Thursday, 29 November 2018

What, When and Where of Autism – Critical Periods and Sensitive Periods

When time is of the essence

All kinds of dysfunctions may appear in autistic brains, which in itself make it a highly complex condition. There is also the when and where aspects of these dysfunctions, which often gets overlooked, or lost in oversimplification.
This then has to fit into the concept of critical periods, that I introduced in an earlier post. 

Critical periods are times during the brain’s development when it is particularly vulnerable to any disturbance, for example an excitatory/inhibitory imbalance.
This then leads to another related concept which is that of sensitive periods; these are periods when the person should be responsive to particular therapy.
Sensitive periods are very important to be understood by those planning clinical trials, because a therapy may indeed be effective only when given within a specific time window. During this time the person is sensitive to the therapy, but they will not be a responder after the time window has passed.
I am pleased to say that more research is beginning to consider the when aspect and not just the what aspect of biological dysfunction in autism.
The where aspect reflects the fact that in one part of the brain there might be, say, NMDA hypofunction, while in another part the opposite is present, NMDA hyperfunction.  Since most therapies come as pills you swallow, you cannot treat one part of the brain for one problem and another part of the brain for the opposite problem. There is currently no way around this issue, you just have to do what is best for the brain overall. In practical terms it means you may make one problem better, but create a new one. 

New research in a mouse model suggests that the drug rapamycin can reverse autism-like social deficits -- but only if given early. The study is the first to shed light on the crucial timing of therapy to improve social impairments in a condition associated with autism spectrum disorder. Its findings could help inform future clinical trials in children with tuberous sclerosis complex. 

Full Paper:


Mefenamic Acid
I have mentioned mefenamic acid (Ponstan) in several posts. It is the only human autism therapy currently in development that has a treatment window.  It is suggested that the sensitive period to take this drug is the second year of life, to avoid severe non-verbal autism. 

The good news is that we have seen time and again that it is never too late to treat autism. Clearly the earlier you do start, the more extensive the long term benefit should be. So once you realize that intervention is possible, best not to delay.
When autism  is of a single gene origin, there really should eventually be scope to make some kind of permanent fix, if you can intervene very early and so still during that intervention’s sensitive period.  This might involve something very clever like gene editing, which you cannot do at home, or it might be just some drug therapy, like Rapamycin in TSC1 as in the above study.

Thursday, 22 November 2018

Sugar-coating Autism and Autism Misinformation

Do you tell it as it really is? Or sugar-coat it, to make it more appealing?
It looks like in the English-speaking world we are more and more being driven by emotional political correctness, rather than calling things out as they actually are. Now this does not really matter if you are talking about relatively trivial subjects, which is what we deal with most of the time, but is a problem when dealing with a serious subject. When it comes to autism, giving the cold truth is quite upsetting to many people.
Bryna Siegel, a Californian Psychologist working with autism for a few decades has been promoting her new book, The Politics of Autism, in various articles.


She tells a lot of home truths that many parents and professionals do not want to hear and people often react very emotionally and quite aggressively. I have found myself on more than one occasion giving her support.
She has several key points to make.  Autism is indeed over-diagnosed and as long there is a financial incentive for this, prevalence will increase.
She is very critical of the results of inclusive education, based on what young people are actually able to achieve when they leave school. The idea of inclusion sounds great, but what actually matters is the end result, in terms of independent living skills and job prospects. She wonders if people with more severe autism are being taught the right skills, rather than just a dumbed-down version of the standard curriculum.
At times, even I think she is perhaps a bit too brutal, but I think I will buy her new book. Monty’s assistants are also keen to read it, so maybe I will also donate a copy to be shared.
I know one little boy with severe autism, who is entirely non-verbal, and has no sign language or facilitated communication device. I do not think he can read or write.  At primary/junior school he now has to learn a foreign language. 

Autism Misinformation
A good example of autism misinformation occurred recently following on from a popular UK daytime TV show, and was highlighted in the Questioning Answers blog.

The host was interviewing a mother about her son with autism and he asked the very reasonable question “has your child always been autistic?” This prompted an outcry from the public and a supposedly knowledgeable organisation called the National Autistic Society (NAS), the UK’s dominant autism organisation. The host was blasted for not knowing that apparently “autism is always present from birth” and “it is not something you can grow out of” and of course it is un-treatable.
Given this child was described by his own mother as having regressed at 18 months and lost his speech, he might well not have been born autistic. The research has shown that many things can trigger “autism” during childhood and we know that about 10% of kids diagnosed with autism do indeed later go on to lose their diagnosis, so they do pretty much grow out of their autism. But why let the scientific facts get in the way of the simple storyline?
I always found the idea of raising autism awareness to be odd; it very often is just promoting misinformation, or putting one random person forward to explain the condition to others. This just confuses other people.
It is much better to just raise public awareness of disability in general, both physical and mental and to tackle bullying at school. Kids should be aware that a small percentage of their peers have severe problems and a much larger percentage have less disadvantaging problems, that can often be mitigated with extra help and understanding during all those years spent at school.
People need to know that just as autism is a spectrum from severe to mild, so are many other conditions like ADHD or dyslexia. Some people just need a little extra help, but some others have profound problems. Sometime soon 10% of all kids will have a medical diagnosis, but only a small fraction will be disabled by it. 
You can have dyslexia and still make it through medical school, but don’t dream about it if your kid has Down Syndrome.

“Dr” Wakefield
I do think Andrew Wakefield was very unfortunate to have studied medicine in the UK and not the US; had he done so I rather doubt he would have ever lost his medical license and he would never have become so well known.  He has a right to his opinions and there are some far more cranky physicians merrily practising today in the US.
Wakefield seems to making himself a new life with Elle Macpherson.  This clearly upsets the UK tabloid media, who still portray him as the devil - how can the devil end up with a super model?  I wish them well. 
Wakefield likes to refer to autism as brain damage, which is rather brutal like Dr Siegel; but he is right in case of DSM3-type autism.
Nowadays people get upset if autism is called a disease, or a mental illness and even some researchers want to sugar-coat it and call it a condition as opposed to a disorder (Autistic Spectrum Condition).  
Giving a nice name to something disabling does not make it go away. It just makes some people without that disability feel better.
Having mentioned Wakefield, I suppose we have to touch on vaccinations.
It would also be great if it was possible to be entirely honest about what we know about vaccines and autism. It is well established that mitochondrial disease can be triggered by vaccinations and it can manifest as regressive autism. This does not mean that all regressive autism is caused by vaccines. This does not mean that people should not be vaccinated; it just means that there is a small risk of something bad happening. Left unvaccinated there is a much larger risk of something else bad happening. Public health believes lay people are too dumb to understand this, I disagree; you just need to be 100% honest and explain it.  It is fashionable to be selectively truthful, or let pass a little white lie. I think being 100% honest, brutally honest, is what is needed when dealing with such an important subject. 

Details do Matter
Whether it is an unusual medical condition like autism, or any scientific investigation, all the details in their entirety are extremely important if you want any chance of solving the problem.
I just had a medical procedure to correct a problem that I first raised 40 years ago. I had an operation 40 years ago for a Meckel’s diverticulum, but it was the wrong operation and for the wrong diverticulum. Last week I had the right operation and, what could/should have been identified and treated in childhood, got treated decades later. When I read the summary of the completed treatment, it is a very well written concise explanation, with all the diagnostic inputs.
Now when I compare this to autism, which is far more complex, I can see mainstream medicine in not yet prepared to try and treat it.
Where do you go to get a precise summary of your child’s unique variant of autism / brain damage, all in 100 words?  Perhaps this will also take another 40 years?
A first small step would be make sure what we do actually know about autism is more widely shared and that at least Autism organisations, with public funding, should be required to have a detailed understanding of what they are supposed to be advocating for. There are excellent organisations to represent other medical conditions, for example diabetes or even Rett syndrome, but not for autism.
Whilst waiting for my operation I had a visit from a curious Nephrologist who dropped by to take my photo (an ultrasound image) to show her friends. Being a liver specialist, she did naturally take a peek at that as well and asked if I knew I had some fat in my liver. Off she went, leaving me to figure out where this fat had come from. 

I am pretty sure it comes from another misdiagnosis I had recently.  I had a sudden reduction in hearing in one ear and not being able to resolve it myself, I went to an ear nose and throat clinic. The diagnosis was a simple case of wax in the ear. Unfortunately this was the wrong diagnosis; by the time I had returned from a trip abroad, quite some time had passed. The second doctor I consulted very quickly diagnosed an inner ear problem (Endolymphatic hydrops) that apparently is quite common but is often left untreated, leading to life-long problems. It leads to a degree of permanent hearing loss, tinnitus and potentially vertigo. A virus, infection or even a physical shock can cause a build-up in pressure in the fluid in the inner ear. If you begin treatment within a week, you have a good chance to avoid permanent hearing loss. My treatment started after almost one month, which was far too late, so I had ten days of injected steroids, starting at a very high dose.  
High doses of steroids can have many side effects, one of which is causing fat to get deposited in your liver. It seems the fat spotted by the curious nephrologist should gradually disappear. I hope so.
Not wanting to be left deaf in one ear and noting the doctor did not seem entirely hopeful, I did quickly engage myself and read up on the science and the medicine.  I regularly do this for my son, but did not think I really should have to do so for my own ear problem. Ménière's disease is an incurable condition, of unknown cause(s), that has major similarities to what was affecting me.  I found a study, with supporting MRI images of the inner ear, showing that the amount of fluid in the ear can be reduced by taking the diuretic acetazolamide/Diamox, at least in some people. I did take note of a Cochrane review saying there is no evidence that diuretics have any benefit, but I did check the MRI images for myself. There is plenty in the blog about Diamox and autism. In Ménière's disease, Diamox responders lose the benefit when they stop taking the diuretic and this is reflected in their MRIs.  Since my condition was hopefully not yet chronic, I thought the immune suppressing actions of the steroid were indeed the long term fix, but at this late stage only pretty immediate rather than gradual loss of inner ear fluid would avoid permanent hearing loss.
Since I have Diamox from a few years ago sitting at the back of my autism pill shelf at home, I decided to add that to my therapy for a few days.  Diamox is cheap, except in the US, and is usually very well tolerated. As a bumetanide family we have a good supply of potassium supplements and bananas, so no chance of hypokalaemia.
My hearing returned and I have no related symptoms (tinnitus, vertigo etc). I have no idea if Diamox helped, but I am certainly glad I took it.
Another side effect of high dose steroid plus acetazolamide/Diamox was a change to my eyesight, both near and distant vision. Both drugs can affect your eyesight, but I think it was the steroid, since I took Diamox once to avoid altitude sickness with no side effects.  The vision side effects gradually fade away when you stop taking the drug.
All this was a timely reminder that drugs and supplements can have unexpected effects and it is best not to get carried away with how many you give your child.  I did recently take Monty, aged 15 with ASD, to see a paediatric cardiologist for a lengthy ultrasound investigation and ECG because, rather bizarrely, his autism drugs are mainly repurposed heart drugs. Where we live it is simple to arrange such a check-up and there is open access to lab tests.  I am fully aware that in countries with universal healthcare trying to access anything unusual may not be possible, unless your GP “gatekeeper” is supportive.   One French parent told me that his doctor would not prescribe bumetanide for his son, but was willing to authorize the blood tests to monitor potassium, if he acquired the bumetanide somewhere else.

In a recent comment our reader David from Spain, who is trying to get his child into the large Stage 3 trial for Bumetanide, informed us that the current prediction is 2023 for commercialization of this autism therapy. That would be 11 years after my son began to benefit.  That is how long it takes to repurpose an existing drug.
This really makes me think that it is not just a case of autism needing personalized medicine, but rather parent-inspired personalized medicine. This is much easier if the parent is a doctor.
As I know to my own cost, medicine currently can struggle with even slightly unusual conditions, so we should not expect wonders from strangers, even when they finally do have approved drugs to prescribe.  
The key will remain parent-inspired personalized medicine. When you do finally get 0.5mg of bumetanide twice a day as an approved autism therapy, it will be up to parents to realize that 1mg once a day or 2mg once a day might actually be much more beneficial.
If you ever have sudden hearing loss in one ear, go to your doctor straight away and have him/her specifically rule out an inner ear problem. If you live in the UK, hopefully you will not be made to wait 2 weeks to get an initial appointment with your GP.  If you don’t live in a country with universal healthcare or don’t have insurance, I suppose some people just go deaf.

Thursday, 15 November 2018

Probiotics/Prebiotics – Very good for Some, but no Panacea

This is another post that I had waiting for completion; it is not saying do not use pre/probiotics, it is just saying make sure you know what you are doing.  Plenty of people appear to be wasting their money on ineffective bacteria, some people are making themselves sick, but others get a genuine benefit worth paying for. The is no one-size fits all. Some bacteria are good for some people and bad for others.

It gets more expensive the further you live
from Switzerland, but with the right oral 
bacteria you need a very modest amount.

One of today’s studies shows that spending money on stool tests for bacteria to fine tune a therapy may be a waste of money, unless you do your homework first. 

There is currently a lot written about the role of the gut microbiome on human health. Unfortunately, it tends to get simplified into just good bacteria and bad bacteria.  Advice like “take a good bacteria” is not very useful.

The reality is that some people take a store-bought pre/probiotic bacterium and it does nothing, for some it makes them feel worse and for others it makes them feel better.

It is rather like taking a random drug from the pharmacy and hoping for the best. In the case of autism, it is clear that some people make their child’s life worse with these pills, while sometimes it makes them better.

The idea of custom-made personalized probiotics sounds interesting, but it assumes that the bacteria found in a stool sample is representative of what is living in different parts of your intestines. Unfortunately, a recent study in humans that took samples from different parts along the intestines and compared the result with a non-invasive stool sample, found that the results did not correlate. In other words, drawing too many conclusions from the bacteria found in stool samples is unwise. This challenges the business case for   custom-made personalized probiotics.Modifying bacteria in your body has huge therapeutic potential for some people, but the science is still in its infancy. There are also promising results from fecal transplants (Bacteriotherapy), which is another way to modify the gut microbiome.

“As of 2013, fecal transplantation is currently not routinely performed for indications other than recurrent C. difficile colitis. More research studies are still needed to determine if fecal transplantation should be performed for other clinical indications. Fecal transplantation for other clinical indications should be considered experimental, and performed only as part of a research study where your safety is closely monitored.”

"Although all of our probiotic-­consuming volunteers showed probiotics in their stool, only some of them showed them in their gut, which is where they need to be," co-author Eran Segal from Weizmann added. "If some people resist and only some people permit them, the benefits of the standard probiotics we all take can't be as universal as we once thought.

A group of scientists in Israel claim foods that are packed with good bacteria - called probiotics - are almost useless.
Their study is among the most detailed analyses of what happens when we consume probiotics.
They are seen as healthy and good for the gut, but the results found they had little or no effect inside the body.
The researchers said probiotics of the future would need tailoring to the needs of each individual.
The team at the Weizmann Institute of Science made their own probiotic cocktail using 11 common good bacteria including strains of Lactobacillus and Bifidobacteria.
It was given to 25 healthy volunteers for a month.
They were then sedated and samples were surgically taken from multiple places in the stomach and small and large intestines.
The researchers were looking to see where bacteria successfully colonised and whether they led to any changes in the activity of the gut.
The results in the journal Cell, showed in half of cases the good bacteria went in the mouth and straight out the other end.



  • The murine & human gut mucosal microbiome only partially correlates with stool
  • Mice feature an indigenous-microbiome driven colonization resistance to probiotics
  • Humans feature a person-specific gut mucosal colonization resistance to probiotics
  • Probiotic colonization is predictable by pre-treatment microbiome & host features
Empiric probiotics are commonly consumed by healthy individuals as means of life quality improvement and disease prevention. However, evidence of probiotic gut mucosal colonization efficacy remains sparse and controversial. We metagenomically characterized the murine and human mucosal-associated gastrointestinal microbiome and found it to only partially correlate with stool microbiome. A sequential invasive multi-omics measurement at baseline and during consumption of an 11-strain probiotic combination or placebo demonstrated that probiotics remain viable upon gastrointestinal passage. In colonized, but not germ-free mice, probiotics encountered a marked mucosal colonization resistance. In contrast, humans featured person-, region- and strain-specific mucosal colonization patterns, hallmarked by predictive baseline host and microbiome features, but indistinguishable by probiotics presence in stool. Consequently, probiotics induced a transient, individualized impact on mucosal community structure and gut transcriptome. Collectively, empiric probiotics supplementation may be limited in universally and persistently impacting the gut mucosa, meriting development of new personalized probiotic approaches.

In this work, we profiled the homeostatic mucosal, luminal, and fecal microbiome along the entirety of the gastrointestinal tract of mice and humans. We demonstrated that solely relying on stool sampling as a proxy of mucosal GI composition and function may yield limited conclusions.
Our results highlight several important concepts. First, we expand the scope of description of the human microbiome bio-geographical compositional and functional landscape, and indicate that extrapolation from stool microbiome communities to those of specific GI mucosal and luminal niches may lead, in some cases, to inaccurate conclusions. By directly comparing the stool and mucosal presence of 11 probiotic strains of the most commonly used probiotic genera, we conclude that probiotic strain expansion in stool, highlighted by most previous studies to be a sign of probiotics efficacy, cannot distinguish between true probiotic-permissive and resistant individuals, in which probiotics in stool represent a transient ‘‘washout’’ of non-colonizing strains passing throughout the GI lumen without significantly adhering to the host mucosal layer.

Second, the marked and person-specific mucosal colonization resistance to probiotics noted in our study may explain the high variability in probiotics effects on the host or its microbiome noted in previous works. One important feature shown in our studies to play a central role in impacting individualized probiotic mucosal colonization is the indigenous gut microbiome, which may drive the observed person-, strain-, and region-specific colonization resistance patterns to probiotics, as previously suggested. Similarly, we have recently demonstrated that person-specific variations in microbiome composition and function may contribute to the variability in glycemic responses to a variety of foods

Finally, the identified baseline microbial and host factors potentially enabling prediction of a probiotics-permissive or -resistant state merit validation in larger cohorts and call for consideration of a transition from anempiric ‘‘one size fits all’’ probiotics regimen design, to one which is based on the consumer. Such a measurement-based approach would enable integration of person-specific features in tailoring particular probiotics interventions for a particular person at differing clinical contexts.

Probiotics can cause SIBO (small intestine bacterial overgrowth)

In the recent study below, it is suggested that probiotic use can lead to small intestine bacterial overgrowth (SIBO) and the elevated levels of D-lactic acid in blood, then leads to “brain fogginess”. Stopping taking the probiotic (and taking an antibiotic) pretty much solves the problem.

We describe a syndrome of Brain Fogginess (BF), gas and bloating, possibly related to probiotic use, SIBO, and D-lactic acidosis in a cohort without short bowel. Patients with BF exhibited higher prevalence of SIBO and D-lactic acidosis. Symptoms improved with antibiotics and stopping probiotics. Clinicians should recognize and treat this condition.

Bacteria to calibrate the immune system

We saw in earlier posts that the bacteria the fetus and baby are exposed to are used to calibrate the future immune response, which is then pretty much fixed for life. During evolution humans have developed expecting to be exposed to certain bacteria, that today we might regard as just dirt. By living in an ultra-clean environment, we are doing the next generation no favours.

Exposure to bacteria from pets and farmyard animals is very healthy, but only when this is done during pregnancy and shortly thereafter. Once the child’s immune system has been programmed to expect almost no bacteria it is maladapted to cope with future allergens and challenges to the immune system. The result is it over-reacts and produces eczema, asthma, food allergies and many other auto-immune diseases.    

An example showing the benefit of applying knowledge of bacteria

At the risk of digression, here is an example of truly beneficial oral bacteria.

Some years ago, in this blog I reviewed the evidence that drinking beetroot juice boosts exercise endurance and lowers blood pressure.  I was intrigued by this idea, since it is a really simple, healthy and it is easy to measure your blood pressure. Beetroot is rich in nitrates (NO3-) and your body coverts these to nitrites (NO2-) and then later on it uses an enzyme called eNOS (endothelial nitric oxide synthase) to produce nitric oxide in your blood vessels. This dilates them (opens them up) and lets more blood through. This allows endurance cyclists, or marathon runners, to keep going longer and for couch potatoes it lowers their blood pressure. People with vascular conditions like vascular dementia should also benefit from more NO, they may lack the enzyme eNOS if they are elderly. We saw this is my post on Arginine, which suggests that older adults should be taking ALA or NAC, rather than blood pressure reducing meds.

Arginine and its Derivatives in Cognitive Impairment

the progressive impairment in endothelium-dependent vasodilation is caused by a progressive alteration of the L-arginine-NO pathwayOnly in old age (after ≈60 years) does the production of oxidative stress appear, leading to the complete compromise of NO availability.  

For the scientist among you, things are actually much more complex.

Cross-talk Between Nitrate-Nitrite-NO and NO Synthase Pathways in Control of Vascular NO Homeostasis

“Inorganic nitrate and nitrite from endogenous and dietary sources have emerged as alternative substrates for nitric oxide (NO) formation in addition to the classic L-arginine NO synthase (NOS)-dependent pathway. Here, we investigated a potential cross-talk between these two pathways in the regulation of vascular function.”

For the rest of us, basically, we are cheating to improve vascular NO homeostasis. Nitrates are present in other food like spinach and kale, foods many people would avoid, just as would beetroot.

I did an experiment to see if a modest dose (200ml) of beetroot juice would reduce my own blood pressure; it did and by more than a trivial amount. So, I thought I would actually continue with it.

Having now done all my homework I have got the blood pressure benefit from just 80ml of beetroot juice a day, along with an understanding of the bacteria in my mouth that converts the nitrate into nitrite. This means I can reduce my beetroot consumption by more than half to a non-bothersome amount.

Any kind of mouthwash will kill the bacteria needed to make nitrite (NO2-), as will toothpaste. Unless you really want to drink a large glass of beetroot juice every day, you just take 80 ml of beetroot juice and slowly swirl it around in you mouth to react with the bacteria that has been multiplying overnight, before you brush your teeth in the morning.

I finally found a 100% beetroot juice that actually tastes pleasant. It is Swiss and so at least it is consistently the same, unlike the others I tried which ended up being more apple juice than beetroot juice or just tasting vile.

The advantages of an 80ml beetroot juice “mouth rinse”: -

·        Lower systolic blood pressure by about 10 mmHG
·        Lower LDL cholesterol, via the flavonoids
·        The betanin (the red colour) protects against Alzheimer’s in animal models
·        Likely has other (neuro) vascular benefits, perhaps including reducing vascular dementia
The bacteria science, as an example of what you can figure out from publicly available sources: -


The salivary glands and oral bacteria play an essential role in the conversion process from nitrate (NO3-) and nitrite (NO2-) to nitric oxide (NO) in the human body. NO is, at present, recognized as a multifarious messenger molecule with important vascular and metabolic functions. Besides the endogenous L-arginine pathway, which is catalysed by complex NO synthases, nitrate in food contributes to the main extrinsic generation of NO through a series of sequential steps (NO3--NO2--NO pathway). Up to 25% of nitrate in circulation is actively taken up by the salivary glands, and as a result, its concentration in saliva can increase 10- to 20-fold. However, the mechanism has not been clearly illustrated until recently, when sialin was identified as an electrogenic 2NO3-/H+ transporter in the plasma membrane of salivary acinar cells. Subsequently, the oral bacterial species located at the posterior part of the tongue reduce nitrate to nitrite, as catalysed by nitrate reductase enzymes. These bacteria use nitrate and nitrite as final electron acceptors in their respiration and meanwhile help the host to convert nitrate to NO as the first step. This review describes the role of salivary glands and oral bacteria in the metabolism of nitrate and in the maintenance of NO homeostasis. The potential therapeutic applications of oral inorganic nitrate and nitrite are also discussed.

The role of salivary glands and oral bacteria in the NO3--NO2--NO pathway. Up to 25% of the circulating nitrate is actively taken up by the salivary glands and concentrated 10- to 20-fold in the saliva to maintain the enterosalivary circulation of NO3--NO2--NO. This key process is mediated by sialin, which is an electrogenic NO3-/H+ transporter in the plasma membrane of salivary acinar cells. When saliva nitrate is secreted into the oral cavity with dietary nitrate—which is reduced to nitrite by the commensal facultative anaerobic bacteria at the posterior aspect of the tongue—some of the nitrite is converted into NO at the stomach. However, most of the remaining nitrate and nitrite are absorbed in the intestine and directly enter the systemic circulation, generating NO in blood and tissues under physiologic hypoxia and playing biological effects.

Role of Oral Bacteria on Nitrate Reduction to Nitrite
Humans, unlike prokaryotes, are believed to lack the enzymatic machinery to reduce nitrate back to nitrite. However, due to the commensal bacteria that reside within the human body, it has been demonstrated that these bacteria can reduce nitrate, thereby providing an alternative source of nitrite. Bacteria are vital in the process of converting nitrate to nitrite—the crucial first step in the NO3--NO2--NO pathway.

Location of Nitrate-Reducing Bacteria in the Mouth
After an oral nitrate loading, gastric NO concentration increases continually. The importance of oral bacteria in gastric NO generation has been clearly illustrated in experiments using germ-free sterile rats, in which gastric NO formation is negligible even after a dietary load of nitrate. The experiment also showed that NO is very low in rats treated topically with an antiseptic mouthwash.
Interestingly, the gastroprotective effects of dietary nitrate, discussed in the section below, virtually disappeared in rats treated with antiseptic mouthwash solutions. The posterior surface of the tongue is responsible for the majority of nitrate reduction, while in the entire oral cavity the nitrate reduction is found to vary widely among individuals. Studies on rats have also shown that nitrate reductase activity occurs on the posterior surface of the tongue and that significantly higher proportions of gram-negative bacteria were found deep within the tongue clefts as compared with the surface.

Composition of Nitrate-Reducing Bacteria

The major nitrate-reducing bacteria can be classified into 2 broad categories—the strict anaerobes (Veillonella atypica and Veillonella dispar) and the facultative anaerobes (Actinomyces odontolyticus and Rothia mucilaginosa;). The facultative anaerobe A. odontolyticus also displays markedly greater ability to reduce nitrate following incubation under anaerobic conditions. However, it is the strict anaerobes (Veillonella spp.) that have been found to be the most prevalent nitrate reducers on the tongue and therefore may be a major contributor to nitrate reduction in the oral cavity. Recently, by using 16S rRNA gene pyrosequencing and whole genome
shotgun sequencing and analysis, scientists have found a higher abundance of Prevotella, Neisseria, and Haemophilus than Actinomyces on the posterior surface of the tongue.

Saliva Nitrate Protecting against Gastric Damage

Nitrate secreted from the salivary glands is found to have an unprecedented function in protecting against stress-induced gastric damage. A water immersion–restraint stress assay in rats shows decreased blood flow in gastric mucosa and induced hemorrhagic erosions after bilateral parotid and submandibular duct ligature. In animals that had received either cardiac ligation or oral treatment with povidone-iodine, a potent bactericidal agent, administration of nitrate failed to increase gastric levels of NO and to inhibit the mucosal injury. NO that is formed close to the gastric mucosa can easily diffuse through the mucosa to the submucosal arterioles, causing vasodilatation and thus increasing gastric mucosal blood flow. This process protects gastric epithelial cells from necrosis. In addition, the decrease of mucosal myeloperoxidase activity and the expression of induced NO synthase with nitrate pretreatment imply that nitrate can reduce tissue inflammation, making this mechanism a possible way of gastric protection. In the absence of a dietary nitrate intake, salivary nitrate originates mainly from NO synthase. Thus, oxidized NO from the endothelium and elsewhere is recycled to regulate gastric mucus homeostasis.


There are some very clever things that can be done by modifying the bacteria in your gut, but if you get it wrong you can very easily make things worse. In some cases, people create a problem where non-existed.

Taking probiotics is not so different to taking drugs, care is needed.

You cannot just produce a general list of good bacteria and bad bacteria. The effects of some bacteria are very specific, and an ever so slightly different variant of one bacterium can do something completely different. Also, what is a good bacterium for one person can be a bad bacterium for the next person.

If you go back to when there was a lot of discussion in this blog about probiotics, this pretty much fits in with the comments. A few people had a good result, some people had a horrific experience and for many there was no effect, except on their wallet.
Many supplements actually contain a relatively tiny number of bacteria and by the time you consume them, you have no idea how many are still alive.

Growing your own bacteria gets around the potency problem, once you have found one that actually gives a benefit.

I do think there is great promise to treat a small number of people by transplanting the microbiome of a healthy person. Only a small number of people are going to need this.

The safest way to “improve” your microbiome is through eating a healthy varied diet, with fruits, vegetables and fiber, which many people resist doing.

Regular exposure to pets and their dust/dirt during pregnancy is on my list of how to minimize future autism. Pets are also calming which should lower oxidative stress and of course dogs make you go for long walks.

For late middle-aged people and older, beetroot juice really is a good intervention and for the really committed add a glass of natural yoghurt with teaspoon of turmeric and high flavanol cocoa (if you can find it), otherwise it is rather expensive Cocoavia from Mars. The yoghurt increases the bioavailability of the turmeric ten times, apparently. 

Tuesday, 6 November 2018

When is an SSRI not an SSRI? Low dose SSRIs as Selective Brain Steroidogenic Stimulants (SBSSs) via Allopregnanolone modifying GABAa receptors and neonatal KCC2 expression

Today’s post might seem to have a very complicated tittle, but to regular readers it is really just another take on what we have seen time and time again.
Today we see how another steroid imbalance in autism – low levels of allopregnenolone in this case – affects the neurotransmitter GABA and indeed the chloride transporter KCC2.

Putting Prozac/Zoloft to a better use?

I did report previously on a trial in adults with autism where pregnenolone was used.

Recall that disturbed hormonal homeostasis is a key feature of autism. What matters is the level of each hormone inside the brain (i.e. centrally), not in your blood. The only way to get a reliable idea of what is going on would be to take a sample of spinal fluid.

Today we look at boosting allopregnenolone not with a steroid hormone, but with a 1/10th dose of Prozac (Fluoxetine) or indeed Zoloft (Sertraline). Prozac is a selective serotonin reuptake inhibitor (SSRI) when given at the usual dose of 20-80mg, but at 2.5mg it does not function as an SSRI.
At regular doses selective serotonin reuptake inhibitors (SSRI) drugs like Prozac are well known to cause problems, as do benzodiazepines like Clonazepam.
Thanks to Professor Catterall we saw in earlier posts how tiny doses of Clonazepam have an effect on one particular sub-unit of GABAA receptors. By fine tuning the response of this receptor we saw how a cognitive improvement can be achieved, in some people. The dose is so low there appear to be no long term side effects. At least one other professor of medicine, I am in contact with, has been treating his son with autism with low dose clonazepam for years.
Many adults and children with autism are prescribed Prozac for anxiety. Even Temple Grandin has said she takes Prozac.
At low, non-serotonergic doses, some drugs like Prozac show a different mode of action, they potently, positively, and allosterically modulate GABA action at GABAA receptors. These drugs achieve this by increasing the amount of the steroid hormone allopregnanolone.
Neurosteroid biosynthesis down‐regulation and changes in GABAA receptor subunit composition are a feature of several neurological conditions, including some autism.
Stimulating allopregnenalone biosynthesis will have multiple effects including on TSPO and endocannabinoid receptors.

Brain principal glutamatergic neurons synthesize 3α-hydroxy-5α-pregnan-20-one (Allo), a neurosteroid that potently, positively, and allosterically modulates GABA action at GABAA receptors. Cerebrospinal fluid (CSF) Allo levels are decreased in patients with posttraumatic stress disorder (PTSD) and major depression. This decrease is corrected by fluoxetine in doses that improve depressive symptoms. Emotional-like behavioral dysfunctions (aggression, fear, and anxiety) associated with a decrease of cortico-limbic Allo content can be induced in mice by social isolation. In socially isolated mice, fluoxetine and analogs stereospecifically normalize the decrease of Allo biosynthesis and improve behavioral dysfunctions by a mechanism independent from 5-HT reuptake inhibition. Thus, fluoxetine and related congeners facilitate GABAA receptor neurotransmission and effectively ameliorate emotional and anxiety disorders and depression by acting as selective brain steroidogenic stimulants (SBSSs).                               
When the results of these in vitro studies are compared to those of our in vivo studies, it becomes evident that in mice the doses of fluoxetine and norfluoxetine that cause a rapid increase in brain Allo levels do not exceed brain concentrations in the low nanomolar range, whereas the fluoxetine concentrations that directly activate 3a-HSD in vitro are in the micromolar range. Moreover, the high potency and stereospecificity of fluoxetine and norfluoxetine in decreasing aggressive behavior and normalizing brain Allo content during social isolation (see Table 1, and Figure 3) support the notion that these compounds facilitate the action of 5a-R type I or 3a-HSD by an unidentified indirect mechanism, which is most probably perturbed by protracted social isolation.

Thus, these drugs, which were originally termed ‘SSRI’ antidepressants, may be beneficial in psychiatric disorders because in doses that are inactive on 5-HT reuptake mechanisms, they increase the bioavailability of neuroactive GABAergic steroids. On the basis of these considerations, we now propose that the term ‘SSRIs’ should be changed to the more appropriate term ‘selective brain steroidogenic stimulants’ (SBSSs), which more accurately defines the pharmacological mechanisms expressed by fluoxetine and its congeners.


The pharmacology of the S stereoisomers of fluoxetine and norfluoxetine appears to be prototypic for molecules that possess specific neurosteroidogenic activity. The doses of S-fluoxetine and S-norfluoxetine required to normalize brain Allo content downregulation, pentobarbital action, aggressiveness, and anxiety in socially isolated mice are between 10-fold to 50-fold lower than those required to induce SSRI activity. However, the precise mechanisms of action by which S-fluoxetine and S-norfluoxetine increase neurosteroids remain to be investigated.

Derivatives of S-fluoxetine and S-norfluoxetine, acting with high potency and specificity on brain neurosteroid expression at doses devoid of significant action on brain 5-HT reuptake mechanisms, may represent a new class of pharmacological tools important for the management of anxiety, related mood disorders, dysphoria, fear, and impulsive aggression.

On the basis of these data, new drugs devoid of SSRI activity but that are potent neurosteroidogenic agents should be developed for the treatment of psychiatric disorders that result from the downregulation of neurosteroid expression, including major depression, and in the prevention of PTSD.

France often gets very negative comments about how it treats people with autism, but in the case studies below it looks like some innovative work is going on in some of their day hospitals, where boys and girls with severe autism are sent to pass their time. 

The system in England has recently been highlighted as being pretty appalling, where over 2,000 people with autism are currently detained in Assessment and Treatment Units (ATUs), privately run secure residential "hospitals", at great cost paid for by the State. Those inside might enter with the approval of their family to stay for 3 weeks for respite care, but end up being detained for 3 years, or even longer. The State assumes their guardianship and the individual and parents are powerless. The individuals are kept in prison-like conditions and not surprisingly get worse not better, the worse they get, the harder it is ever to be released. Hard to believe this is still happening.  If you live in England, best not to hand your child over to the State. Someone has even written a book about escaping from such a unit. This is no better than the old State Hospitals in the US, that finally were closed down in the 1970s, that warehoused mentally disabled people, until their premature death.

Autism Spectrum Disorder (ASD) is defined by the copresence of two core symptoms: alteration in social communication and repetitive behaviors and/or restricted interests. In ASD children and adults, irritability, self-injurious behavior (SIB), and Attention Deficit and Hyperactivity Disorders- (ADHD-) like symptoms are regularly observed. In these situations, pharmacological treatments are sometimes used. Selective Serotonin Reuptake Inhibitors- (SSRI-) based treatments have been the subject of several publications: case reports and controlled studies, both of which demonstrate efficacy on the symptoms mentioned above, even if no consensus has been reached concerning their usage. In this article four clinical cases of children diagnosed with ASD and who also present ADHD-like symptoms and/or SIB and/or other heteroaggressive behaviors or irritability and impulsivity treated with low doses of fluoxetine are presented.
Case 1 
An 8-year-old girl (19 kg) had an ASD diagnosis according to the DSM-5 and ADI-R criteria based on information provided by parents. She also had significant mental retardation, with severe SIB (banging her head against objects and biting her hands), forcing her entourage to maintain a daily and permanent physical restraint. She spends most of her time in a day hospital. She received the following pharmacological treatment: risperidone 2 mg/d and cyamemazine 80 mg/d without modifications to her SIB and at the price of a major slowing down and a manifestation of a tendency toward blunting. The CGI severity of illness score was at five (markedly ill). We decreased and stopped risperidone and started valproic acid. After four weeks of valproic acid 400 mg/d in combination with cyamemazine (60 mg/day), SIBs did not improve. Then, we added fluoxetine 2.5 mg/d and increased it after one week to 5 mg/d and to 10 mg/d in the third week. After one week, the CGI improvement scale (CGI-I) was at two; after three weeks, it lowered to 1 (very much improved). We also observed a significant decrease in anxiety as well as the disappearance of SIB (disappearance of the behavior consisting of the banging and rubbing her head against objects). However, it should be noted that the entourage kept the bandages on her hands because she continued to bite them, even if she did it with less intensity than before. There were no side effects. After three months of fluoxetine, her clinical state remains stable.

Case 2 
A 12-year-old boy (70 kg), with DSM-5 criteria for an ASD and ADI-R confirming this diagnosis, exhibited extreme irritability, violence, and impulsiveness as well as SIB (he had thrown seven television sets out of the window). The CGI severity illness scoring was at six (severely ill). In the day hospital where he spent most of his time, it was difficult for staff to manage his impulsivity and unpredictability. His treatment included risperidone 4 mg/d as well as loxapine 80 mg/d. Despite this pharmacological treatment, episodes of aggression and SIBs continued. This treatment induced a significant weight gain (8 kg in 5 months). Treatment with fluoxetine 2.5mg/d was introduced and increased to5mg/d after one week and to 10 mg/d at the beginning of the third week. After one week, there was a CGI-I score of three, which decreased to two after two weeks of treatment and to one after three weeks. Such a positive clinical response allowed for a reduction in risperidone to 2mg/d and in loxapine to 60 mg/d. The treatment was tolerated well by the patient, and he began to lose weight (4 kg). After two months off luoxetine, his clinical state remains stable.

Case 3
 A 6-year-old male child (30 kg) with DSM-5 criteria and ADI-R for an ASD exhibited problems of SIB and repetitive behaviors (washing his hands for more than 30 minutes at least two to three times per day), severe irritability, frequent crying, social withdrawal, and inappropriate speech. Treatment with risperidone 2mg/d had improved irritability and partially the SIB, but it had also produced significant weight gain (four kg in three months). A decrease in the risperidone dosage seemed necessary. Treatment with fluoxetine2.5mg/d was begun, which quickly led to a reduction in inappropriate behavior (for example, impulsive crawling on the ground in the classroom). After one week, the CGI-I scoring was at two. The dosage was gradually increased to 5 mg/d the second week and to 7.5mg/d the third week. The repetitive behaviors gradually subsided. After three weeks the CGI-I score was at one, and it remained stable for nine weeks. The risperidone dosage could be decreased to 0,5 mg/day and the patient’s weight remained the same.
Case 4 
A 12-year-old boy (62kg) withDSM-5 and ADI-R criteria for a severe case of ASD, including severe ADHD-like symptoms, often required physical restraint and did not improve despite a long-term treatment of risperidone 3 mg/d as well as melaton in 4mg at bedtime. The CGI severity illness scoring was at 6 (severely ill). The behavioral pattern included irritability, marked agitation, crying, severe hyperactivity, and other behaviors typical of this disorder. He was also anxious, rendering the situation at his day hospital where he spent most of his time all the more difficult. A prescription of fluoxetine 2.5mg/d was initiated with an immediate and complete improvement of ADHD-like symptoms:CGI-I at one week of treatment was at a one, making this case the most remarkable of the four presented here. Treatment with fluoxetine was continued with a dosage increase up to 5 mg/d to allow for a decrease in the risperidone dose to 1 mg/d. CGI-I score remained stable at one for the duration of the nine weeks.

Our reader Mira, whose son has FXS, recently referred to Dr Hagerman’s trial of low dose Sertaline/Zoloft in Fragile X. GABAA malfunction appears to be a feature of Fragile X, but it is not necessarily the identical malfunction to those with idiopathic autism who respond to bumetanide.


Observational studies and anecdotal reports suggest sertraline, a selective serotonin reuptake inhibitor (SSRI), may improve language development in young children with fragile X syndrome (FXS). We evaluated the efficacy of six months of treatment with low-dose sertraline in a randomized, double-blind, placebo-controlled trial in 52 children with FXS ages 2–6 years.


Eighty-one subjects were screened for eligibility and 57 were randomized to sertraline (27) or placebo (30). Two subjects from the sertraline arm and three from the placebo arm discontinued. Intent-to-treat analysis showed no difference from placebo on the primary outcomes: the Mullen Scales of Early Learning (MSEL) expressive language age equivalent and Clinical Global Impression-Improvement (CGI-I). However, analyses of secondary measures showed significant improvements, particularly in motor and visual perceptual abilities and social participation. Sertraline was well tolerated, with no difference in side effects between sertraline and placebo groups. No serious adverse events occurred.


This randomized controlled trial of six-months of sertraline treatment showed no primary benefit with respect to early expressive language development and global clinical improvement. However, in secondary, exploratory analyses there were significant improvements seen on motor and visual perceptual subtests, the Cognitive T score sum on the MSEL, and on one measure of Social Participation on the Sensory Processing Measure–Preschool. Further, post hoc analysis found significant improvement in early expressive language development as measured by the MSEL among children with ASD on sertraline. Treatment appears safe for this 6-month period in young children with FXS, but we do not know the long-term side effects of this treatment. These results warrant further studies of sertraline in young children with FXS using refined outcome measures, as well as longer term follow-up studies to address long-term side effects of low-dose sertraline in early childhood.

Neurosteroid biosynthesis down‐regulation and changes in GABAA receptor subunit composition: a biomarker axis in stress‐induced cognitive and emotional impairment

By rapidly modulating neuronal excitability, neurosteroids regulate physiological processes, such as responses to stress and development. Excessive stress affects their biosynthesis and causes an imbalance in cognition and emotions. The progesterone derivative, allopregnanolone (Allo) enhances extrasynaptic and postsynaptic inhibition by directly binding at GABAA receptors, and thus, positively and allosterically modulates the function of GABA. Allo levels are decreased in stress-induced psychiatric disorders, including depression and post-traumatic stress disorder (PTSD), and elevating Allo levels may be a valid therapeutic approach to counteract behavioural dysfunction. While benzodiazepines are inefficient, selective serotonin reuptake inhibitors (SSRIs) represent the first choice treatment for depression and PTSD. Their mechanisms to improve behaviour in preclinical studies include neurosteroidogenic effects at low non-serotonergic doses. Unfortunately, half of PTSD and depressed patients are resistant to current prescribed 'high' dosage of these drugs that engage serotonergic mechanisms. Unveiling novel biomarkers to develop more efficient treatment strategies is in high demand. Stress-induced down-regulation of neurosteroid biosynthesis and changes in GABAA receptor subunit expression offer a putative biomarker axis to develop new PTSD treatments. The advantage of stimulating Allo biosynthesis relies on the variety of neurosteroidogenic receptors to be targeted, including TSPO and endocannabinoid receptors. Furthermore, stress favours a GABAA receptor subunit composition with higher sensitivity for Allo. The use of synthetic analogues of Allo is a valuable alternative. Pregnenolone or drugs that stimulate its levels increase Allo but also sulphated steroids, including pregnanolone sulphate which, by inhibiting NMDA tonic neurotransmission, provides neuroprotection and cognitive benefits. In this review, we describe current knowledge on the effects of stress on neurosteroid biosynthesis and GABAA receptor neurotransmission and summarize available pharmacological strategies that by enhancing neurosteroidogenesis are relevant for the treatment of SSRI-resistant patients. Linked Articles This article is part of a themed section on Pharmacology of Cognition: a Panacea for Neuropsychiatric Disease? To view the other articles in this section visit

Too little allopregnanalone can induce autism.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with core symptoms of social impairments and restrictive repetitive behaviors. Recent evidence has implicated a dysfunction in the GABAergic system in the pathophysiology of ASD. We investigated the role of endogenous allopregnanolone (ALLO), a neurosteroidal positive allosteric modulator of GABAA receptors, in the regulation of ASD-like behavior in male mice using SKF105111 (SKF), an inhibitor of type I and type II 5α-reductase, a rate-limiting enzyme of ALLO biosynthesis. SKF impaired sociability-related performance, as analyzed by three different tests; i.e., the 3-chamber test and social interaction in the open field and resident-intruder tests, without affecting olfactory function elucidated by the buried food test. SKF also induced repetitive grooming behavior without affecting anxiety-like behavior. SKF had no effect on short-term spatial working memory or long-term fear memory, but enhanced latent learning ability in male mice. SKF-induced ASD-like behavior in male mice was abolished by the systemic administration of ALLO (1mg/kg, i.p.) and methylphenidate (MPH: 2.5mg/kg, i.p.), a dopamine transporter inhibitor. The effects of SKF on brain ALLO contents in male mice were reversed by ALLO, but not MPH. On the other hand, SKF failed to induce ASD-like behavior or a decline in brain ALLO contents in female mice. These results suggest that ALLO regulates episodes of ASD-like behavior by positively modulating the function of GABAA receptors linked to the dopaminergic system. Moreover, a sex-dependently induced decrease in brain ALLO contents may provide an animal model to study the main features of ASD.

Some steroids, whose levels are raised in autism (allopregnanolone, androsterone, pregnenolone, dehydroepiandrosterone and their sulfate conjugates) are neuroactive and modulate GABA, glutamate, and opioid neurotransmission, affecting brain development and functioning. These steroids may contribute to autism pathobiology and symptoms such as elevated anxiety, sleep disturbances, sensory deficits, and stereotypies among others.

Tuning the Brain
I did write a post a while back to show the effect of tuning GABAa receptors.

The effect of allopregnanolone of KCC2 expression and hence the level of chloride within neurons.

Neonatal allopregnanolone or finasteride administration modifies hippocampal K(+) Cl(-) co-transporter expression during early development in male rats.


The maintenance of levels of endogenous neurosteroids (NS) across early postnatal development of the brain, particularly to the hippocampus, is crucial for their maturation. Allopregnanolone (Allop) is a NS that exerts its effect mainly through the modulation of the GABAA receptor (GABAAR). During early development, GABA, acting through GABAAR, that predominantly produces depolarization shifts to hyperpolarization in mature neurons, around the second postnatal week in rats. Several factors contribute to this change including the progressive increase of the neuron-specific K(+)/Cl(-) co-transporter 2 (KCC2) (a chloride exporter) levels. Thus, we aimed to analyze whether a different profile of NS levels during development is critical and can alter this natural progression of KCC2 stages. We administrated sustained Allop (20mg/kg) or Finasteride (5α-reductase inhibitor, 50mg/kg) from the 5th postnatal day (PD5) to PD9 and assessed changes in the hippocampal expression of KCC2 at transcript and protein levels as well as its active phosphorylated state in male rats. Taken together data indicated that manipulation of NS levels during early development influence KCC2 levels and point out the importance of neonatal NS levels for the hippocampal development.                                                                                                                           

Add very low dose Prozac to the long list of possible SIB therapies, more practical than electroconvulsive therapy (ECT), that is for sure!

This post was long waiting in my “to-complete” pile. I thought it would be a short one, but it kept growing.  It does draw together several interesting issues and shows there is a pattern developing in all these blog posts.
The majority of psychiatric drugs have such severe drawbacks that the great majority of children are better off without them.  However, there are many existing drugs that have little known neurological effects that can be highly beneficial and are known to be safe to use long term.
Psychiatric drugs that can be repurposed at lower dosages for different purposes may indeed be free of the major drawbacks encountered at higher doses.
It looks like humans with Fragile X Syndrome (FXS) are leading the way with low dose SSRI therapy to modulate GABA.  It would seem highly plausible that other idiopathic autism might also benefit and the French case studies in this post are examples of those who did benefit.
I think this is another example of fine-tuning the brain to optimize its functioning. It probably will not produce miracles, but the science shows that allopregnenalone can be tuned to vary mood in humans.  Low levels of allopregnenalone can produce autistic-like behaviours in mouse models.
The effect of allopregnenalone on KCC2 expression may only be present in tiny babies, if it continues into childhood that would be another reason to consider it as a target for modulation.  If that were the case, then Finasteride the cheap generic drug for prostate enlargement, should be investigated.
As is always the case in autism, both extremes are likely to exist; some people will likely benefit from low dose SSRIs but it will make some others worse (anxiety, SIB etc). If you start with elevated allopregnenalone, you would want less, not more.
Repurposing existing drugs has huge unrealized potential.
The OTC antihistamine Clemastine, which I highlighted in an earlier post as being a Positive Allosteric Modulator (PAM) of P2X7, and so helps remyelination, is yet another example of repurposing a safe drug.  Reportedly, it has this effect even below the regular dosage for allergy; at the high dosage usage in MS trials it will send you to sleep and risk some other side effects. As MS is not a singular condition, it seems that some people respond much more so than others. It also seems to have a benefit is some psychiatric disorders; not bad for a cheap OTC antihistamine.