Wednesday, 8 March 2017

Take your Bumetanide Studies with a Pinch of Salt

This blog does try to be based on evidence, but sometimes you do have to question the validity of what appears in peer reviewed journals.  It might concern what does, or does not cross the blood brain barrier, or what works in vivo versus in vitro.

Two interesting papers were recently brought to my attention regarding Bumetanide.

With a pinch of salt is an English idiom which means
to view something with skepticism 

In Tyler’s paper it was rats with epilepsy showing big improvements when taking Bumetanide. 

In Agnieszka’s paper, involving mice and Chinese hamsters, researchers are making the point that so little Bumetanide crosses into the brain that its therapeutic value is limited. 

So which is true? 

Well it seems that in some humans with autism enough bumetanide crosses the blood brain barrier (BBB) to show a positive effect.  Perhaps if a more penetrative analogue of Bumetanide was developed, it would show even greater effect, otherwise adjunct therapies may be needed (Acetazolamide, potassium bromide, estradiol etc) to gain the full benefit of lowering intracellular chloride. 

In the past I have made the case for bumetanide possibly reducing the incidence of epilepsy developing in autism and that this really would be important. This does not mean that one person with autism might not develop epilepsy around the same time he started taking bumetanide. In the study below the rats with seizures seemed to be protected by bumetanide and the number of harmful neural connections detected in the brain was significantly reduced. 


There is accumulating evidence that bumetanide, which has been used over decades as a potent loop diuretic, also exerts effects on brain disorders, including autism, neonatal seizures, and epilepsy, which are not related to its effects on the kidney but rather mediated by inhibition of the neuronal Na-K-Cl cotransporter isoform NKCC1. However, following systemic administration, brain levels of bumetanide are typically below those needed to inhibit NKCC1, which critically limits its clinical use for treating brain disorders. Recently, active efflux transport at the blood-brain barrier (BBB) has been suggested as a process involved in the low brain:plasma ratio of bumetanide, but it is presently not clear which transporters are involved. Understanding the processes explaining the poor brain penetration of bumetanide is needed for developing strategies to improve the brain delivery of this drug. In the present study, we administered probenecid and more selective inhibitors of active transport carriers at the BBB directly into the brain of mice to minimize the contribution of peripheral effects on the brain penetration of bumetanide. Furthermore, in vitro experiments with mouse organic anion transporter 3 (Oat3)-overexpressing Chinese hamster ovary cells were performed to study the interaction of bumetanide, bumetanide derivatives, and several known inhibitors of Oats on Oat3-mediated transport. The in vivo experiments demonstrated that the uptake and efflux of bumetanide at the BBB is much more complex than previously thought. It seems that both restricted passive diffusion and active efflux transport, mediated by Oat3 but also organic anion-transporting polypeptide (Oatp) Oatp1a4 and multidrug resistance protein 4 explain the extremely low brain concentrations that are achieved after systemic administration of bumetanide, limiting the use of this drug for targeting abnormal expression of neuronal NKCC1 in brain diseases.

Prolonged epileptic seizures may cause serious problems that will continue for the rest of a patient's life. As a result of a seizure, neural connections of the brain may be rewired in an incorrect way. This may result in seizures that are difficult to control with medication. Mechanisms underlying this phenomenon are not entirely known, which makes current therapies ineffective in some patients.
A study conducted with a rat epilepsy model at the Neuroscience Center of the University of Helsinki showed that a change in the function of gamma-aminobutyric acid (GABA), a main neurotransmitter in the brain, is an underlying cause in the creation of harmful neural connections.
After a prolonged convulsive seizure, instead of the usual inhibitory effect of the transmitter, GABA accelerates brain activity. This, in turn, creates new, harmful neural connections, says Research Director Claudio Rivera.
The accelerating effect of GABA was blocked for three days with a drug called bumetanide given soon after a seizure. Two months after the seizure, the number of harmful connections detected in the brain was significantly lower.
"Most importantly, the number of convulsive seizures diminished markedly," says Claudio Rivera.
In this study, new indications may be found for bumetanide in the treatment of epilepsy. Bumetanide is a diuretic already in clinical use. Extensive clinical studies have already been conducted with bumetanide regarding its ability to reduce the amount of convulsions or prevent them entirely in the acute phase of seizures. This, however, is the first time that bumetanide has been found to have a long-term effect on the neural network structure of the brain.
Further study of the newly found mechanism may eventually help limit the exacerbation of epilepsy and prevent the onset of permanent epilepsy after an individual serious seizure. It may also be possible that a similar mechanism is responsible for the onset of epilepsy after a traumatic brain injury.
"The next step is to study bumetanide both by itself and in combination with other clinically used drugs. We want to find out the ways in which it may offer additional benefits in the treatment of epilepsy in combination with and even in place of currently used antiepileptic drugs," says Claudio Rivera.

Vitamin D and Autism

Two medical readers of this blog highlighted this recent paper showing an apparent universal benefit of vitamin D supplementation in autism.

Is it too good to be true?  Time for the pinch of salt?

One important point to note is that this study was in Egypt and, although sunny, are children there eating food that has already been fortified with vitamin D, like it is in Western countries?

Randomized controlled trial of vitamin D supplementation in children with autism spectrum disorder



Autism spectrum disorder (ASD) is a frequent developmental disorder characterized by pervasive deficits in social interaction, impairment in verbal and nonverbal communication, and stereotyped patterns of interests and activities. It has been previously reported that there is vitamin D deficiency in autistic children; however, there is a lack of randomized controlled trials of vitamin D supplementation in ASD children.


This study is a double-blinded, randomized clinical trial (RCT) that was conducted on 109 children with ASD (85 boys and 24 girls; aged 3-10 years). The aim of this study was to assess the effects of vitamin D supplementation on the core symptoms of autism in children. ASD patients were randomized to receive vitamin D3 or placebo for 4 months. The serum levels of 25-hydroxycholecalciferol (25 (OH)D) were measured at the beginning and at the end of the study. The autism severity and social maturity of the children were assessed by the Childhood Autism Rating Scale (CARS), Aberrant Behavior Checklist (ABC), Social Responsiveness Scale (SRS), and the Autism Treatment Evaluation Checklist (ATEC).


Supplementation of vitamin D was well tolerated by the ASD children. The daily doses used in the therapy group was 300 IU vitamin D3/kg/day, not to exceed 5,000 IU/day. The autism symptoms of the children improved significantly, following 4-month vitamin D3 supplementation, but not in the placebo group. This study demonstrates the efficacy and tolerability of high doses of vitamin D3 in children with ASD.


This study is the first double-blinded RCT proving the efficacy of vitamin D3 in ASD patients. Depending on the parameters measured in the study, oral vitamin D supplementation may safely improve signs and symptoms of ASD and could be recommended for children with ASD. At this stage, this study is a single RCT with a small number of patients, and a great deal of additional wide-scale studies are needed to critically validate the efficacy of vitamin D in ASD.

Take your research with a pinch of salt.


  1. Well in the study on Bumetanide not crossing the BBB, the nature of how it works is under major scrutiny these days as the BBB seems to be more or less permeable under certain non-pathological conditions and under inflammatory stress (such as in autism) it tends to be more permeable. So in a healthy brain with no inflammatory stress, maybe less Bumetanide makes it into the brain (if you assume the Chinese hamster study to be correct and apply to humans), while in a brain with increased BBB permeability due to reasons such as oxidative stress, you might get more Bumetanide. Also, ventral regions of the brain such as the amygdala and hippocampus are more susceptible to BBB permeability from oxidative stress and also happen to be major subcortical areas that seem to be very dysfunctional in autism. There is also the hypothalamus of which one of its nuclei is not really shielded by the BBB at all so that it can sample the blood for hormones, glucose, salt, and other substances that typically don't pass the BBB at all or else without some sort of regulation.

  2. I finally got around to reading a paper I had in the queue for a few days on NAFLD (Non-Alcoholic Fatty Liver Disease) but I feel it is relevant to autism because obesity tends to track with autism and abdominal obesity tends to track with NAFLD. In fact, I think Petra mentioned it being one of the biggest comorbid concerns with her child and antipsychotics tend to promote severe weight gain as well:

    To summarize the findings, what was first found (in rats) was that there were two main factors causing hepatic steatosis and those were Glutathione exhaustion and NAD+ exhaustion. They then hypothesized that providing the precursors to NAD+ synthesis and GSH synthesis would help improve the symptoms of NAFLD in mice so they decided on a cocktail of N-Acetyl-Cysteine (NAC), Nicotanimide Riboside (NR), and Serine which is a precursor to Glycine which is necessary for recycling GSH in the liver and administered it to mice fed a western-mimicking diet (high sugar and fat) which leads to NAFLD and it largely prevented NAFLD. They then tested serine supplementation in humans with NAFLD and it significantly improved liver markers.

    1. D-serine (DSR) has been mentioned earlier in this blog. It has been shown to help neurological disorders, particularly schizophrenia.

      "A first generation of proof-of-concept animal and clinical studies suggest beneficial DSR effects in treatment-refractory schizophrenia, movement, depression, and anxiety disorders and for the improvement of cognitive performance"

      When people check liver enzymes (ALT and AST)in autism, very often the results are odd.

      I think the liver is reflecting what is happening in the brain. The liver is providing a convenient biomarker. So Petra's son could get a double benefit from D-Serine.

    2. J Agric Food Chem. 2009 Jul 8;57(13):5982-6. doi: 10.1021/jf900470c.
      Acetic acid upregulates the expression of genes for fatty acid oxidation enzymes in liver to suppress body fat accumulation.

      I have already mentioned that moderate ethanol consumption seems to hepl my son's brain process as if he were neurotypical. Ethanol is converted to acetic acid and thought there may be something there relevant to his brain/liver metabolism disorder, particularly in view of such low LDL cholesterol levels in blood and fat deposits in liver.
      If Peter, Tyler, AJ, or anyone here that could comment on this hypothesis, would be really helpful. I know alcohol is a taboo issue here, as most people are trying to treat children, but I am raising this issue just in case there are interventions that could mimic the effect of alcohol.

    3. Petra, on a slightly different subject, is your son using verapamil?

      Calcium channel blockers as potential therapeutics for obesity-associated autophagy defects and fatty liver pathologies

      "Verapamil also reduces hepatic lipid droplet accumulation, insulin resistance and steatohepatitis, suggesting that calcium channel blockers can be used for correction of general NAFLD pathologies."

    4. Peter, when my son had very high liver enzymes and CRP doctors told me to stop all medication in case the infection was drug induced, so I stopped Verapamil.
      Also he sometimes reacts badly even with low dose magnesium which is a calcium channel blocker.
      This extract is from your recent post:
      Calcium channel blocking drugs used to treat high blood pressure, abnormal heart rhythm, angina pectoris, panic attacks, manic depression and migraine may occasionally cause drug-induced parkinsonism.
      Such things made me think twice about Verapamil.

    5. Petra, maybe do a trial of Verapamil and then measure the liver enzymes and see if they improve?

      The question is whether the NAFLD is a symptom of an underlying autism-related dysfunction, or just a coincidence.

      Lack of autophagy, oxidative stress and calcium channel dysfunction are features of both autism and NAFLD.

      Almost all drugs have side effects in someone, so you do have to be careful. In theory NAFLD is not treatable, perhaps because it can be caused by different things.

    6. Ethanol does so many different things, I would not know where to start. The other question with regards to ethanol is how much. I used to ferment kefir (and no ferment Biogaia) every day and depending on how long you let it ferment, you would get different levels of alcohol. On average the kefir I would give my kids was probably 2% alcohol and I didn't really worry about such a small amount because it is not like they drank kefir by the gallon full. Very small amounts of alcohol are easily handled by the body, as are other toxins, but once you go beyond grog levels of alcohol and get into the beer/wine range, then you start getting increasingly negative health and cognitive effects from its use.

      As for drugs that mimic the effects of alcohol, well there are plenty though of course every drug is a little different from another in terms of its full spectrum of effects.

      I am pretty sure alcohol does pretty much nothing positive and only negative for the liver, contrary to what you may read in the press about red wine (the most recent studies controlled for income as wealthier people drink more alcohol because of its association with status and once that was taken into account, there were only negative health benefits from red wine).

      But if you son has cognitive benefits from alcohol, it is likely from its pro GABAergic effects and anti NMDA effects.

      There are of course other possibilities, especially from alcohol's metabolites. Acetylaldehyde causes a histamine reaction (you can get the same result from regular old niacin as well). Acetylaldehyde also has dopaminergic effects. I have read that NAC is good at countering some of the secondary health issues to alcohol exposure and I have read anecdotal resports Nicotanimide Riboside (NR) is good at increasing alcohol tolerance (i.e. preventing drunkeness), likely because alcohol reduces the NAD+/NADH ratio and NR increases the ratio (this is speculation of course).

      One way to give you a hint about whether it is the alcohol itself or the metabolites and secondary effects that are causing these cognitive improvements would be to take NAC and NR a half hour before ingesting alcohol and see if the positive cognitive changes you speak of are not blunted or removed altogether. If they are not, then it is likely the GABAergic effects, and if they are blunted, then it may be dopaminergic from the acetylaldehyde.

  3. Peter, I would like to trial D-serine for my son.
    It lowers cortisol and lets glucose be utilized by cells, among other possible benefits.
    There is a product from Now Foods 100mg and Solgar 500mg, both from soya. I read that soya may not be as good as bovine sources but then there is always the risk of mad cow disease.
    If you eat 100mg chicken hearts you can get 400mg D-serine in theory.
    What do you recommend?

    1. Petra, use google to look at clinical trials of D-serine in schizophrenia. The doses seem to be 30mg/kg and higher. I would use a standardized dose so you can make a rational trial. Soja based supplements look best. You can probably find feedback from current users via google.

  4. Tyler, I was wondering if D.serine would be a good choice for my son, what do you think? have you tryed it?

    1. No I have not tried it. Also, in the study I alluded to I believe they used L-Serine which is much different than D-Serine in terms of its effects in the body and brain.

    2. Tyler, my son´s godfather arrives next week, I added one more jar of NR and L-Serine from bulk.

  5. Petra, I think phosphatidylserine would be a better choice than d serine alone and mixed with PE, phosphatidyl ethanolamine and PC,phosphatidylcholine. You can find this mix in amazon, soy free.The brand is Natural Bioscience

  6. Peter, My son's seizures increased in frequency as I was weaning from breastfeeding. I wonder if the hormones in the milk might have had some effect looking back. I believe the hormones had a neuroprotective effect. Estradiol, progesterone, prolactin, thyroxine, triiodothyronine, cortisol, prolactin, EGF, Thyroid hormones, Relaxin, Beta Endorphins, EPO, GnRH, Insulin, androgens, gastrin, adiponectin, resistin, ghrelin, and leptin......Then they get AA's, nutrients, living cells, and enzymes. Looking at your interesting diagrams I can see how certain hormones might help.

    1. Hormones act in surprisingly connected ways and in autism some are clearly disturbed. It is just not easy to now which one(s) could be modified for a long-lasting positive effect. I think a little extra estradiol may do the trick for some. It will reduce testosterone and I think leptin. Leptin is the subject of a new post and is increased in early onset autism and will contribute to inflammatory-type symptoms. RORalpha is linked to the relationship between testosterone and estrogens. RORalpha4 affects the leptin produced in fat cells. So extra estradiol will affect RORalpha and indirectly hopefully also reduce leptin production.
      RORalpha appears to be a hub where things going wrong in autism can be traced back to.

  7. Petra, my husband was found to have mild fatty liver a few years back. At that time, I read that phosphatidylcholine was the best for it. He used it for several months. Since then, he has made sure that he eats at least two eggs every day, for the choline. Maybe you can run a small trial and test.

    1. RG- Make sure that the egg yolks aren't overly cooked as this reduces the choline available and requires more antioxidants to process in the body.

  8. Hi dear all,

    I'm the 1st author of the paper mentioning great improvement of bumetanide on harmful neuronal network connections and subsequent seizures in rats. I'm a PhD in neuroscience, not a MD, so I may not have hints for the patients but could share my modest knowledge on the field. First of all, thank you for lifting up this very interesting topic.
    As concerning the paper demonstrating that bumetanide poorly cross the BBB, this is not the sole and only respectful study showing that and the paper depicted in this blogspot comes from a well-known, respected, talented and real specialist, Dr. W. Loscher who has unequivocally showed for decades the limitations of bumetanide on crossing the BBB. In our paper (beneficial effect of bumetanide on seizure), we in purpose used all the knowledge gained in part by Loscher Lab and others and used bumetanide not iv or ip but bumetanide was applied directly into the brain using osmotic mini-pumps. This to circumvent on the known limitation of this drug in crossing the BBB. I agree with the 1st comment of Tyler claiming that BBB can be disrupted in many cases such as inflammation, traumatic brain injury and so. This said bumetanide had no effect on newborn seizures in humans and had detrimental effect on hearing ( However, although the exact mechanism of action remain unknowed, nowadays promising resultants under clinical trials show stunning outcomes on autism syndrome disorder using bumetanide in humans ( In conclusion, our intent is to show bumetanide or its pro-drugs (as mentionned in the comments above, and as developed in rodent by Loscher lab) is really potent by itself on epileptic brain in vivo and could not only reduce the convulsions in adult rats but also constrain the underlying neuronal circuit supposedly at the origin of the seizures to have long-term effects. It is a fundamental research aiming at showing proof-of-concept findings rather than possibility for straightforward clinical translation from rat to human.
    But there is more hope for bumetanide since it is an FDA approved drug already available and in use... Also a case report showed direct brain delivery of valproate to dampen seizures in australia (, similarly to what we did in our paper with bumetanide in rats. Many more efforts are needed though if one day bumetanide would be used to cure adult epileptic patients...

  9. Peter, how can I get bumetanide as it's for heart condition, it's hard getting the prescription from a psychiatrist or doctor. I feel like it's not their medicine

    1. It depends where you live. People in the US/Canada are buying online from Mexico. In Europe it us available in Spain by asking in a pharmacy, no prescription needed.

    2. Is this the tablet form? Here in Australia is have to get it from doctor.

    3. It is a prescription drug. It is likely to be approved in Europe as an autism therapy in 2021. Until then it is just an off-label therapy of a drug used to lower blood pressure. It is a tablet. You would have to show the research to your doctor to persuade him to prescribe it, or buy it on line from an overseas internet pharmacy.


Post a comment