Potassium Bromide has been on my to do list ever since I read a case study about Ida, a girl with epilepsy and non-verbal autism being treated at London’s Great Ormond Street Hospital 150 years ago. Of course, the doctor not did not use the term autism, but it was obviously present.
What I took away was not the resolution of her seizures but her behavioral change and most importantly the initiation of age-appropriate play.
What I took away was not the resolution of her seizures but her behavioral change and most importantly the initiation of age-appropriate play.
Later I read a Brazilian paper called “Combined effect of bumetanide, bromide, and GABAergic agonists: An alternative treatment for intractable seizures”.
My first toe in the water in treating my son’s autism was to use Bumetanide. That trial was successful and ever since I have looked at ways of increasing this bumetanide effect.
Bumetanide partially blocks the flow of chloride (Cl-) into neurons and over time lowers the concentration towards where it should be, in typical mature neurons. This allows the neurotransmitter GABA to function as it should and brings back neurons into a less excitatory state and hence gives better cognitive function.
Other ideas to further lower the level of chloride included using the AE3 ion exchanger and so I proposed the possible use of Diamox.
It might also be possible to increase the expression of KCC2, the transporter that takes chloride out of neurons; this might be achieved using intranasal insulin or indeed IGF-1.
Yet another theoretical method might be to introduce bromide and allow it to compete with chloride. We know that Br– ions cross cellular membranes more quickly than Cl–. So by adding bromide we should automatically reduce chloride concentration within neurons.
Medical use of Potassium Bromide
It is surprising how medicine varies so much by country. One example is the continued use of potassium bromide (KBr) to treat childhood epilepsy in Germany, Austria and Japan.
It is currently used to treat severe forms of generalized tonic-clonic seizures, early-childhood-related Grand-Mal-seizures, and also severe myoclonic seizures during childhood.
KBr was the world’s first epilepsy drug and its use was pioneered by Sir Charles Locock in 1857. It is still the first-line treatment for treating epilepsy in dogs, but no longer in humans.
Due to a very long half-life, it takes a month of use to reach a stable level, so in the earlier years it is likely that un-necessarily high doses (up to 6g per day) were used. This led to side effects. The modern dosage is 50 to 70 mg/kg in infants and toddlers, 30 to 50 mg/kg in school children and 20 to 30 mg/kg in adults. Tolerability of bromide treatment is much improved.
It is possible to start therapy with a loading dosage to overcome the problem of the long half life, but I expect this just increases the chance of side effects.
My thought was that at a lower concentration than prevents seizures, bromide might still be effective in some autism that responds to bumetanide. At such a dosage the side effects that occur in German epilepsy therapy might become trivial.
The main side effects are usually drowsiness (19%) and acneiform skin eruption (13%) at the 50mg/kg dosage. I was thinking that at a quarter of this dose you might get the good without the bad.
If you have one of the many kids with autism and intractable epilepsy then you might as well follow the standard dosage and just accept the risk of some spots. After all, the standard anti-epileptic drugs (AEDs) all have side effects and we are not just taking about spots.
Interestingly, while KBr does not interact directly with other AEDs, it is found in Germany that previously ineffective AEDs can become effective when the person is given KBr. There are various theories to explain this. As a result KBr look doubly useful for intractable epilepsy.
Interestingly, while KBr does not interact directly with other AEDs, it is found in Germany that previously ineffective AEDs can become effective when the person is given KBr. There are various theories to explain this. As a result KBr look doubly useful for intractable epilepsy.
Dravet Syndrome
KBr seems to be particularly effective in people with SCN1A-mutations suffering from Dravet syndrome. You may recall that Professor Catterall trialed his low dose clonazepam therapy in the mouse model of Dravet syndrome. German and Austrian clinicians have shown that KBr is highly effective in treating seizures in the human form of Dravet, while a Japanese retrospective analysis of 99 patients which found complete prevention of status epilepticus in 41.7% of patients receiving bromide.
Mode of Action
Nobody knows exactly why KBr is effective in epilepsy, but that also applies to many other AEDs.
The Brazilian view is:-
“bromide may exert antiepileptic activity not only because of its reinforcement of the Cl– hyperpolarizing Nernst potential, but also because of its low affinity for the NKCC enzyme in comparison with Cl– . In summary, bromide's antiepileptic effect may be divided into three parts: (1) compensation of Cl– accumulation by means of its hyperpolarizing effect on chloride channels; (2) antagonism of chloride flow through the channels because of its competition with chloride; (3) low affinity for the NKCC enzyme”
That paper is:-
The German view is:-
“While the exact mode of action of bromide is still unknown, the most acceptable hypothesis besides an inhibition of carbonic anhydrase is stabilization of excitable membranes through hyperpolarization of neurons. Bromide crosses cellular membranes more quickly than chloride, enhancing
GABA-activated inhibitory postsynaptic potentials and leading to hyperpolarization. Not only GABA-activated chloride channels are more permeable to bromide, but also voltage dependent channels. Studies using combined rat hippocampus-entorhinal cortex slices showed that bromide reduced or even blocked low calcium and low magnesium induced recurrent discharges, including the low magnesium induced late recurrent discharges which do not respond to most clinically used anticonvulsants. This mechanism might explain why our patients who previously did not
improve with various other antiepileptic drugs responded to treatment with bromide.
The above is from one of many good German papers on KBr :-
Intractable Epilepsy
About one-third of people with epilepsy will eventually develop intractable epilepsy. This means that standard anti-epileptic drugs (AEDs) do not work well, or at all, to control the seizures.
Intractable epilepsy can have a big effect on life. People with intractable epilepsy may have trouble at work or school. They may worry a lot about when their next seizure will come. They may also have injuries that result from their seizures.
In the case of the 30+% of people with strictly define autism (SDA) and epilepsy things can get particularly difficult and depend a great deal on where you live.
In the US some children with severe autism and recurring seizures can still be collected from home by the school bus and dropped back at the end of the day. Not only do they have qualified nurses at school to deal with any seizures but even the bus has a nurse.
I was just reading about a teenage girl in the UK who no longer attends school at all because she may have a seizure. The irony here is that the girl has been to the county’s top children’s hospital, Great Ormond Street. Had she been there one hundred and fifty years ago she would have been prescribed KBr. Had she attended a hospital in Innsbruck or Salzburg, Austria this year she would very likely also have been prescribed KBr.
The literature supporting the use of KBr is published in the English language and so there is no excuse for epilepsy experts not to be aware of it. Both the US and the UK have provisions in place where clinicians can apply to treat patients with non locally approved drugs. So there is nothing to stop a neurologist or epileptologist in the US or UK from using KBr if he really wants to. He just has some extra paperwork. The simpler solution if you have intractable epilepsy might be to pay a visit to Germany, Austria or indeed Japan. Or you go see the vet.
Conclusion
This blog does not have many German/Austrian readers, in fact for a condition “invented” by Austrians (Kanner and Asperger) there is very little coming out of that part of the world nowadays.
German/Austrian parents would be the ones best placed to see the effect of KBr on intractable epilepsy and perhaps some autism.
Any readers that do try potassium bromide are very welcome to share their experiences.