner?  Who would know that the person was chipped?  If you have to have a mark saying “I’m chipped” you might as well just write the person’s name and address indelibly on their forearm.  Better still don’t lose them.

Sense of Danger

Some people say that their child with autism has no sense of danger, but is that because he has not yet developed one, or he will never have one?  I remember being in an outdoor green market with Monty when we met an older boy who was in our mainstream school for a year or two.  He was non-verbal, autistic and had seizures. We usually saw him strapped into an oversized pushchair.  He could walk, but clearly it was deemed preferable to keep him strapped in.

Monty was used to exploring the stalls in the market and often he would be given something to taste.  The other boy was there with his mother and his assistant. I started talking to the mother, Monty started to move the next stall and then the assistant “pounced”, like Monty was about to walk in front of a bus.  I explained that is was OK, he was not about to run away; he had already learned a sense of danger from experience.

Clearly people are very different, but you do have to give people some space to develop and explore, if you expect them to learn.

Monty likes fire, but rather than hide him from it he is one who lights our open fire at home.  He is now fully aware that you can burn yourself (and your house). We do have several smoke detectors.

So I think some people may be over protective and not allowing the child to develop a sense of danger, while some others let their moderately autistic young child roam the street in front of their home and are surprised when trouble occurs.

Dressed to Kill

Many people like to be snappy dressers; I think people should be equally attentive to how they dress their adult-sized offspring with severe autism.

I recall a news article a while back when a mother let her adult son with severe non-verbal autism wander from home.  He was dressed in green military attire, like a big version of Rambo.  He wandered into a neighbour’s garden and the occupant saw the intruder and called the police.  The police arrived and tackled the non-responsive, threateningly-dressed, intruder to the ground.  The mother turned up and was upset that the officer had man handled her child.  I think this was in Canada, a little further south and the officer might have shot him.

Had the youth been dressed in shorts and a Mickey Mouse sweatshirt I doubt the home owner would have called the police in the first place, rather “it’s just that boy Jimmy from down the street wandering again, I must call his mother, she did tell me that he wanders”.

It does matter how you are dressed and how you behave.  I recall another parent commenting that adults with autism are not cute, that sounded odd to me.  An 8 year old with autism banging his head against the wall certainly is not cute.  A well behaved adult-sized person with classic autism can be cute, more than likely he is just a big kid, or a gentle giant.  If he is a permanent “big kid”, dress him like one and nobody is going to feel threatened by any unexpected behaviours.

Conclusion

Wandering can be deadly; if someone with non-verbal autism is prone to wander technology can only be of limited help.

The tendency to wander has to be matched by the level of supervision.

This blog is usually about pharmacological therapies and in many cases these should be able to improve cognition and self-awareness so that wandering is much less likely.

There will always be curious or adventurous types that will find a way over the fence and out into the wider world. Better make sure they know how to cross roads and know how to swim.  Even if they are only minimally verbal, from a very early age they need to know their name and address.  If they are totally non-verbal, you need a better fence, a tracking device that cannot be removed, or that permanent marker.