Thursday, 1 February 2018

Myelin and Skill Acquisition, Treating MS, plus Tuning P2X7

Today’s post was prompted by a recent visit from Monty’s assistant from when he was 3 to 9 years old. She was asking about how to improve fine motor skills in one of her class. In the background Monty, now aged 14 with ASD, was playing the piano and I said just look at those fingers move, no sign of a fine motor skill disorder any more.

Slow going without Myelin

So how do you improve both fine and gross motor skills and why are deficits so common in autism?
It does look like practice makes perfect, but there is actually some science behind this and it might help explain in part why young people with autism are very slow to acquire skills.  I should point out that there are multiple contributing factors, not least any kind of excitatory-inhibitory imbalance, but today’s post is about myelin.
Normally developing babies gradually start to develop fine and gross motor skills, become toilet trained and learn to talk.
The process by which you learn all these skills is at least partially understood. Myelin’s role particularly in acquiring motor skills has been the subject of a great deal of research in recent years.
We now know that without myelin you cannot acquire new skills.
When you acquire a new skill a network has to be created linking neurons together.
Neurons, when myelinated, look something like this:- 

The detail of inside the body of the neuron contains some of things we have looked at like Mitochondria and Endoplasmic reticulum.

Dendritic spines are those small protrusions from the dendrite which are like docking stations where one neuron connects with another. An axon terminal (far right on the first illustration) of one neuron connects with dendritic spine of a neighboring neuron.
A skill (like an app on your smart phone) is just a network of these connections between neurons. To make this network efficient and hopefully permanent, myelin is deposited along this pathway. This speeds up the rate at which the electrical signals can pass along the network. Myelin is white in colour and these myelinated pathways become the brain’s white matter. 
Here is the animation from the beginning of this post, showing that it is slow going, on the left, without myelin.


The Synapse
Just for completeness, the synapse is the place where the axon end of one neuron connects with the dendrite end of another neuron. The synapse is where lots of clever things are happening and sometimes things go wrong. Drugs often target the synapse.

Multiple Sclerosis (MS)
Most people have heard about MS, this is a condition caused by the loss of myelin or the inability to constantly maintain the myelin layer, via remyelination.
MS mainly affects females but has some similarities with autism; there is oxidative stress and chronic inflammation. By treating oxidative stress (with ALA) it has been shown that there is a benefit in MS, just as there is in autism. 
MS may be a family of conditions, because many different things are implicated, bacteria, virus etc.
MS is usually a cyclical disorder with regressions, improvements and remissions.
The inflammatory response in MS leads to damage of the myelin protective insulation in networks in the brain that have been created for specific skills. 
There are experimental finding in MS that might help promote myelination in other disorders. Some MS therapies are immunomodulatory, for example using gut bacteria, while other seek directly to promote (re)myelination and some clever ones do both. Not surprisingly there is some overlap with autism therapies.

Myelination in Autism
The research does show that myelination in autism is different to that found in most people. It does not look like that found in MS. 

There is less myelin in the brains of people with autism than in those of controls, according to a study published 11 August in Psychological Medicine1. Researchers applied a method that measures myelin in living brains with autism for the first time.
Magnetic resonance imaging (MRI) has previously shown abnormally structured white matter in people with autism. White matter is composed of axons, the long, myelin-coated projections that transmit electrical signals between neurons. 
The researchers looked at myelin content in the brains of 14 young men with autism with a mean age of 24 years and 14 controls with a mean age of 28 years, none of whom have intellectual disabilities. They found that those with autism have less myelin in some brain regions than do controls. In the autism group, those with the most severe social interaction difficulties have the lowest myelin levels.
The researchers speculate that low myelin explains the weak connectivity observed in the brains of people with autism. Without proper insulation, electrical signals travel slowly along the axons, making it difficult for regions of the brain to coordinate their activity. 
Full study:- 


Myelin and Learning
Logically you would then look at the role of myelin in both skill acquisition in childhood and then in older age look at a role for myelin in the loss of those very skills.

·        Myelination and skill acquisition

·        Demyelination and loss of skills 

In the case of regressive autism you might consider the role of demyelination in the loss of key skills. This would also apply to the old diagnosis of Childhood Disintegrative Disorders (CDD); perhaps CDD is an extreme case of demyelination.
In middle to older age in typical people we also have brain shrinkage, about 5% per decade.

Myelin, Motor Skills and Broader Cognitive Function
Another issue is whether learning motor skills in particular leads to more myelination as opposed to acquiring non-physical or cognitive skills.  To what extent is there a broader benefit to the brain from all this extra myelination? 
First let’s deal with brain shrinkage. I imagine that in aging there is an element of “use it or lose it”.  

Brain Shrinkage and the Mediterranean Diet 
I am interested in the Mediterranean Diet and the Okinawan Diet, both of which may reveal useful information regarding cognitive function. There will soon be a post on the Okinawan Diet.
The study below is supposed to show how eating the Mediterranean diet can stop your brain shrinking, but it was based on research in Scotland, which is notorious for bad diet and reduced life expectancy particularly in urban areas. There is even something called the Glasgow Effect, trying to explain poor health and shorter lifespan.

Mediterranean diet. 

Data from the Scottish Collaborative Group 168-item Food Frequency Questionnaire, version 7,12,13 were used to construct the MeDi score. Exclusions were made for incomplete data (39 had >10 missing items) and for individuals with extreme energy intakes (<2 .5th="" or="">97.5th centile, n = 46) to obtain the most reliable food frequency data.12 For scoring of the MeDi, we closely followed accepted procedure.14 Briefly, individuals were given a value of 1 for each beneficial food component (fruit, vegetables, legumes, cereal, and fish) and a value of 0 for each detrimental component (meat, dairy). The ratio of daily consumption (in grams) of monounsaturated fatty acids to saturated fatty acids was a further beneficial component. Caloric-adjusted sex-specific medians were used as the boundary defining low and high consumption for each of the components. For beneficial components, scores at or above the median were assigned a value of 1, whereas for detrimental components, scores at or above the median were given a value of 0. Moderate alcohol consumption was another positively scored component. It was defined for men as between 10 and 50 g alcohol per day and for women between 5 and 25 g per day. The MeDi score (range 0–9) was calculated by summing the scores for each of the components, with higher scores indicating higher MeDi adherence. 
There is so much more to the Mediterranean diet, to learn about it you need to go to southern Italy or Greece and see how (rural) people eat; not a deep-fried Mars bar in sight, rather a very wide range of vegetables, fruits, herbs etc that actually taste good.

Objective: To assess the association between Mediterranean-type diet (MeDi) and change in brain MRI volumetric measures and mean cortical thickness across a 3-year period in older age (73–76 years).
Conclusions: Lower adherence to the MeDi in an older Scottish cohort is predictive of total brain atrophy over a 3-year interval. Fish and meat consumption does not drive this change, suggesting that other components of the MeDi or, possibly, all of its components in combination are responsible for the association.

From the LA Times:-

This study likely just compared people with a moderate consumption of fruit and vegetables to the group that ate virtually none at all.

One key part of the Mediterranean diet is the large quantity and variety of herbs that are consumed. This is rarely replicated by foreigners. 

Brain Shrinkage in MS
Brain shrinkage, not surprisingly, is another feature of MS. Here one of the drugs that this blog seems to plug, Ibudilast, seems to be highly beneficial

“In 2016, the drug received Fast Track designation from the US Food and Drug Administration (FDA) to help speed its development as an MS treatment.”

Significantly, the presentation included news that a Phase 2 clinical trial shows the drug slows brain shrinkage and the loss of the protective myelin coating around nerve cells in people with MS.

The Phase 2 SPRINT-MS trial (NCT01982942) tested ibudilast’s safety and effectiveness in progressive MS patients, and their ability to tolerate it.

Ibudilast met the trial’s primary objective of reducing brain shrinkage. “Compared to placebo, ibudilast treatment was associated with a 48% slowing in the rate of atrophy (shrinkage) progression,” 

Acquiring Motor Skills 

The following study suggests that “slow and steady” skill acquisition is likely the best for the brain and that motor skills are the key. 

Experience-dependent structural changes are widely evident in gray matter. Using diffusion weighted imaging (DWI), the neuroplastic effect of motor training on white matter in the brain has been demonstrated. However, in humans it is not known whether specific features of white matter relate to motor skill acquisition or if these structural changes are associated to functional network connectivity. Myelin can be objectively quantified in vivo and used to index specific experience-dependent change. In the current study, seventeen healthy young adults completed ten sessions of visuomotor skill training (10,000 total movements) using the right arm. Multicomponent relaxation imaging was performed before and after training. Significant increases in myelin water fraction, a quantitative measure of myelin, were observed in task dependent brain regions (left intraparietal sulcus [IPS] and left parieto-occipital sulcus). In addition, the rate of motor skill acquisition and overall change in myelin water fraction in the left IPS were negatively related, suggesting that a slower rate of learning resulted in greater neuroplastic change. This study provides the first evidence for experience-dependent changes in myelin that are associated with changes in skilled movements in healthy young adults.  
Our results suggest that myelin is modifiable by experience in humans. Increases in myelin may be aided by oligodendrogenesis associated with behavioral changes, as has been demonstrated in a mouse model using optogenetic stimulation [9]. Even modest increases in myelination may

result in large increases in signal propagation speed resulting in more rapid information transfer between gray matter processing centers and improved synchrony between distant cortical regions [7].These results provide insights into tissue specific experience-dependent changes in white matter. Our findings may have important clinical implications and future investigations should evaluate the effect of intensive motor practice on myelin plasticity in individuals with neurologic conditions (e.g., stroke or those with demyelinating diseases such as multiple sclerosis) in order to assess the efficacy of behavioural training on myelin plasticity in the diseased brain.  

New evidence of myelin’s essential role in learning and retaining new practical skills, such as playing a musical instrument, has been uncovered by UCL research. Myelin is a fatty substance that insulates the brain's wiring and is a major constituent of ‘white matter’. It is produced by the brain and spinal cord into early adulthood as it is needed for many developmental processes, and although earlier studies of human white matter hinted at its involvement in skill learning, this is the first time it has been confirmed experimentally.
For a child to learn to walk or an adult to master a new skill such as juggling, new brain circuit activity is needed and new connections are made across large distances and at high speeds between different parts of the brain and spinal cord. For this, electrical signals fire between neurons connected by “axons” – thread-like extensions of their outer surfaces which can be viewed as the ‘wire’ in the electric circuit. When new signals fire repeatedly along axons, the connections between the neurons strengthen, making them easier to fire in the same pattern in future. Neighbouring myelin-producing cells called oligodendrocytes (OLs) recognise the repeating signal and wrap myelin around the active circuit wiring. It is this activity-driven insulation that the team identified as essential for learning.    

Novel Treatments for Multiple Sclerosis  (MS)
In a recent phase II clinical trial, an over-the-counter allergy drug was shown to improve nervous system function in patients with multiple sclerosis.
See the section further below on P2X7, for the reason why an antihistamine can help myelination.

Of the three strains of bacteria, one known as Prevotella histicola effectively suppressed MS in the mice. Specifically, P. histicola produced a drop in two cell types that encourage inflammation, which are known as pro-inflammatory cytokines.Conversely, it increased the level of certain cell types that fight disease, including dendritic cells, T cells, and a type of macrophage. Overall, inflammation and demyelination were reduced, about which the researchers are excited but cautious.
The current findings knit together with other recent studies in a similar vein - for instance, studies looking at MS patients' microbiomes have found lower levels of bacteria in the Prevotella genus. Similarly, levels of Prevotella have been shown to increase when MS patients take drugs that combat the condition.
Another neat dovetail is that Western diets promote an abundance of Bacteroides, whereas a high-fiber agrarian, or cereal-based, diet seems to encourage increased levels of Prevotella, marking another trail of clues to follow.
Although the study has concentrated on MS, the scope of these findings is much broader. First study author Ashutosh Mangalam, Ph.D. - from the University of Iowa Carver College of Medicine in Iowa City - says, "[...] it's not just for MS, because this may have a similar modulating effect on other nervous system and autoimmune diseases."  

Dr. Spain and colleagues suggest that lipoic acid - a naturally occurring antioxidant that is available as an over-the-counter supplement - could be an effective treatment for SPMS (secondary progressive multiple sclerosis), after finding that it helped to reduce the rate of whole brain atrophy among patients with the condition.
Compared with participants who took the placebo, the researchers found that those who took lipoic acid showed a 68 percent reduction in the rate of whole brain atrophy.

Purinergic signaling in Inflammation 
Purinergic signaling is complex and only partially understood. There are three types of purinergic receptor:- 
·        P1 receptors which are activated by adenosine

·        P2Y receptors which are activated by nucleotides, primarily ATP

·        P2X receptors which are activated by ATP

Purinergic signaling is involved in just about every process in humans, to the extent that the purinergic signalling complex of a cell is referred to as the “purinome”.
In this very superficial review we are just looking at inflammation.
Purinergic signaling is an important mechanism in a wide range of inflammatory diseases. There are many instances in which signaling events initiated by adenosine P1 receptors and those initiated by nucleotide P2 receptors have opposing effects in biologic systems, and shifting the balance between purinergic P1 and P2 signaling is an emerging therapeutic concept in efforts to dampen pathologic inflammation and promote healing.
Pharmacologic P2-receptor antagonists inhibit inflammation such as that which occurs in inflammatory bowel disease (IBD), lung inflammation, and ischemia. 
In pathologic conditions such as asthma and vascular inflammation, P2-receptor knockout mice are protected from inflammatory diseases.
Examples of nucleotide ­receptor signaling in inflammatory conditions include P2Y6­ or P2X7­receptor signaling, which mediates vascular inflammation P2Y1­, P2X1­, and P2Y12 ­receptor signaling, which mediates platelet activation. Activation of P2 receptors of the P2Y2 and P2X7 family that are expressed on dendritic cells is thought to play a role in promoting lung inflammation in chronic lung diseases such as asthma. 
P2X7 receptors are known to play a key role in mast cell degranulation and hence allergies.

The results indicate that P2X7 receptors may play a significant role in contributing to the unwanted activation of mast cells in chronic inflammatory conditions where extracellular ATP levels are elevated.

 Note that at times of inflammation the level of extracellular ATP is elevated.  

Not so simple - P2X7 in MS
As mentioned earlier purinergic signaling is complex and only partially understood. In an inflammatory condition like MS, P2X7 appears very likely to be involved, but is it having a good or bad effect? The answer is both, as you can see in the paper below.

The right question to ask becomes is the net effect of P2X7 signaling good or bad?  

Multiple sclerosis (MS) is characterized by macrophage accumulation and inflammatory infiltrates into the CNS contributing to demyelination. Because purinergic P2X7 receptor (P2X7R) is known to be abundantly expressed on cells of the hematopoietic lineage and of the nervous system, we further investigated its phenotypic expression in MS and experimental autoimmune encephalomyelitis conditions. By quantitative reverse transcription polymerase chain reaction and flow cytometry, we analyzed the P2X7R expression in human mononuclear cells of peripheral blood from stable and acute relapsing-remitting MS phases. Human monocytes were also challenged in vitro with pro-inflammatory stimuli such as the lipopolysaccharide, or the P2X7R preferential agonist 2'(3')-O-(4 Benzoylbenzoyl)adenosine 5'-triphosphate, before evaluating P2X7R protein expression. Finally, by immunohistochemistry and immunofluorescence confocal analysis, we investigated the P2X7R expression in frontal cortex from secondary progressive MS cases. We demonstrated that P2X7R is present and inhibited on peripheral monocytes isolated from MS donors during the acute phase of the disease, moreover it is down-regulated in human monocytes after pro-inflammatory stimulation in vitro. P2X7R is instead up-regulated on astrocytes in the parenchyma of frontal cortex from secondary progressive MS patients, concomitantly with monocyte chemoattractant protein-1 chemokine, while totally absent from microglia/macrophages or oligodendrocytes, despite the occurrence of inflammatory conditions. Our results suggest that inhibition of P2X7R on monocytes and up-regulation in astrocytes might contribute to sustain inflammatory mechanisms in MS. By acquiring further knowledge about P2X7R dynamics and identifying P2X7R as a potential marker for the disease, we expect to gain insights into the molecular pathways of MS.  

A recent trial has shown that the common H1 antihistamine Clemastine is therapeutic in MS.
Clemastine is seen as a positive allosteric modulator of P2X7, meaning that it increases P2X7 signaling. In our superficial view of the science increasing P2X7 signaling looks like a crazy idea to treat an inflammatory condition.
As you can see in the paper below increasing P2X7 signaling has a pro-inflammatory effect and an anti-inflammatory effect.
What matters is the net effect and that will vary depending on the exact type and location of the inflammatory activity.
In the case of MS, the net effect of increasing P2Y7 is highly beneficial.  

Because clinical data do not hint to severe or obvious clemastine-induced adverse drug responses that may involve P2X7 potentiation, augmentation of P2X7 activity in the presence of therapeutic concentrations of the antihistamine possibly exert more subtle changes that require a more thorough and focused evaluation. In addition, although we demonstrated release of the proinflammatory cytokine IL-1β from hMDM, P2X7 activation also gives rise to production and secretion of IL-1 receptor antagonist (IL-1Ra), which is in turn expected to exert anti-inflammatory activity (52,,54). Hence, the pro- or anti-inflammatory net effect of a clemastine-induced P2X7 potentiation may additionally depend on the targeted cell type, local availability of ATP, and pathophysiological background. An accumulating body of evidence points to a beneficial role of P2X7 activation in monocytes and macrophages to contribute to elimination of intracellularly located parasites and mycobacteria (55, 56). Even more strikingly, P2X7 activation in dendritic cells chiefly contributes to the orchestration of the adaptive antitumor immunity by triggering the caspase-1-dependent inflammasome activation in dendritic cells followed by IL-1β secretion and priming of interferon γ-producing CD8+ T cells (57). Therefore, selective P2X7 activators or positive allosteric modulators are intensely sought. In addition, the use of P2X7 activators, by triggering apoptotic cell death, has been put forward as a concept to treat several malignancies (Ref. 58 and references therein). Thus, the approved drug clemastine may serve as an interesting and immediately available starting point to explore these mechanisms in clinical settings.  

Full results from a randomized controlled trial (RCT) suggest that the over-the-counter (OTC) antihistamine clemastine fumarate is safe and effective for treating chronic demyelinating injury in multiple sclerosis (MS)֫ — even in patients who have had symptoms of myelin degeneration for years.

Although preliminary results were presented at the annual American Academy of Neurology meeting last year, full data from the ReBUILD trial were published online October 10 in the Lancet. 

Why P2X7 as the mode of action in MS? 
You may be asking why has Peter assumed that P2X7 is the helpful mode of action of Clemastine in treating MS, nobody else seems to highlight this.
Clemastine is an H1 antihistamine and as such does also have so-called cholinergic effects, meaning it act like the hormone acetylcholine. 
There is a whole class of drugs that increase the amount of  acetylcholine, by inhibiting cholinerases which normally act to degrade acetylcholine.
So if acetylcholine was magical for MS, then you would expect an acetylcholinerase inhibitor like Donepezil to work wonders for MS.  It has been trialed at least twice.

“A small study followed 69 people with MS taking either donepezil or a placebo for 24 weeks. It found that twice as many people in the treatment group reported memory improvement (65.7%) than those on placebo (32.4%). Health professionals also reported that more people in the treatment group showed improved cognitive symptoms. However, a larger study involving 120 people with MS showed no difference in improving memory between donepezil and placebo

Of course there is some existing research showing the role of P2X7 in MS:- 

How about P2X7 more broadly in Neurological Conditions? 


·         P2X7 receptor channels allow the passage of both small and large molecular weight cations.
·         P2X7Rs are expressed on all different cell types of the CNS but their expression is highly dependent on external stimuli.
·         P2X7Rs contribute to various neurodegenerative diseases.
·         P2X7Rs may participate in the pathophysiology of psychiatric disorders.
The ATP-sensitive homomeric P2X7 receptor (P2X7R) has received particular attention as a potential drug target because of its widespread involvement in inflammatory diseases as a key regulatory element of the inflammasome complex. However, it has only recently become evident that P2X7Rs also play a pivotal role in central nervous system (CNS) pathology. There is an explosion of data indicating that genetic deletion and pharmacological blockade of P2X7Rs alter responsiveness in animal models of neurological disorders, such as stroke, neurotrauma, epilepsy, neuropathic pain, multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), Alzheimer's disease, Parkinson's disease, and Huntington's disease. Moreover, recent studies suggest that P2X7Rs regulate the pathophysiology of psychiatric disorders, including mood disorders, implicating P2X7Rs as drug targets in a variety of CNS pathology.

P2X7 in Schizophrenia:-

P2X7 receptors (P2X7Rs) are ligand-gated ion channels sensitive to extracellular ATP. Here we examined for the first time the role of P2X7R in an animal model of schizophrenia. Using the PCP induced schizophrenia model we show that both genetic deletion and pharmacological inhibition of P2X7Rs alleviate schizophrenia-like behavioral alterations. In P2rx7+/+ mice, PCP induced hyperlocomotion, stereotype behavior, ataxia and social withdrawal. In P2X7 receptor deficient mice (P2rx7−/−), the social interactions were increased, whereas the PCP induced hyperlocomotion and stereotype behavior were alleviated. The selective P2X7 receptor antagonist JNJ-47965567 partly replicated the effect of gene deficiency on PCP-induced behavioral changes and counteracted PCP-induced social withdrawal. We also show that PCP treatment upregulates and increases the functional responsiveness of P2X7Rs in the prefrontal cortex of young adult animals. The amplitude of NMDA evoked currents recorded from layer V pyramidal neurons of cortical slices were slightly decreased by both genetic deletion of P2rx7 and by JNJ-47965567. PCP induced alterations in mRNA expression encoding schizophrenia-related genes, such as NR2A, NR2B, neuregulin 1, NR1 and GABA α1 subunit were absent in the PFC of young adult P2rx7−/− animals. Our findings point to P2X7R as a potential therapeutic target in schizophrenia.

More on Clemastine for MS in plain English:-

Modulating P2X7 with H1 antihistamines
Using 2 existing antihistamine drugs you can either increase or decrease the response from P2X7 receptors.
The complication is that pro or anti-inflammatory effect of P2X7 varies depending on which cell types are involved. So it is not so obvious whether a particular condition wants more or less P2X7 activity.  
In the case of MS a positive allosteric modulator of P2X7 (Clemastine) helps. In some other condition it may need the opposite, a P2X7 antagonist (Oxatomide).
Both Clemastine and Oxatomide are well understood inexpensive antihistamines, in many countries Clemastine is OTC. Oxatomide (Tinset) seems very popular in Italy. 

Because clinical data do not hint to severe or obvious clemastine-induced adverse drug responses that may involve P2X7 potentiation, augmentation of P2X7 activity in the presence of therapeutic concentrations of the antihistamine possibly exert more subtle changes that require a more thorough and focused evaluation. In addition, although we demonstrated release of the proinflammatory cytokine IL-1β from hMDM, P2X7 activation also gives rise to production and secretion of IL-1 receptor antagonist (IL-1Ra), which is in turn expected to exert anti-inflammatory activity (52,,54). Hence, the pro- or anti-inflammatory net effect of a clemastine-induced P2X7 potentiation may additionally depend on the targeted cell type, local availability of ATP, and pathophysiological background. An accumulating body of evidence points to a beneficial role of P2X7 activation in monocytes and macrophages to contribute to elimination of intracellularly located parasites and mycobacteria (55, 56). Even more strikingly, P2X7 activation in dendritic cells chiefly contributes to the orchestration of the adaptive antitumor immunity by triggering the caspase-1-dependent inflammasome activation in dendritic cells followed by IL-1β secretion and priming of interferon γ-producing CD8+ T cells (57). Therefore, selective P2X7 activators or positive allosteric modulators are intensely sought. In addition, the use of P2X7 activators, by triggering apoptotic cell death, has been put forward as a concept to treat several malignancies (Ref. 58 and references therein). Thus, the approved drug clemastine may serve as an interesting and immediately available starting point to explore these mechanisms in clinical settings.

P2X7 receptor antagonist activityof the anti-allergic agent oxatomide. 


Activation of the P2X7 receptor by extracellular ATP is associated with various immune responses including allergic inflammation. Anti-allergic agents, such as H1-antihistamines, are known to inhibit the effects of different chemical mediators such as acetylcholine and platelet-activating factor. Therefore, we hypothesized that some anti-allergic agents might affect P2X7 receptor function. Using N18TG2 and J774 cells, which express functional P2X7 receptors, the effects of several anti-allergic agents on P2X7 receptor function were investigated by monitoring the ATP-induced increase in intracellular Ca(2+) concentrations ([Ca(2+)]i). Among the various agents tested, oxatomide significantly inhibited P2X7 receptor-mediated [Ca(2+)]i elevation in a concentration-dependent manner without affecting the P2Y2 receptor-mediated response in both N18TG2 and J774 cells. Consistently, oxatomide inhibited P2X7 receptor-mediated membrane current and downstream responses such as mitogen-activated protein kinase activation, inflammation-related gene induction, and cell death. In addition, oxatomide inhibited P2X7 receptor-mediated degranulation in mouse bone marrow-derived mast cells. Whole cell patch clamp analyses in HEK293 cells expressing human, mouse, and rat P2X7 receptors revealed that the inhibitory effect of oxatomide on ATP-induced current was most prominent for the human P2X7 receptor and almost non-existent for the rat P2X7 receptor. The potent inhibitory effects of oxatomide on human P2X7 receptor-mediated function were confirmed in RPMI8226 human B cell-like myeloma cells, which endogenously express the P2X7 receptor. Our results demonstrated that the antihistamine oxatomide also acts as a P2X7 receptor antagonist. Future studies should thus evaluate whether P2X7 receptor antagonism contributes to the anti-allergic effects of oxatomide. 

Other ideas for MS? 
How about immunomodulation by antibiotic to treat MS? We have seen how macrolide antibiotics have immunomodulatory properties, but so do both (fluoro)quinolones and tetracyclines. In MS it is the tetracycline antibiotic minocycline that has the desired immunomodulatory effect. This is another  cheap way to treat MS. Minocycline is a common antibiotic often used to treat acne. In my earlier post we looked at Azithromycin and the idea of modifying such a drug to stop being an antibiotic but retain the immune-modulating property.
There will be a post on (fluoro)quinolones and tetracyclines in the near future.

My earlier post.

If you have MS a PDE4 inhibitor like Ibudilast looks a good idea. Ibudilast is currently only licensed in Japan, where it has long been used for asthma. In the West a different PDE4 inhibitor called Daxas/Roflumilast is approved to treat COPD and we saw in an earlier post that at one fifth of the regular dose it seems to treat sensory gating impairments and also improve cognition in some.
Clemastine, an OTC antihistamine in many countries, shows improved myelination in MS. I suspect the mode of action relates to P2X7.
The cheap tetracycline antibiotic Minocycline is likely another good choice. 
In people with mitochondrial disease, who lose skills, it appears that remyelination may be disturbed and they may be the most likely subgroup of autism that might benefit from the therapies that increase myelination.
Some of the MS therapies are “just” anti-inflammatory and by blunting the immune response, they remove a barrier to remyelination.
A PDE4 inhibitor is anti-inflammatory but it also increases something we have come across called PKA (protein kinase A). If you want myelin you want to activate PKA.
How about autism (and big brother, schizophrenia)? I think much of what helps MS may help at least some autism and vice versa.
For autism the Prevotella histicola bacteria looks interesting and quite possibly more or less P2X7R activity is going to help some autism/schizophrenia.

The yellow box means, we know it works, at least for some people, based on trial results.  

Regarding aging we know that learning new activities, physical activity and avoiding a terrible diet are all good ways to slow your brain shrinking.
Learning a new language, at any age is good for you, but if you are lucky enough to do this from birth you have less chance of dementia later on.
Very recent research shows the benefit of being bilingual if you happen to be autistic. Having strictly defined autism means you will not appear fluent in either language, but you have learnt that there at least two ways of doing the same thing. Some people with autism are extremely inflexible, but if you are bilingual there are two ways to ask for everything and you learnt this as soon as you started to speak.
In the first study of its kind, scientists show that bilingual children with autism spectrum disorders can switch mental gears more easily than those who can only speak one language.
A focus on developing/improving motor skills from a very early age in those even suspected of having autism may well have much broader cognitive benefits.
It is best not to accept sloppy handwriting and lack of coordination when playing ball; gradually improving these skills will pay broader dividends.
Going back to the start of this post and what Monty’s old assistant might do with her new young learner with poor fine motor skills, my advice was to ignore the psychologist and spend half an hour a day practicing fine motor skills with a photocopiable workbook like this one, that years ago she used with Monty:-

I have to make sure to ask for it back !  


  1. Excellent! Thanks for giving me something to study for the weekend.

  2. The myelination stuff with autism is indeed tricky. Reduced myelination can occur for many reasons, but one of them can be that there is just not enough space for oligodendrocytes to myelinate the axons of neurons as dendritic overgrowth and reduced synaptic pruning are common findings in autism studies, not to mention excess gray matter relative to white matter in various regions of the brain as well as the macrocephalic autism phenotype compressing the brain which causes reduced ventricle size.

    Crows have amazing intelligence for an animal with such a small brain and being that they are not mammals, they have no myelination. It is thought they make up for this relative deficit with more numerous, smaller, and more efficient neurons packed into dense neuron nuclei that are all relatively close to each other. However, without myelination there is always going to be a ceiling in brainsize before transmission times become prohibitive, hence why you will never ever see any real life Big Birds from Sesame Street anytime soon.

    So if you have a big "bird brain" like it appears in autism, you are going to have problems getting messages from one part of the brain to another, even if those messages make multiple hops through relay centers such as the thalamus.

    Also, there is a basal ganglia model of function called "surround theory" which is different from the classical direct and indirect pathways in that it posits that you have a direct pathway to initiate movement, an indirect pathway to suppress unwanted movements, and then finally a hyperdirect pathway which stops a movment. This hyperdirect pathway depends on cortical fibers travelling straight to the subthalamic nucleus deep in the brain and this long distance is made possible via very heavy amounts of myelination. If the hyperdirect pathway is dysfunctional, then you may start a motor movement or a behavior or an emotion and have problems stopping and switching to something else. In Huntington's disease the subthalamic nucleus is damaged or even destroyed which interestingly presents some of the same symptoms you find in severe autism.

    Perhaps dysfunction of the subthalamic nucleus in some autisms could mostly just be a myelination issue causing motor and behavioral start/stop deficits that lead to stereotypes and compulsive behaviors.

  3. Thank you for sharing your ideas Peter.

  4. Peter, I have some very good results with Afobazole (10mg/d). It's really helpful with cognition and learning and doesn't seem to have any side effects.
    Connecting Afobazole, which is a sigma 1 receptor agonist, with your brilliant post here, I found that it can block P2X7 receptors and decrease the incidence of depression.

    Afobazole Modulates Microglial Function via Activation of Both σ-1 and σ-2 Receptors

    Also I'd like to add that taurine may be helpful with remyelination process and there are several articles claiming this. When I trialed 10mg afobazole I felt something like a taurine activated mechanism, which may sound a bit arbitrary, but I know how taurine feels. In the beginning you feel the surge but after a few minutes you just feel the benefit of it, nothing like taking a taurine supplement which can make you feel overload and heartbreaking.

    Effects of afobazole on the content of neurotransmitter amino acids in the striatum in global transient ischemia.

    Peter, I'd like to point out that I've learned a very important thing from you, to follow the cognitive way of thinking for my son, so just because my son has asperger's and high IQ doesn't mean that we don't face cognitive issues and when I say afobazole helps with cognition I mean it. I try to focus on that first thing first.

    1. Hi Petra,

      Hope all is well. Petra, I hadn't heard of afobazole before, and your comments are very intriguing.

      In doing a quick search, it seems to be viewed as a nootropic, which may make it easier to obtain than a prescription.

      Petra, would you kindly provide some more details in terms of the nature and extent of the cognitive improvement? Also, how long did you use it before you noticed improvements?

      For me, of my daughter's 3 main symptoms (cognition, speech, and socialization), cognition is the most important to me. She has improved a lot over the last year in all 3 (mainly due to getting rid of bad gut bugs and replacing with better bugs). She is absolutely brilliant when it comes to facts (e.g. names of objects, figuring out how things work, etc.) but then isn't very strong with more abstract ideas (e.g. the difference between yesterday, today, and tomorrow).

      I would be thrilled with improvements in cognition, especially those that relate to more abstract ideas.

      Any insights you can provide would be appreciated.

      Thanks very much Petra!


    2. Hi AJ,
      Hope you are fine and thanks for your interest.

      Afobazole is a nootropic, OTC, cheap, Russian drug, not FDA approved and not for people under 18 years of age.

      My son is in a constant cognitive improvement course, as your daughter is,so I would expect results, if any, on the very same day, hopefully.
      It's not sedative, a little bit stimulant, boosts cognition with some positive mood. It is used for brain hypoxia and it's said to be neuroprotective.
      In the beginning your cheeks get a little red, your heart beats a little faster but as soon as you realise it, this stops. Then you just feel a better version of yourself and forget about it.
      In our case it definitely helps with abstract meanings comprehension.
      I am currently trying to find a Russian specialist to give me clear instructions on how to use as I may need to stop and start again(?), if it's ok to activate sigma receptors for long, such things...

      Hope this is helpful, AJ.


    3. Hi Petra,

      Thanks so much for your response. Yes, my daughter has really improved since we replaced the bad bugs / yeast in her GI system with good ones, and cut out gluten and casein. The difference is pretty noticeable.

      Of course, it is not a cure by any means, but we're headed in the right direction. My main hope is to improve the cognitive issues, as this would obviously help a lot in her schooling. The fact that this nootropic helps with cognition is something I will keep in mind as a future option.

      Please share anything you find out from the Russian specialist, including to your point if this can be taken long term (assuming they even know), if there is a need to take "holidays", and maybe if you can, what some of the initial symptoms are of side effects that should lead one to stop / reduce dosage.

      I'm very glad your son is experiencing constant cognitive improvement. I really believe we are getting closer and closer to better treatments for our kids.

      Have a wonderful day Petra!


  5. This is all very interesting. I think motor skills in autism is another neglected part of the story.

    If a child does not progress with motor skills despite intensive training, I mean spending definitely more than half an hour a day on practicing, does this point to myelination problems? What else can contribute?

    If overt mast cell activation symptoms are an issue, would you try clemastine despite its P2X7 potentiating properties, which is also apparent in the oxatomide paper?

    In the clemastine trial they used ~10 mg daily, while the usual adult dose is 2x1 mg and maximum as antihistamine is said to be 6 mg. I wonder what is the significance of this approach and why they started with such hefty dose? Is this needed to affect P2X7? What dose would you try in a child?

    Fine motor skills training was a part of my son's intensive early intervention, but he learned to use a zip only at the age of 9 and within weeks after acetazolamide introduction (or rather adding acetazolamide to bumetanide). At the same time he learned to swim independently despite having lessons since infancy.

    1. Agnieszka, if we consider a skill as a long chain of interconnected neurons, we do not just need the electrical insulation (myelin), but we also need each connection between the neurons (synapses) to function correctly. We know that the synapses in much autism do not function quite as they should. Your acetazolamide improved how the synapse functioned, which was the rate limiting factor in your son mastering how to use a zip. Now that skill has been myelinated so he will not forget it, if he did not practice the skill he would not retain it. In my son it was Bumetanide that opened the door to learning.

      Clearly there are lots of things that block skill acquisition and myelin is just one.

      In people who respond remarkably to ABA and do not need bumetanide, perhaps myelin was more critical and all the repetition of ABA is what was needed.

      The data from the myelin investigated in Asperger's above does show that the myelin layer was thin in key areas. If they looked at severe autism the difference might be more profound. We can only speculate.

      I would start at a low dose of clemastine/oxatomide and gradually increase and look for any changes. You would expect one drug to produce a net gain and the other a net loss, or just no impact beyond the H1 effect.

    2. Thanks Peter. I wonder if there is anything specific in learning motor skills - in terms of treatment targets?

      My general thought is also that early intervention, ABA schools etc would better take more insight into neuroscience when developing their programs for children with autism. If I understood correctly the papers highlighted in your post, developing motor skills can have broader effect so it should be significant part of the therapy for at least some children. That is not the case where I live.

      Also I wish all children with autism were taught swimming and coping with stress. Both ideas are science based. The latter is perhaps easier said than done.

    3. Agniesksa I would take it a step farther and say that ABA should be prescribed by a medical doctor and not just assumed all with autism will benefit from it from early intervention. I know Peter and many people are fans of it, but there are many families who are not, based on their kid’s experience with it especially when used as early intervention. And it doesn’t matter if it is made to seem fun with tickles and high fives and even candy/food enforcers, for those susceptible to stress, all of the former does not make it better. For a 2-3 yr old sitting at a table or even on the floor doing repetitive programs is too much. I agree wholeheartedly that at this age play and gross motor skills should be the focus - this is what a great occupational therapy program can provide. That was the best thing for my son at that young age - wish we never did ABA. It made his stress and anxiety worse. He didn’t need that kind of repitition to learn - he needed medical treatment and a proper health diagnosis then to make him feel better so he can show that he learns.

    4. And the topic, about teaching coping with stress - yes that is so difficult. But I think if you can identify triggers that makes a huge difference. Either physiological triggers or emotional. For the kids with little to language that can be very difficult to figure out but it can be done. I have learned a lot about triggers just reading what people with bi polar disease discuss: the looping worrying thoughts, how getting off of a loose schedule affects them, the changing of seasons, loud overbearing people, hustle bustle city environments, better by exposed to television news, disruption in exercise activities, etc. I noticed with my son I cannot talk about anything his health related if he is within earshot - it is an emotional trigger for him, Even if I am speaking to his grandmother and mention how his allergies are flaring or his gut is off - it is upsetting. He simply cannot bear it, feels like it is a criticism. He does not want to be treated like a “project”. And this is not just mom putting a cutesy little spin on it - I really feel there are many with ASD who are sensitive to this.

    5. Argh all my typos:
      meant to type made worse by being exposed to television news

  6. Hi Peter, Iam back home and things have changed for the better. I will continue with bumetanide, can get more packs. I don´t know why bumetanide didn´t help with the stress that the holidays generated him.It seems that its effect is limited to not only to alergies but also to the situations that stress him.Is it possible? I can get Tinset, not clemastine, don´t know if it is the right one, if it was not,should i expect a regression? If MS were heredable, could say that may son has myelin problems, both fine and gross motor skills are compromised.Valentina

    1. Valentina, stress is indeed very important. For example, we saw how people's sensory gating problems get much worse during stress.

      I think you could try the standard dose of Tinset and see if it helps at all. That is quite a safe trial to make.

      There is a debate as to whether some types of MS are heritable. At least one type is, involving the gene NR1H3.

      Practicing fine/gross motor skills is a good idea and can be made to be fun.

    2. Peter, about my son´s sensory hyperresponsivness what do you suggest to correct abnormal P50 supression? There is a relation between anxiety and sensory registration. Valentina

    3. Valentina, the research quoted in previous posts suggests that (100mcg) one fifth of a Daxas/Rofluminast pill a day should help this problem. It could also help with any inflammatory conditions elsewhere in the body and it may well improve cognition in some people. Daxas is not cheap, but one pack would last 5 months. This dose was found in the trial to be free of side effects.

    4. Peter, Roflumilast is a phosphodiesterase type 4 inhibitor, here I can´t get it.Between PDE4 inhibitors I found luteolin,do you think that it could help with this problem acting in the same way?

    5. Valentina, luteolin has many beneficial effects, but it is not well absorbed so I doubt it will give the effect of Roflumilast. It is widely used by people with allergy and some with autism, so no harm in trying it.

  7. Hi Peter, What is your sense of cholesterol role in myelin? This is part of an abstract that I had seen at some point:

    The largest pool of free cholesterol in mammals resides in myelin membranes. Myelin facilitates rapid saltatory impulse propagation by electrical insulation of axons. This function is achieved by ensheathing axons with a tightly compacted stack of membranes. Cholesterol influences myelination at many steps, from the differentiation of myelinating glial cells, over the process of myelin membrane biogenesis, to the functionality of mature myelin. I always thought that choline (and b12) were critical to the myelin sheath. In terms of practice, practice practice -- I subscribed to your posts where you need to first address some of the underlying dysfunctions. I know you can't wait forever, but my child would not have been a competitive university athlete if we had practiced gross motor a lot (without fixing some of his dysfuctions). Thank you for your wonderful posts Best, MH

    1. Sorry, the abstract (before my other thoughts..)

      "The largest pool of free cholesterol in mammals resides in myelin membranes. Myelin facilitates rapid saltatory impulse propagation by electrical insulation of axons. This function is achieved by ensheathing axons with a tightly compacted stack of membranes. Cholesterol influences myelination at many steps, from the differentiation of myelinating glial cells, over the process of myelin membrane biogenesis, to the functionality of mature myelin"

      Best, MH

    2. MH, myelin is mostly made of cholesterol, but I do not think lack of cholesterol is often the problem, rather underperforming oligodendrocytes.

      Most of the cholesterol in the brain is synthesized there. There are disorders that affect myelin synthesis, one being SLOS (Smith–Lemli–Opitz syndrome) which causes low cholesterol and is a subtype of autism. So in rare cases of autism like SLOS, a lack of cholesterol could well impact myelination and impact cognition and behavior.

      In the brain (as opposed to outside the CNS) myelin is deposited by oligodendrocytes, one oligodendrocyte can myelinate several axons at the same time. A single oligodendrocyte can extend processes to up to 50 axons, and has the capacity to renew their myelin sheaths three times within 24 hours. So they keep themselves busy.

      In autism it appears they are somewhat lazy, resulting in thinner myelin layers.

      In MS it is thought that the immune system attacks both the myelin layer and the oligodendrocytes.

      Oligodendrocytes express glutamate (AMPA, kainite and NMDA) and ATP (P2X7) receptors rendering them susceptible to excitotoxicity. So too much glutamate can destroy oligodendrocytes. P2X7 antagonists can prevent damage to oligodendrocytes and myelin.

      There is no oligodendrocyte-based treatment of MS in current use, but in the above post there is a P2X7 therapy, but it is the opposite that you would expect.

      Much of the puzzle remains.

  8. Hi Peter and Community,

    So I spent nearly an hour last week writing up a post, only to have it not go through (technical glitch, not sure why). Interestingly enough, It was about Prevotella Histicola which Peter briefly mentions in this post. Here is what I found about Prevotella Histicola:

    1. Prevotella was just recently noted to be very low in ASD kids relative to normal children in analyses of the Oral Micriobiome

    In fact, the following paragraph is key: “At the genus level, increased abundance of Streptococcus and Haemophilus, as well as markedly reduced abundance of Prevotella, Alloprevotella, Selenomonas, Actinomyces, Porphyromonas and Fusobacterium in ASD samples were observed, suggesting a characteristic dysbiotic signature. The family Prevotellaceae, including the genera Prevotella and Alloprevotella, also showed a relatively low abundance in children with ASD. This was evident in dental samples as demonstrated in the co-occurrence network (Fig. 4). In agreement with these findings, Finegold et al. recorded a depletion of Prevotella in the gut of autistic patients compared to sibling controls. Meanwhile, Kang et al. reported that Prevotella, as the most significantly altered genus between autistic and neurotypical subjects, decreases dramatically in abundance in stool samples from autistic patients. A low abundance of Prevotella was also detected in feces from patients with Parkinson’s disease and untreated Multiple Sclerosis, supporting the relevance of this bacterium in CNS disorders. Prevotella is a commensal microorganism in multiple human habitats, including the intestine and oral cavity; it does not only interact with the immune system but also plays a key role in degrading a broad spectrum of saccharides. Interestingly, it was reported that autistic children may have deficiencies in saccharide metabolism and impaired carbohydrate digestion. Prevotella species also have essential genes for the biosynthesis of vitamins, which were reported to mitigate ASD symptoms. Future studies are warranted to further interrogate the role of Prevotellaceae, also evaluating its therapeutic potential for ASD.”

    2. This diminished population of Prevotella, more importantly is found to be significantly reduced in the gut microbiome of ASD kids:

    3. And more evidence that reduction of Prevotella is a potential key piece of the puzzle in ASD:

    - In fact, if you look at the following table, you can see the lack of Prevotella in ASD kids while healthy kids have this bacteria in their gut microbiome:

    - The following table also outlines the incredible lack of Prevotella between ASD kids and neurotypical kids

    4. The big question therefore is, would Prevotella actually impact the symptoms? Fascinatingly, when ASD kids received a Fecal Microbiota Transplant (yes, that's a poop transplant) from healthy donors, they improved significantly, which appears to be at least partially attributable to changes in Prevotella abundance (as well as the other changes to the gut microbiome)

    In fact, when you look at the following chart, specifically graphic 3f, Prevotella seems to be the most significantly changed bacteria relative to baseline following FMT

    Unfortunately, it's not available yet, but I do believe it could make a positive impact if available (much better than an FMT!). Given my experience with replacing bad bugs with good, the gut microbiome does seem to be a factor in at least some ASD kids.


    1. AJ -- thank you for your info. What has worked well and conversely, not well, for managing the bacteria in your daughter's gut? Thanks, MH

    2. Hi MH,

      So it all came out of OAT testing that we did. My daughter has never had any GI issues - at all! So I assumed that she likely didn't have bad bugs / yeast but the OAT testing showed she had both.

      So we used Vancomycin (oral) and Nystatin (oral) to kill the bad bacteria and yeast and used several probiotics and Sac Boulardii daily since. That is, while we were killing off bad bugs, and ever since, we have made sure that the replacement bugs are provided daily to crowd out any bad bugs coming back.

      Also, we have mostly cut out gluten and casein, and have tried to lower sugar as much we reasonably can with a 5 year old. We use Stevia when we can to replace sugar. So for example, we replaced my daughter's nightly cow's milk with Almond milk, her bread is gluten free (For my fellow Canucks, try Little Northern Bakehouse, it is the best! But you have to toast it), etc.

      We will be re-running the OAT testing soon, to see what the results are in terms of levels of bad bacteria and yeast, but she became a different kid since we started this. I don't know if its the good bugs over bad, good yeast over bad, no gluten, or no casein, but the impact is very noticeable. Much better mood, improved speech and socialization. She seems much more playful and has a great sense of humour. Not a cure by any means, but sustained improvement to be sure. Not sure it will work for anyone else, but it sure did for us. If you haven't done OAT (Organic Acid) testing yet, I would highly recommend it. We found other issues above and beyond bugs / yeast.

      Hope this helps MH!


    3. AJ, if you want to increase the amount of Prevotella bacteria, just eat a teaspoonful a day of inulin. This is very cheap, has numerous claimed benefits, some are likely genuine. Also, it does not taste bad.

      "Quantitative analysis of caecal microbiota demonstrated that inulin increased the numbers of total bacteria and the Bacteroides-Prevotella-Porphyromonas group, FOS increased bifidobacteria, and both fructans decreased Clostridium cluster XI. In the faecal samples, both inulin and FOS decreased total bacteria, Bacteroides-Prevotella-Porphyromonas group, and Clostridium clusters XI and XIVa."

    4. Thanks AJ, nice summary!
      And thanks to Peter for the "possible treatment"-angle.

      You are great! :)


    5. Hi Peter and Ling,

      Peter, I actually have several small containers of Inulin at home as I started to use it but found an article or paper somewhere where it also increased something I didn't want increased (Don't recall what but I will try to find it).

      Having said that, I have been giving my daughter Bimuno for almost a year now, but when I looked at the impact of that, it seems to lower Prevotella ... so now I wonder should I use both? It's never easy ....

      Ling, I'm happy to help! My next adventure is trying to make (at home) the things my daughter loves, but with Stevia instead of sugar or non-gluten flour instead of flour. My daughter loved Goldfish, so I'm going to see if I can make homemade Goldfish, and then chocolate with Stevia instead of sugar.

      Have a great evening!


    6. AJ, it is clear that you have to be careful with all these prebiotics and probiotics. There is no one size fits all solution. Some people may need nothing at all. Some products have clever benefits, but only in some people. It is easy to waste your money.

      It looks like the microbiota goes back to where it was a couple of weeks after stopping these products, so no great harm done.

      Some day soon there will be customized products and people will be obsessed with their quarterly bacteria status reports.

      At least Inulin is cheap and if it helps there should be some visible effect.

    7. Hi Peter,

      I absolutely agree. My daughter continues to improve so whatever we're doing is helping us go in the right direction.

      One thing I do want to pursue is a microbiome test.

      I would go with Explorer for several reasons, including the fact that it may be the only option for non-US residents.

      I actually reached out to them and they gave me access to what the Explorer online report would look like, and its pretty good. I was thinking about getting a baseline of bacteria and phenotype, making a change like adding inulin, and then seeing what the bacterial mix becomes and how it affects the phenotype.

      I'm also expecting our genetic test results shortly - that may help us figure out at least one cause for my daughter's condition, which will hopefully lead to some new treatment options.

      Have a great day Peter!


    8. HI All,

      First thanks to Peter for this amazing blog which shares so much useful information in an intelligent way that non scientists can read and absorb. So grateful.

      I wanted to report on our experience with bumetanide and to offer our 'next step' queries. Our biomedical doctor agreed to provide a prescription and we began a 60 day trial in mid November at 0.5mg 2x day. Since many factors can affect a day we tried to restrain the tendency to conclude it was significantly effective at reducing the intensity of our son's oppositions, irritability and anxieties. As in many families, we began 4 years ago with GFCF diet, MB12 injections, and micronutrient therapy (vitamins, CLO, Vit D, methylfolate, magnesium, NAC, vinpocetine, 5 HTP, taurine GABA theanine alcar uridine alpha-gpc phosphatidylserine glutamine etc) all of which gradually helped with big leaps attributed to magnesium glutamine MB12 and Gcmaf (notwithstanding bad rep there). Then the irritability and shouting were further reduced throughout 2017 by introduction of low dose guanfacine and low dose ADHD medication.
      But now with the Bumex - very very noticeable 'big leap' improvements. The positive benefits: approx 20% decrease in intensity of bad reactions and increase in being present and immediately (which was a shock) responsive to others. That 'immediate responsiveness' brought unprompted comments from a teacher. Negatives: anxiety over having no regular effective way of testing his potassium, need to insist on sweet potato, avocado, spinach, banana or one of every day; and huge urination change - within 30 minutes of first pill of the day. During the 60 days we had to put him back in pull-ups for nighttime, psychologically a downer, and teachers complained about the number of bathroom breaks.

      Overall - thanks to this blog -- I feel this is a major improvement for our son. We are now seeking renewal of prescription but we need to decide whether to now request a higher dosage, from 0.5 to 1.0 or 2.0. I remember on this blog a discussion about how 2.0 is more effective than 1.0 and wonder if that is still the general view, Peter? I was also interested in the talk about ways to enhance effectiveness and tried the beet juice but we had too much opposition to that and I am eager to learn other ways to potentially enhance the Bumex effect.



    9. Mira, I am glad your son responds well to bumetanide.

      You may well find 1mg once a day works better than splitting the dose in two. This also means diuresis just once a day. My son currently takes 2mg once a day. The drug does not cross the blood brain barrier well and only a tiny amount makes it through, so there may be big variations between different people. This means what works best may vary, so you need to see what is best for your son. You can try decaffinated coffee flavanols to boost the effect, or just use a higher dose of bumetanide.

  9. HI Peter,
    I'd really like to try the clemastine/oxatomide as my son was given the diagnosis of CDD and he had a major regression around age 5. We have lost a lot of time but I continue to search for ways to get him back onto a learning curve. I have no idea which one to try or what does (He is about 180 pounds).
    I know there are mast cell issues as his skin has cleared immensely with cromolyn sodium and L-Histamine.
    I welcome your thoughts on this.

    1. Nancy, clemastine is the one that helped in MS and is OTC in North America. Since it is sold for allergy (mast cells) your son will benefit from that effect anyway. As for dosage I would go for the upper end of what it says on the pack, for MS they did use a higher dose than for allergy. But best to try the regular dose first.

  10. I think the study into children with autism benefitting from being bilingual is fascinating. Thanks for highlighting it.

  11. Peter, do you know of any treatments to enhance reelin? I think you somewhere mentioned statins in this context, but not how they would affect it. I just found out thyroid hormones can do this, but not sure if this could be turned into a treatment.

    1. Hi Ling,

      The following paper isn't about a specific Reelin agonist per se, but highly relevant nonetheless as it speaks to why Reelin may be underexpressed in some ASD:

      Epigenetic regulation of RELN and GAD1 in the frontal cortex (FC) of autism spectrum disorder (ASD) subjects.
      Zhubi A1, Chen Y2, Guidotti A3, Grayson DR4.
      Author information

      Both Reelin (RELN) and glutamate decarboxylase 67 (GAD1) have been implicated in the pathophysiology of Autism Spectrum Disorders (ASD). We have previously shown that both mRNAs are reduced in the cerebella (CB) of ASD subjects through a mechanism that involves increases in the amounts of MECP2 binding to the corresponding promoters. In the current study, we examined the expression of RELN, GAD1, GAD2, and several other mRNAs implicated in this disorder in the frontal cortices (FC) of ASD and CON subjects. We also focused on the role that epigenetic processes play in the regulation of these genes in ASD brain. Our goal is to better understand the molecular basis for the down-regulation of genes expressed in GABAergic neurons in ASD brains. We measured mRNA levels corresponding to selected GABAergic genes using qRT-PCR in RNA isolated from both ASD and CON groups. We determined the extent of binding of MECP2 and DNMT1 repressor proteins by chromatin immunoprecipitation (ChIP) assays. The amount of 5-methylcytosine (5mC) and 5-hydroxymethylcytosine (5hmC) present in the promoters of the target genes was quantified by methyl DNA immunoprecipitation (MeDIP) and hydroxyl MeDIP (hMeDIP). We detected significant reductions in the mRNAs associated with RELN and GAD1 and significant increases in mRNAs encoding the Ten-eleven Translocation (TET) enzymes 1, 2, and 3. We also detected increased MECP2 and DNMT1 binding to the corresponding promoter regions of GAD1, RELN, and GAD2. Interestingly, there were decreased amounts of 5mC at both promoters and little change in 5hmC content in these same DNA fragments. Our data demonstrate that RELN, GAD1, and several other genes selectively expressed in GABAergic neurons, are down-regulated in post-mortem ASD FC. In addition, we observed increased DNMT1 and MECP2 binding at the corresponding promoters of these genes. The finding of increased MECP2 binding to the RELN, GAD1 and GAD2 promoters, with reduced amounts of 5mC and unchanged amounts of 5hmC present in these regions, suggests the possibility that DNMT1 interacts with and alters MECP2 binding properties to selected promoters. Comparisons between data obtained from the FC with CB studies showed some common themes between brain regions which are discussed.


    2. Ling, I think you have read my post on Reelin.

      There is an interesting patent with plenty of information.

      Reelin rescues cognitive function

      In this embodiment, the disease or disorder of the nervous system can be selected from the group consisting of fragile X syndrome, William's syndrome, Rett syndrome, Down's syndrome, Angelman syndrome, autism, ischemia, hypoxia, Alzheimer's disease, Reelin deficiency, schizophrenia, neurodegeneration, traumatic brain injury, mental retardation, dementia, and stroke. The therapeutically effective amount of Reelin or an agonist of a lipoprotein receptor is, in one example, approximately 5 nM.

      I cannot prove that Atorvastatin increases reelin, but when I looked into the subject I thought it was quite likely.

      The great thing about Atorvastatin and autism is that you respond from the first pill and then lose the benefit the day after you stop taking it. So it is crystal clear who is a responder.

    3. God, I wish my daughter didn't have to have everything going wrong in her little brain. Too little reelin is really bad, and it is still just a tenth of her condition.
      For anyone who wants to know more on the reelin pathway there is a nice simple picture on Wikipedia (but not on the RELN page) here:
      (Don't know what it has to do with malaria)

      We can clearly see how it is connected to PI3 and GSK-3.
      AJ, was it you who looked into GSK-3-inhibitors?

    4. My own entrance here was the downregulation of the autism gene TBR1. TBR1 works together with something called CASK (calcium/calmodulin-dependent serine kinase) and CINAP to promote reelin and the NMDA receptor NR2B (GRIN2B) among other things. Both of these play important roles in long-term potentiation.

      I was hoping to find anything that could upregulate TBR1, but instead found something about its co-agonist CASK:

      "PKA phosphorylation appears to regulate CASK’s nuclear functioning in neurons as it up-regulates the interactions between CASK and Tbr-1. To test this possibility, we determined whether NMDAR2b, one of the downstream targets of Tbr-1, is cAMP-responsive and whether the Tbr-1-CASK complex mediates the cAMP responsiveness of NMDAR2b expression. First, we investigated whether NMDAR2b expression is stimulated by the PKA pathway. Forskolin treatment increased the total NMDAR2b protein levels in cultured rat cortical neurons"

      So, forskolin activates cAMP and PKA. This is also what PDE4-inhibitors like Roflumilast, Rolipram, and Ibudilast from a previous post do. And, it looks like at least Rolipram + forskolin synergize, according to Figure 6 here:

      Another interesting compound mentioned here is Fisetin which given orally to mice increases long-term memory (but not as much as rolipram as per Figure 5). It does not contribute to cAMP, but instead works in a parallell pathway which includes ERK1/2.
      Now, as I have read a lot on the SATB2 (which promotes TBR1) I know that it is evoked through ERK1/2 activation. This might be a coincidence, or not. It certainly looks as yet another way for enhancing learning/cognition.

      This sounds very promising, but has to be tested in autism/children. Also, I have not checked the safety profile of neither fisetin nor forskolin, but I know a lot of biohackers use them.


    5. I finally took the time to plunge into the reelin signalling pathway. It really is implicated in so many brain diseases (ASD, AD, BD, SCZ...), but also in atherosclerosis and blood coagulation.
      Here are some important quotes from my research:

      "reelin application to adult mice hippocampal slices leads to enhanced glutamatergic transmission mediated by NMDA receptors (NMDARs) and AMPA receptors (AMPARs) through distinct mechanisms."

      "Reelin may physiologically modulate learning and memory by modulating NMDA receptor functions. (..) These data fit with the observations that in the absence of Reelin or the Reelin receptors, neurons exhibit stunted dendritic growth, a reduction in dendritic branches and significantly fewer spine" (figure with text)

      "The activation of RELN signalling may inhibit excitotoxic neurotransmission and Tau phosphorylation, and may activate neurogenesis [in mice]"

      "Reelin signaling through Apoer2 markedly enhances LTP"

      "both surface GluR1 and NR2A were significantly increased, and the level of surface NR2B was significantly reduced after chronic Reelin treatment. C) Reelin treatment significantly increased levels of total GluR1, NR2A, and decreased level of total NR2B"
      From the patent application above

      "Recently, it was shown that reelin signaling is required for maturation of glutamate receptor function during postnatal development. For example, reelin is required for the normal developmental switch (from NR2B to NR2A) of somatic NMDAR subunits in cultured hippocampal neurons"
      "Moreover, both NR2A and NR2B can be tyrosine phosphorylated in response to synaptic activity and reelin signaling. Furthermore, reelin has been shown to promote AMPAR surface expression and reduce the number of silent synapses in cultured hippocampal slices."
      "mice lacking either Tbr1 or Pax6 [gene]. Both of these mice exhibit decreased expression of reelin"

      "Reelin overexpression delays amyloid plaque formation and rescues the recognition memory deficits"

      /Ling (to be continued...)

    6. So, a lot of people including me would like to upregulate reelin, at least until that patent holder above starts production of a supplement. These are my findings:

      "Chronic treatment of NT2 cells with retinoic acid (RA) results in differentiation of this cell line. Differentiation of NT2 cells is preceded by a gradual and significant upregulation of reelin expression within 6 days. (..) . Site-directed mutagenesis demonstrated that the Sp1 site, but not the Pax6 site in the proximal promoter, was necessary for the RA-induced increase in reelin expression."

      Peter, is retinoic acid safe?

      Possible Involvement of Standardized Bacopa monniera Extract (CDRI-08) in Epigenetic Regulation of reelin and Brain-Derived Neurotrophic Factor to Enhance Memory

      Bacopa monnieri has been trialled in children (from 6 years of age) with some success for ADHD, so I assume it is a fairly safe substance:
      "The children received SBME at a dose of 225 mg/d for a period of 6 mo"

      "The present results further demonstrated that the demethylation status of reelin and bdnf, and acetylated H3 and acetylated H4 at the reelin and the bdnf promoters in the mPFC were enhanced by the delivery of LTP-inducing high-frequency stimulation (HFS) (..)
      Administration of NaB [sodium butyrate, not benzoate I presume], a HDAC inhibitor, increased LTP induction and the levels of acetylated H3 and acetylated H4 at the reelin and the bdnf promoters in the mPFC, as well as the mPFC-dependent long-term trace fear memory.

      "increased maternal care was found to [positively] correlate with reelin expression in rat pups; such correlation was reported in hippocampus and in the cortex" [About a 10% upregulation]
      "According to one report, prolonged exposure to corticosterone significantly decreased reelin expression in murine hippocampi, a finding possibly pertinent to the hypothetical role of corticosteroids in depression"

      The psychotrophic medication Olanzapine upregulates reelin mRNA and protein. (not recommending this one, I think also Fluoxetine also upregulates reelin mRNA)

      Beware of methylation promoters:
      "Animals subjected to L-methionine exhibited significant decreases in the expression of reelin in cortical GABAergic neurons, and this decrease was associated with an increase in the methylation of the reelin promoter and deficits in sensory-motor gating and social interaction" (again)

      Peter, if you want to write a post of this you are very welcome.


    7. Ling, it looks like reelin in involved in most neurological disorders. It is another nexus where numerous different dysfunctions meet up. In male “reeler” mice, with reduced reelin expression, you can reverse their “autism” with estrogen.

      Much of the research is quite old, so it likes like it may be a dead end. They look at effective schizophrenia drugs and say that along the way reelin is increased. So what improves SATB2, will very likely also increase reelin.

      I would look at the ERβ-SATB2 pathway.

    8. Working on many frontiers here...
      I am a bit vary of neurosteroids, since I can't find much on progesterone for children / safety. Earlier puberty and shorter stature? Allopregnanolone was used in two children with refractory status epilepticus:


    9. Ling, will your daughter drink soy milk?
      You would have to drink a lot of it, but it does have the same effect as estrogen.

  12. Hi everyone,

    Interesting new paper:

    Embryonic stem cell transplants as a therapeutic strategy in a rodent model of autism

    Autism is a neurodevelopmental disorder characterized by disruptions in three core behavioral domains: deficits in social interaction, impairments in communication, and repetitive and stereotyped patterns of behavior or thought. There are currently no drugs available for the treatment of the core symptoms of ASD and drugs that target comorbid symptoms often have serious adverse side effects, suggesting an urgent need for new therapeutic strategies. The neurobiology of autism is complex, but converging evidence suggests that ASD involves disruptions in the inhibitory GABAergic neurotransmitter system. Specifically, people with autism have a reduction in parvalbumin (PV)-containing interneurons in the PFC, leading to the suggestion that restoring interneuron function in this region may be a novel therapeutic approach for ASD. Here we used a dual-reporter embryonic stem cell line to generate enriched populations of PV-positive interneurons, which were transplanted into the medial prefrontal cortex (mPFC) of the Poly I:C rodent model of autism. PV interneuron transplants were able to decrease pyramidal cell firing in the mPFC and alleviated deficits in social interaction and cognitive flexibility. Our results suggest that restoring PV interneuron function in the mPFC may be a novel and effective treatment strategy to reduce the core symptoms of autism.


  13. Peter, I found this very old (1992) paper that says that bumetanide prevents NMDA receptor activation. My gut feeling says that this conclusion is wrong, and that bumetanide only attenuates GABA. But I don't know, and it makes me a bit nervous that bumetanide might be favoring hypo NMDAr. What do you think?

    Chloride transport blockers prevent N-methyl-D-aspartate receptor-channel complex activation.


    1. Ling, I think if you dig deep enough you will find most drugs have multiple modes of action. It would not surprise me if bumetanide has an effect on NMDARs. I am surprised that some readers report an immediate effect from bumetanide, this cannot be the GABA effect. There is an effect on K+ and possible dehydration. Perhaps some people see an NMDAR effect? The drug is seen as safe so I would not worry too much about NMDARs, what matters is the net effect.

  14. Yeesh, Ibudilast was really good for my asthma! Asthma induced by cold temperatures was gone, and within one hour of intake I could literally feel my throat open to more air. I thought I was well managed with steroids... Of course, my ongoing cold/flu might have raised the bar for now.
    It is really a pity that Ibudilast is so expensive to get, because it would probably add a year or two to my lifetime. You do wonder what it is worth to pay to have top-quality breathing?

    I have not noticed any cognitive effect on myself after 1 week with 2*10 mg or 2*20 mg, maybe a tiny tiny nausea at the higher dose but it could also be placebo.

    Deciphering the Ibudilast leaflet has not been easy - still undone - and japanese speaking friends (non-native) could not help me out. Machine translation made it look like a surrealistic but humorous haiku.
    So, there is a lot I don't know about this drug, like medical interactions and patient cohorts (children?) I did find this site though:


  15. Another link on Ibudilast, that merely says that they will try it on small infants (1-2 years old):

    Krabbe disease is one of those really nasty diseases you wish you didn't knew of.


  16. Finally I got that Ibudilast leaflet in english - linked from Wikipedia to Kyorin who manaufacture it as KETAS:
    These seem to be a sustained release form of Ibudilast, so opening the capsule is not recommended.


  17. It looks like we will want a PDE inhibitor in our permanent polypill, and I want that to be as safe as possible, long-term.

    Pterostilbene low dose is what we trial right now, and I'll report on that later, but I need to observe for a couple of weeks more.

    Unfortunately there aren't any PDE inhibitors trialled in children (are there?) and I guess the tiny amount luteolin in NeuroProtek isn't exactly comparable to the amount in say artichoke extract.

    Also, would a selective PDE4 inhibitor be "safer" than a more general one acting on different PDEs?


    1. Ling, from what I read the current PDE4 inhibitor drugs are not entirely selective and that is why some people experience some side effects. The side effects seem to be dose dependent, only affect some people and usually fade over time.

      Ibudilast is the PDE4 drug chosen for development as a therapy for MS.

      Given Ibudilast is a Japanese therapy for asthma, rather than COPD, I would expect it does not usually have troubling side effects. You can treat asthma in many ways that do not have troubling side effects. COPD can be deadly, asthma drugs are only partially effective and so people will accept some GI side effects from Daxas/Roflumilast to avoid the ER.

      Some people do treat their child's autism with Ibudilast.

      Also, very relevant for children:-

      FDA grants rare pediatric disease status to ibudilast for Krabbe disease

  18. Hi Peter. Your blog and the amount of research you have done is nothing short of incredible! Thank you for making the results of your research available to all of us.

    I see you've said some people do treat their children's autism with ibudilast. Can you provide me with more information about that? Dose form, protocol, improvements observed, side effects, etc?

    I have found a source of ibudilast powder and am very interested in trying it for my eight year old son who has regressive autism.

    When I first heard of the effects of ibudilast on glial cell activation I thought it might have promise in treating autism. When I searched for ibudilast and autism I stumbled upon your blog. :)

    1. Unfortunately most people do not want to go into the details of their trials of things that are experimental. So I cannot tell you what dosage they use.

      I think you should be looking for improvement in cognition. Long term use might well improve faulty remyelination (via PKA), if it was present. Very recently, it has shown promise as a treatment for Multiple Sclerosis at a dose of 100mg/day.
      The very similar drug, Roflumilast/Daxas, normally used to treat COPD (severe asthma), used at a 1/5 dose (100mcg), is being developed as a therapy to improve cognition.

      Ibudilast is used as a therapy for regular asthma in Japan. That dosage you can find.

      Both are PDE4 inhibitors and it looks like Ibudilast has less of the GI side effects of Roflumilast, making it the better option.

    2. Unknown, is your source in the US? I'm still hoping for a european source...

      I haven't found any more information on usage in children than discussed here, but would be very interested to know the dosage they are going to try on the babies with Krabbes disease.
      If you haven't already, you might want to look at this guys site: and for easy-to-read stuff on the topic.

      Ibudilast as eye drops inhibits human PDE4A, 4B, 4C and 4D with IC50 values at 54, 65, 239 and 166 nM, respectively ( The normal asthma dose for an adult would be 2*10 mg/day, and that antiinflammatory effect is thanks to the PDE4B inhibition.

      Roflumilast and Pterostilbene work on PDE4D, and both seem to have some cognitive effects (pterostilbene at 0.41 to 1.62 mg/kg/day, effect kicks in at day 21) but perhaps not via microglia.

      If you try Ibudilast, please share your dosage and experience with us.


  19. Peter, I am looking at this post and I have a naïve question: If you can raise ATP, with say Niagen, wouldn't that also target P2X7 receptors?

    Asking because I just learned from the paper you mentioned earlier today that some ERK1/2 inhibitors work as ATP-competitive substances. As I want the opposite, ERK1/2 activation, maybe more ATP can do the trick.

    From another paper on osteoblasts, which I'm not sure if it can be generalized to brain cells:

    "In this study, we examined the role of Ca2+i and ATP release on the activation of ERK1/2 in [..] pre-osteoblastic cells. We find that extracellular Ca2+ entry through [.. L-type VGCC ..] was essential for the activation of ERK1/2. We further demonstrate that protein kinase C activation contributes to the Ca2+-dependent phosphorylation of ERK1/2. We also show that this activation is dependent on ATP release and that activation of the P2X7 receptor is at least partially responsible for phosphorylation of ERK1/2."

    Ca2+ -> VGCC -> ATP -> P2X7 -> ERK1/2 activation
    (and PKC is also needed for synergy)


    1. Ling, Niagen should increase NAD+, which should be helpful if you were short of it, as old people are found to be. If you are young and energetic I doubt you will make any more ATP, because you already produce enough.

      Raising NAD+ with Niagen has other potential benefits beyond ATP. You would have to try it, to know if it helps.

      I think the antihistamine Clemastine, as a positive allosteric modulator of P2X7, is interesting. If it can help in MS then it has some potency. I also think Oxatomide is interesting, as I pointed out in the above post.

    2. Peter, I do believe some of this is probably due to placebo, but I have trialed Niagen for a week or so (I am in my 50s!) and I think it is having a positive affect. I think mood and energy has improved with my three teenagers (who don't take many supplements) but only been a week. Two of them have autoimmune issues. I will report back because it could be other factors (or placebo) but our family is quite happy, upbeat and good energy levels this week! Tyler, Peter or Ling or others, curious about your interpretation.

    3. Congratulations on having a good week Anonymous!

      My interpretation goes like this:
      Nicotinamide riboside (=Niagen) activates the mitochondrial unfolded protein response (UPRmt), at least in mice.
      Except for the well-marketed effect of longevity (which is true in roundworms and unknown in humans), the UPRmt is involved in mitochondrial function (so more energy), endogenous antioxidant defense via NRF2+ATF4 (protects against free radicals), and lipid/amino acid synthesis (obviously very important).
      There is also a connection to induction of Heat shock proteins here. Heat shock proteins, like the Hsp families Hsp60, Hsp70 and Hsp90, are immune system regulatory signals and highly interesting for autoimmunity and cancer research.

      Peter, I really think the UPR (mitochondrial, ER or endothelial) deserves a blog post. It's yet another hub where many things meet, and many interventions too.

      For the energy/antioxidant part, I think you could as well try Fisetin or sulforaphane.


    4. If you try it for a while longer, then make a pause and see if you lose the perceived benefit and then you will know how much is a placebo effect.

    5. Sounds good -- Ling and Peter, thanks very much for your guys' input. I will definitely report back after we have given it some time (and then off, and back on). Was interesting to see what looks to make a difference in so many members of my family.


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