Melatonin for Kids with Autism, and indeed their Parents

I have long heard about kids with autism having sleeping problems; these range from difficulty falling asleep, waking frequently during the night and waking up very early in the morning.  The same problems apparently occur in ADHD.

I think some of the sleep related problems are behavioral in nature; some children with ASD live actually with less structure than typical kids.  Some kids with ASD do not get much physical exercise to tire them out by bed time.  

Having said all that, there does seem to be something else going on.

Long ago people found out that Melatonin, a hormone available cheaply without prescription in many countries, had a very positive effect on sleeping patterns.

What is also interesting, is the other properties of Melatonin and the other types of people who can benefit from it.  This does take us some way from our core theme of autism, towards treating cancer and other illnesses of older age.  I expect most my readers are parents of a child with ASD, well this time science has some news for you too.

What is Melatonin?

Melatonin is a hormone secreted by the Pineal Gland in the brain. It helps regulate other hormones and maintains the body's internal clock. The circadian rhythm is an internal 24-hour clock, that plays a critical role in when we fall asleep and when we wake up. When it is dark, your body produces more melatonin; when it is light, the production of melatonin drops. Being exposed to bright lights in the evening or too little light during the day can disrupt the body’s normal melatonin cycles.

Melatonin helps control the timing and release of female reproductive hormones. Some researchers also believe that melatonin levels may be related to aging.

Young children have the highest levels of night time melatonin. Researchers believe these levels drop as we age. Some people think lower levels of melatonin may explain why some older adults have sleep problems.

Melatonin has powerful antioxidant effects. Research suggests that it may help strengthen the immune system.

Melatonin is derived from serotonin. Serotonin levels in autism are often high in the blood, but can be low in the brain.  Serotonin cannot cross the blood brain barrier.  The Pineal Gland is inside the brain, but outside the blood brain barrier.

 

Dose Response

One clever study tried to establish the dose at which Melatonin had an effect on sleep.  It is interesting that they found the dosage was not correlated to weight.  The vast majority of drugs are dosed on how big you are, and often trials assume this to be the case.

Melatonin for Sleep in Childrenwith Autism: A Controlled Trial Examining Dose, Tolerability, and Outcomes

Dose-response

All 24 children who completed study procedures obtained a satisfactory response (as defined above) to melatonin at doses between 1 mg and 6 mg. Seven children obtained a satisfactory response at 1 mg, 14 at 3 mg, and only 3 required 6 mg. The child’s age or weight was not associated with melatonin dose response. The mean age/weight (standard deviation) of children responding to 1 mg was 5.9 (1.9) years/26.4 (11.1) kg; and to 3 or 6 mg was 5.9 (2.3) years/25.4 (11.2) kg.

In effect you are treating a hormone deficiency, like any other.  Just as a small person may need more thyroid hormone than a very big person; the same appears to be true with Melatonin.

Much of the “specialist advice” from "doctors" on the web looks incorrect on this subject:-

Melatonin. This naturally occurring peptide released by the brain in response to the setting of the sun has some function in setting the circadian clock. It is available without prescription at most pharmacies and health food stores. Typically the dosage sizes sold are too large. Almost all of the published research on Melatonin is on doses of 1 mg or less, but the doses available on the shelves are either 3 or 6 mg. Nothing is gained by using doses greater than one milligram. Melatonin may not be effective the first night, so several nights' use may be necessary for effectiveness.

(this was advice for people with ADHD, which I regard as part of ASD)

 

Abnormal Melatonin Synthesis in ASD and in Parents

A surprising amount of work has been done looking at abnormalities in melatonin synthesis in both kids with ASD and their parents.  Hence the title of this post.

The low level of melatonin synthesis is acquired from one or more parent, who will probably also have a sleep disorder.  Not only that, but low melatonin is also linked to increased risk to some serious health conditions, more on that later. 

Abnormal Melatonin Synthesis in ASD

"In autism spectrum disorders (ASD), low melatonin levels have been reported by three independent groups,^13–15 but the underlying cause of this deficit and its relationship to susceptibility to ASD was unknown

the serotonin level was significantly higher in individuals with ASD (P=2×10⁻¹¹) and their parents (P=10⁻⁸) than in controls

 Our results confirm that low plasma melatonin concentration (half the mean of the control values) is a frequent trait in ASD patients, as observed in 65% of the patients tested, a proportion very similar (63%) to that previously reported by Tordjman et al.¹⁵ We show for the first time that abnormal melatonin levels are also present in the unaffected parents of ASD patients, suggesting a genetic origin. Indeed, the melatonin deficit observed in the patients was associated with low ASMT activity, suggesting that variations in the ASMT gene could be the cause of this deficit."

Effect of Hormone Supplementation on the Pineal Gland

If you start interfering with human hormones, you need to be aware of the possible consequences.  For example, a relatively common autism therapy in the US is to give thyroid hormones T4 and T3 to children who are not clinically hypothyroid.  Some parents report great improvements, but some comment that over time they have to increase the dosage.  This is because the feedback loops that control the thyroid gland are telling it to gradually shut down.  Over time, such a child might become entirely dependent on the T4/T3 tablets.

So, if you have a pineal gland that does not produce enough melatonin, what happens to it when you take supplements?  I do not think anyone can tell you with certainty.

There have been long term trials over a few years in sleep disorders.  When supplementation stops the sleep disorder returns.  Nothing bad was reported.

Natural release of melatonin is controlled by exposure to light and dark.  To what extent does this change when supplements are added?

To what extent to supplements interfere with other less well understood melatonin mechanisms?  

On balance, common sense would tell you to leave a fully functioning pineal gland well alone; but if you have an autistic child with a challenging sleep disorder, this would be suggest that the pineal gland needs some external help.  In an ideal world, your doctor would test the pineal gland function and check Melatonin levels were age appropriate.

Melatonin and Behaviours

Research in ADHD suggests that while Melatonin improves sleep disorders it does not improve behaviour.

Effect of melatonin on sleep, behavior, and cognition in ADHD and chronic sleep-onset insomnia. 

Abstract

OBJECTIVE:

To investigate the effect of melatonin treatment on sleep, behavior, cognition, and quality of life in children with attention-deficit/hyperactivity disorder (ADHD) and chronic sleep onset insomnia.

METHOD:

A total of 105 medication-free children, ages 6 to 12 years, with rigorously diagnosed ADHD and chronic sleep onset insomnia participated in a randomized, double-blind, placebo-controlled trial using 3 or 6 mg melatonin (depending on body weight), or placebo for 4 weeks. Primary outcome parameters were actigraphy-derived sleep onset, total time asleep, and salivary dim light melatonin onset.

RESULTS:

Sleep onset advanced by 26.9 +/- 47.8 minutes with melatonin and delayed by 10.5 +/- 37.4 minutes with placebo (p < .0001). There was an advance in dim light melatonin onset of 44.4 +/- 67.9 minutes in melatonin and a delay of 12.8 +/- 60.0 minutes in placebo (p < .0001). Total time asleep increased with melatonin (19.8 +/- 61.9 minutes) as compared to placebo (-13.6 +/- 50.6 minutes; p = .01). There was no significant effect on behavior, cognition, and quality of life, and significant adverse events did not occur.

CONCLUSION:

Melatonin advanced circadian rhythms of sleep-wake and endogenous melatonin and enhanced total time asleep in children with ADHD and chronic sleep onset insomnia; however, no effect was found on problem behavior, cognitive performance, or quality of life.

 

The studies in autism indicate a different story; behaviours do improve.  After a good night’s sleep, most people’s behaviour improves; it would be odd if it did not.

I think this is another case of ADHD disorders being of a different magnitude to disorders further along the autistic spectrum.  

For the impact in autism, it best to read the studies; here is an excerpt from Melatonin for Sleep in Children with Autism: A Controlled Trial Examining Dose, Tolerability, and Outcomes:-

“The behavioral outcome measures that showed change with melatonin (e.g., attention-deficit hyperactivity, withdrawn, affective problems, stereotyped behaviors, compulsive behaviors) resemble that of prior work. The literature emphasizes that the behavioral construct of hyperactivity is affected by sleep disturbance—this had been documented in ASD populations (Goldman et al 2009; Mayes and Calhoun 2009) as well as typically developing children treated for obstructive sleep apnea (Chervin et al 2006). Other behavioral parameters which have been associated with poor sleep in children with ASD include repetitive behavior, including compulsive behavior, and oppositional and aggressive behavior, anxiety, depression, and mood variability (Malow et al 2006; Goldman et al, 2009; Mayes and Calhoun 2009). In an intervention study of parent education, hyperactivity and restricted behaviors showed improvements with treatment (Reed 2009).”

Strangely, when it came to parental stress, they found less impact:-

“Parenting stress, as measured by the Difficult Child Subscale, improved with treatment. We did not find improvement in the PSI parent-related domains (Parental Distress or Parent-Child Dysfunctional Interaction) suggesting that parental stress in autism is multifactorial and may not be addressed with a single intervention.”

 

Why is Melatonin so good for the CNS (Central Nervous System)?

It appears that Melatonin does some very useful things

·        It is an antioxidant/free radical scavenger

·        It stimulates the production of the body’s other key antioxidants

·        It inhibits the production of pro-oxidative enzymes

·        Protects nuclear and mitochondrial DNA

Free radical-mediated molecular damage. Mechanisms for the protective actions of melatonin in the central nervous system.

Abstract

This review briefly summarizes the multiple actions by which melatonin reduces the damaging effects of free radicals and reactive oxygen and nitrogen species. It is well documented that melatonin protects macromolecules from oxidative damage in all subcellular compartments. This is consistent with the protection by melatonin of lipids and proteins, as well as both nuclear and mitochondrial DNA. Melatonin achieves this widespread protection by means of its ubiquitous actions as a direct free radical scavenger and an indirect antioxidant. Thus, melatonin directly scavenges a variety of free radicals and reactive species including the hydroxyl radical, hydrogen peroxide, singlet oxygen, nitric oxide, peroxynitrite anion, and peroxynitrous acid. Furthermore, melatonin stimulates a number of antioxidative enzymes including superoxide dismutase, glutathione peroxidase, glutathione reductase, and catalase. Additionally, melatonin experimentally enhances intracellular glutathione (another important antioxidant) levels by stimulating the rate-limiting enzyme in its synthesis, gamma-glutamylcysteine synthase. Melatonin also inhibits the proxidative enzymes nitric oxide synthase and lipoxygenase. Finally, there is evidence that melatonin stabilizes cellular membranes, thereby probably helping them resist oxidative damage. Most recently, melatonin has been shown to increase the efficiency of the electron transport chain and, as a consequence, to reduce election leakage and the generation of free radicals. These multiple actions make melatonin a potentially useful agent in the treatment of neurological disorders that have oxidative damage as part of their etiological basis.

 

Why is Melatonin good for the Immune System?

It is known that Melatonin interacts with the immune system, but the mechanism is not fully understood yet.  As you see below, Melatonin is not just produced in the Brain, it is also sythesized by the immune system. 

A review of the multiple actions of melatonin on the immune system

Abstract

This review summarizes the numerous observations published in recent years which have shown that one of the most significant of melatonin's pleiotropic effects is the regulation of the immune system. The overview summarizes the immune effects of pinealectomy and the association between rhythmic melatonin production and adjustments in the immune system as markers of melatonin's immunomodulatory actions. The effects of both in vivo and in vitromelatonin administration on non-specific, humoral, and cellular immune responses as well as on cellular proliferation and immune mediator production are presented. One of the main features that distinguishes melatonin from the classical hormones is its synthesis by a number of non-endocrine extrapineal organs, including the immune system. Herein, we summarize the presence of immune system-synthesized melatonin, its direct immunomodulatory effects on cytokine production, and its masking effects on exogenous melatonin action. The mechanisms of action of melatonin in the immune system are also discussed, focusing attention on the presence of membrane and nuclear receptors and the characterization of several physiological roles mediated by some receptor analogs in immune cells. The review focuses on melatonin's actions in several immune pathologies including infection, inflammation, and autoimmunity together with the relation between melatonin, immunity, and cancer.

 

Anti-aging Treatment

There are all sorts of products and therapies put forward to an eager public to combat the aging process; melatonin is one of these products.   I think, in this case, they may very well have got is right.  Yet again, a drug for older people seems to be effective for kids with ASD. 

In anti-aging, one well known practitioner, Dr Pierpaoli, recommends:-

30-39 years of age             1.5mg at bedtime

40-49 years of age             1.5mg to 3mg at bedtime

50-74 years of age             3mg at bedtime

Above 75 years                   3mg to 6mg at bedtime

 

Other use of Melatonin, related to subjects covered in this blog

Melatonin appears to help in Alzheimer’s by interfering with Amyloid beta, which was covered in an earlier post.

Amyloids, APP, ADAM17 and Autism

Melatonin appears to reduce symptoms in irritable bowel symptom.

Melatonin has been used to treat cluster headaches.

Information for Parents

We have seen earlier in this post that parents of a child with ASD also tend to have a low level of Melatonin.  If you read the layperson’s guide from the University of Maryland, you will see that a low Melatonin level in women is linked to increased risk of breast cancer and in men an increased risk of prostate cancer. 

“Studies show that men with prostate cancer have lower melatonin levels than men without the disease. In test tube studies, melatonin blocks the growth of prostate cancer cells.”

“Laboratory experiments have found that low levels of melatonin stimulate the growth of certain types of breast cancer cells, while adding melatonin to these cells slows their growth”

Since Melatonin is a powerful antioxidant, this may just mean that breast cancer and prostate cancer are linked to oxidative stress and so Melatonin is being used up; but it might also mean that Melatonin is somehow protective.

I read a long time ago that NAC improves outcomes in breast cancer and I expect it does on other types of cancer.

I already take NAC daily, I should probably take some Melatonin as well.  And you?

Conclusion

Melatonin would seem a good candidate for a drug that can make small positive improvements in autism.  Based on an earlier post, it is under consideration for the yellow side of the Polypill.

 

Note that Melatonin has to be given just before bed time.

Note that Melatonin interacts with some drugs used in autism and ADHD.

 

 

How to avoid Autism (and also treat TBI)

It appears that in classic autism, most of the damage is done before birth, but a gradual second decline does often seem to occur between 24 and 54 months, even in a child who you would not think of as suffering from regressive autism.

When people think back about their child with regressive autism, they often recall examples of odd behaviours occurring long before the big regression occurred.

So my "extrapolation" from this, is that there are actually two waves of neurological damage in these two common types of autism. It is just that in one case there is a tidal wave before birth and a smaller change as a toddler.  In regressive autism, the first wave usually passes unnoticed, and the main, unmistakable damage occurs in the second wave.

Perhaps we can avoid this first wave of damage done before birth, in both classic early onset autism and regressive autism.

In an earlier post, I made my case for why girls do not get mild autism and why mothers, who are alpha-females, are more prone to have kids with ASD.

Why Girls don’t get Mild Autism and Why Alpha Females may have Kids with Autism.

This was based on reading that the female hormone progesterone is extremely neuro-protective and that oxidative stress, now seen as a cause of autism, has many causes and is extremely damaging to the brain.  A good example of progesterone use, is its experimental use immediately after a traumatic brain injury.  All I did was extend this to autism.  Now it appears I am not the only one.

Here is a paper I spotted in a corner on Paul Whiteley’s ASD blog.

Low maternal progesterone may contribute to both obstetrical complications and autism

Abstract

Studies show increased autism risk among children born to mothers experiencing obstetrical complications. Although this is usually interpreted as suggesting that the obstetrical complications could be causing autism, it is possible that a single factor could be responsible for both complications and autism. We hypothesized that low levels of the hormone progesterone is responsible since it is supplied to the fetus maternally and does not only support pregnancy but also promotes brain development. Following a review of the literature, we report findings from a survey of mothers of autistic children (n=86) compared to mothers of typically-developing children (n=88) regarding obstetrical histories, including five obstetrical risk factors indicative of low progesterone Using this analysis, the ASD group had significantly more risk factors than controls (1.21 ± 0.09 vs. 0.76 ± 0.08, p< .0001), suggesting low progesterone. Thus, results suggest that low progesterone may be responsible for both obstetrical complications and brain changes associated with autism and that progesterone levels should be routinely monitored in at-risk pregnancies. Our hypothesis also suggests that ensuring adequate levels of progesterone may decrease the likelihood of autism.

The authors’ hypothesis suggests that ensuring adequate levels of progesterone may decrease the likelihood of autism.  Well, I for one, find this interesting.

In another earlier post, I referred to my advice to Ted, the nom de guerre of my very neuro-typical elder son, on how to avoid autism in the next generation.  I think I can now extend that advice further:-

People like Ted, with a close relative with ASD, could do some of the following:-

·        Find a partner who is calm beta-type female

·        Ensure she avoids emotional stress and shocks during pregnancy (particularly early on)

·       Take maternity leave straight after pregnancy is noticed, rather than mainly after birth; or, best of all, have the partner quit work as soon as pregnancy is noted

·        Ensure high levels of neuro-protective agents throughout pregnancy

·        Progesterone

·        Glutathione GSH (i.e. take NAC)

 

You might be expecting me to have statins on my list, since they are also very neuro-protective, but I do not;  even though:-

Johns Hopkins – a new use for statins

Statins in traumatic brain injury

During pregnancy, statins are detrimental to human placental development.  So although people in high speed skiing accidents, who suffer traumatic brain injuries, would have a clear benefit, for a woman with a 10% chance of having a child with ASD, the risks would outweigh the possible benefit.  Most likely, the primary, cholesterol lowering effect of the statin, is doing the damage, since the baby’s brain does need cholesterol. 

Statin warning for pregnant women

Progesterone would also be a potential therapy for people with ASD.  It might though not be wise for boys around puberty.  There are reports of people with ADHD finding progesterone helpful.
 

Should I happen to have a TBI (traumatic brain injury), please put in my IV drip progesterone, atorvastatin/lovastatin and N-acetylcysteine.


P.S.  During pregnancy, ensuring the mother is not hypothyroid and does take folic acid will also shift the odds away from an outcome with ASD.

 

 

Increasing Good Behaviors and Reducing Bad Behaviors in Autism

This blog is all about clever chemicals that can make life better for people with autism, but for several years I have also been learning all about behavioral therapy to achieve the same goal.  So I thought I should look for any lessons that I might apply from my earlier endeavours.  

Two of the best books in my ABA collection, based on feedback from all of our Assistants/Therapists/Friends are the oldest, and indeed the lightest.  They are more than 30 years old, as you might imagine from the front cover, which is a big turn off for many parents.

They are great books, that tell you what you actually want to know: how to get rid of horrible behaviours and how to encourage nice ones.

Dr Foxx is still going strong and won the 2013 Award for Distinguished Professional Contributions to Applied Research from the American Psychological Association. Foxx is a professor of psychology at Pennsylvania State Harrisburg and an adjunct professor of pediatrics at the Pennsylvania State University College of Medicine.

The thing I always found odd was why Dr. Foxx wrote two separate books, surely it is all the same subject matter.  He had his reasons.

Here is my parallel with my quest to develop a smart combination of safe drugs to help in autism. 

So far, most of what I have been doing is focused on decreasing the bad behaviors, so the blue part of the pill; the remaining work is find to ways to promote the good behaviors, the yellow part of the pill.

This might actually be more relevant that you realize.  While it is clear that bad behaviors in autism vary widely in both type and extent, desirable good behaviors should have much more in common.  We know that many individual drugs on the "blue side" are effective only in a minority of people, but perhaps there will be much more commonality on the "yellow side".  I expect this to be the case.

So my Polypill is taking colour, as well as shape.

Another good piece of news is that I found a precedent for orphan drug designation in classic autism.  It appears that in 1998 the FDA awarded orphan drug status to Naltrexone to treat childhood autism with SIB.  In the US, orphan drug status is only possible for rare diseases affecting less than 200,000 people.  There are other cases of orphan drugs in autism, but they are for rare genetic variants. Currently the FDA website for orphan drugs does not list Autism for Naltrexone.

Also, an interesting Australian drug NNZ-2566,  mentioned in a previous post, has recently been given orphan drug status in the US, this time based on Fragile X designation.  The drug is an analogue of IGF-1 and looks interesting to me.

If you want to see what orphan drug designation in the EU means, here is what Novartis received for its new Fragile X treatment, Mavoglurant.

Orphan drug status reduces the cost of approving a drug.  But how rare is classic autism, these days?

 

Matching Pathology with Behaviours in Autism

 
I think the wrong people are in charge of autism research; forensic scientists or even air-crash investigators might do much better.

We have seen in this blog that many drugs have a positive effect in specific types of autism. In many, but not all cases, the mechanism of that drug and its effect on the pathology of autism is understood. 

If you have followed an ABA programme, you will know that an experienced autism therapist would very easily be able to give a long list of behavioral issues that occur in varying combinations among her clients.

From reading the research, it is clear that the people who understand the biology, often do not understand the psychology and the behavioral issues they are trying to treat - but perhaps they should.  Only then can you target treatments for specific problems.  There can be no single drug for autism, but there can be a drug for obsessive behaviours, and another for self-injury.  You cannot say a low dose of X helps with social cognition, but for aggression you need a high dose of X.  To me at least, this is complete nonsense and shows a complete failure to understand the underlying psychology.

Just as most people struggle with all the jargon of biochemistry, I suppose the medical researchers fail to grasp the nuances of the psychologists’ jargon.  We need to match both sides, because we need science to solve a complex problem that presents itself in hard to describe, odd behaviours and not as nice neat equation to solve.

It is difficult to accurately describe and quantify the behavioral issues of a child with ASD.  It is very hard for a parent, but it is definitely possible for a psychologist using tools like ABBLS and others.  Then you can move towards seeing precisely what behavioral effects a drug has and stop expecting improvements in areas that are completely unrelated.

Having produced the list of deficit areas you can then try and understand the underlying pathology as to why a drug is effective.

I make no claims to have great expertise in this area, but it looks like nobody else does either.

Here are some examples:

Obsessions

Obsessive compulsive behaviours are well known to affect some people with autism.  This is a type of behaviour that most people would understand and would notice if they saw it, although they might find it hard to quantify.

Oxidative stress is a measurable pathological condition that is present in some people with autism.  Oxidative stress exists in other medical conditions and has a known therapy, an antioxidant like NAC.

By chance, it was found that treating someone with obsessive compulsive behaviours with NAC, greatly reduced those behaviours.

In the case of people with autism and obsessive compulsive behaviours, it would be good to know if other deficit areas were also impacted.  Clearly, taking away the obsessive compulsive behaviours, you would expect to see a general improvement, since the person is now much calmer and better able to function and so many behaviours should improve to a certain extent.  But does NAC reduce head banging and other SIB?  I think not.

So we can then conclude that oxidative stress triggers obsessive compulsive behaviours and NAC should be prescribed.  Oxidative stress may exist to a lesser degree in subjects that do not (yet) display obsessive behaviours.

 

Anxiety

I have not tried to treat anxiety in autism, but many people have.  Anxiety lies on the axis running from happy to depressed.  By raising the level of serotonin in the brain you move from depressed towards happy.  The antidepressant Prozac is given to many children with ASD to reduce anxiety. Prozac is a selective serotonin reuptake inhibitor (SSRI).

The problem with such drugs is their side effects and use can result in dependency.  If that was not the case, the advice would be simple.

I think a better and safer way exists to raise brain serotonin levels in autism.

Seizures and SIB

Not all people with SIB (Self-injurious Behavior) have seizures, but I expect many people with seizures have SIB.  Both conditions appear to be channelopathies (ion channel/transporter dysfunctions); but there is more to it than that, what triggers the channelopathy?  It would seem that in both cases the message comes via inflammatory signalling from the vagus nerve.  So to treat these conditions you can block the inflammatory signalling (vagus nerve stimulation), or you can treat the resulting ion channel/transporter dysfunction in the brain; doing both may be quite unnecessary.

If you have neither seizures nor SIB, then using any of the above therapies would be of little effect.

Many open questions remain

All is not clear; for example, where does hyperactivity fit in?  Where does anger fit in?  Is anger just a mild version of SIB?  It is extreme anxiety?  Is it something entirely different?

An interesting finding of mine was that showing affection appears to be pathologically related to self-confidence and lack of inhibition.  The pathology linking them appears to be neuroinflammation, or rather the control of it.

 

 

4G and Autism - Glutamine, Glutamate, GABA & GAD

This post is not about your IPad, it’s still about autism.

There are a few important substances that I have not fully addressed yet in this blog; as is often the case in biology, the names do all rather look alike.  A complete understanding of these 4 Gs will definitely help to understand the literature and hopefully separate science from pseudoscience and the voodoo.

We know for a fact that in autism some strange things are going on here, but it remains to be proved exactly what is going on, and whether all types of autism are similarly affected.  So it may be premature to visit the supplement shop.

 

The 4 Gs

Glutamine, like Creatine, is one of those chemicals that is widely used by body builders and sometimes given to children with autism.  It is an amino acid.

Glutamine is a precursor chemical to Glutamate.  Glutamate is a major excitatory neurotransmitter in the brain.

Glutamate is a precursor chemical to GABA, another very important neurotransmitter.

Glutamate is converted to GABA by the neuronal enzyme glutamate decarboxylase (GAD).

Glutamate is synthesized from glutamine via glutaminase, but after release in the synapse, glutamate is converted back into glutamine in glial cells, by glutamine synthetase.

 

Some Facts

Glutamine

Glutamine is known to help heal injuries and recover from abdominal surgery.  It was thought that this would extend to helping maintain the gut barrier, which is sometimes implicated in autism.  DAN type doctors use glutamine to “heal the gut”; however, when trials were made in Crohn’s disease, an inflammatory bowel disease similar to the type sometimes implicated in autism, supplementing with glutamine had no effect.
 

Glutamate

Glutamine + H2O

→ Glu + NH3

 

Glu is actually glutamic acid, the salts and esters of glutamic acid are called glutamates.  Often the literature mixes the terms glutamate and glutamic acid.

NH₃ is ammonia, which is also important and plays a role in some people’s autism theories.

Excessive glumate release is implicated in autism.  Glutamic acid is implicated in epilepsy, which is highly comorbid with autism.

Glutamate decarboxylase (GAD) is an enzyme that catalyzes the conversion  of glutamate  to GABA and CO₂.

HOOC-CH₂-CH₂-CH(NH₂)-COOH → CO₂ + HOOC-CH₂-CH₂-CH₂NH₂

Where HOOC-CH₂-CH₂-CH₂NH₂  is GABA (Gamma-Aminobutyric acid)

 
GABA

GABA is another amino acid and important neurotransmitter.  It is also known to regulate muscle tone, which is often affected in autism.

GABA works by binding at receptors, this binding causes the opening of ion channels to allow the flow of either negatively charged chloride ions into the cell or positively charged potassium ions out of the cell.

There are two classes of GABA receptor : GABA_A and GABA_B

The drug Baclofen is an agonist for the GABA_B receptors. A version of this drug called Arbaclofen is being developed as a treatment for autism and Fragile X.

Baclofen is a drug to treat spasticity, which is a condition where there can be strange effects on the muscles like spasms, stiffness and tightness.  Some people with ASD have a tendency to clasp their hands and fingers in a strange tight claw-like fashion and indeed some walk with an odd gait.  That would appear to me to be a form of spasticity.  Baclofen was stumbled upon by accident as a possible autism drug, where it would treat a form of mental spasticity.

Baclofen also has a long forgotten secondary effect that interested me; it stimulates the production of GH (Growth Hormone).  GH does appear to be implicated in autism along with IGF-1 and its analogues.

An antagonist of the GABA_A receptor, bumetanide, works by blocking the NKCC1 cation-chloride co-transporter, and thus decreases internal chloride concentration in neurons. In turn, this concentration change makes the action of GABA in some people with autism, returning it from excitory to inhibitory, where is should be.

I think it is clear that GABA plays a major role in some types of autism.

Recent Studies

As noted in previous posts, some very practical research comes out of Iran these days.

Increased Glutamate and Homocysteine and Decreased Glutamine Levels in Autism: A Review and Strategies for Future Studies of Amino Acids in Autism

"2.1. Glutamate

Glutamate is a major excitatory neurotransmitter in the brain. The high level of plasma glutamate level especially in children with normal IQ is supposed to be a diagnostic screening test. The increased plasma level in adults with autism is also reported. Higher glutamate level is not limited to plasma, and some studies confirmed its higher level in some brain regions (amygdala-hippocampal regions but not in parietal region) of patients with autism compared to the controls. The increased plasma glutamic acid is not limited to patients with autism, but its level is increased in their siblings and parents. "

"2.2. Glutamine

The low level of plasma glutamine level is suggested as a screening test for detecting autism in children especially those with normal IQ. The decreased level has been reported before in all children with autism."

A very recent study by King's College London looked at the level of glutamate and glutamine in adults with ASD using clever proton magnetic resonance spectroscopy in two brain regions. 

Reduced subcortical glutamate/glutamine in adults with autism spectrum disorders: a [1H]MRS study 

They found reduced levels of the combined signal of glutamate and glutamine in autism versus the control group.  It all sounds very clever until you get to the discussion part, where they say:-

"Hence, it could be that serotonergic abnormalities underlie the differences in Glx we observed—either indirectly via influences on neurodevelopment or through direct action on glutamate metabolism."

This may be the case of over-analyzing certain variables, because the technology exists, even though you can only understand 20% of the problem.  The end result is lots of complicated looking data and analysis that may actually lead nowhere.

A reality check is required.  We have to come back to definitive facts otherwise the research is just generating confusion.

We already know serotonergic abnormalities are present in autism.  We know that drugs that increase brain serotonin, such as LSD and Prozac, improve autistic behaviours.  So the researchers at Kings College have very likely just measured a consequence of these abnormalities.  As a result, the glutamate/glutamine issue may indeed join the long list of consequences, rather than causes of autism.

 

The fever effect (again)

Another reason for this post is that both Glutamine and Glutamate have been put forward as possible explanations for the fever effect in autism; that is a reduction in autistic behaviour when person is sick, with a high temperature.

The fever effect is so dramatic in some people, that it would be ever so easy to validate a hypothesis.  In doing so, you would open the door to a very useful therapy for many people.

Does infectious fever relieve autistic behavior by releasing glutamine from skeletal muscles as provisional fuel?

 

This paper was published in the Journal Medical Hypotheses, but the full version is not always available free, the first link is to the author’s own site.  It is a very thorough analysis and worth a read, but in the end the author seems to disprove his own hypothesis.

A preliminary version of this paper was sent to several hundred ASD practitioners (DAN Doctors) formerly listed on the ARI site, for feedback. Fourteen replies suggest ASD practitioners commonly give oral glutamine to heal the intestines, from 250 mg to 8 g/day, with few side effects (some hyperactivity) but few notable improvements in behavior.

So now on to the next candidate, glutamate.

The second hypothesis is by Ghanizadeh, the Iranian author of the paper I referred to earlier.

Could fever and neuroinflammation play a role in the neurobiology of autism? A subject worthy of more research.

Abstract

Autism is neuropsychiatric disorder in which a hyperglutamate state may play a role. It is suggested here that fever or hyperthermia may be able to alter glutamate levels in the brain and may therefore be able to impact on the symptoms of autism. More study on this possibility is clearly warranted.

Conclusion

Of the 4 Gs, I am sticking with GABA as the key one, but I will not be buying any GABA supplements, even though they do exist.  Some DAN-type doctors favour Glutamine supplements, even though some well-known “holistic” type doctors like Dr Mercola say specifically not to give it to kids with ASD and ADHD.

I have no doubt that glutamate plays an important role in autism, but as with GABA it is not just a matter of swallowing some.

There is a line to be drawn between science, pseudoscience and pure voodoo. For the time being, you have to find this line yourself.

Epigenetics and Autism

I have touched on the subject of epigenetics in a previous post; it is a new area of science that shows how the environment can modify your genes.  Rather than you being purely a product of your parents’ genes, you actually also have both your own environmentally acquired epigenetic changes, and some of the acquired epigenetic changes of your ancestors.

These acquired epigenetic changes are caused by things like emotional trauma, chemical insults and even smoking.

Epigenetic control systems generally involve three types of proteins: “writers”, “readers”, and “erasers.” Writers attach chemical marks, such as methyl groups (to DNA) or acetyl groups (to the histone proteins that DNA wraps around). So-called “readers” bind to these marks, thereby influencing gene expression; erasers remove the marks.

 

In theory epigenetic changes should be reversible, but this is not simple.

You may recall in an earlier post about asthma, we learnt that it is very hard to treat former smokers.  Once a person has smoked heavily, a change occurs whereby the body remains in permanent oxidative stress and conventional asthma drugs are not very effective.  The fact that the person gave up smoking 20 years previously does not help.  The only way to treat the patient is to first treat them with an antioxidant and NAC was the most effective; even then the result is not so good.

Epigenetics and Autism

It is said that autism is caused by a combination of genetic and environmental factors; but it might be better stated that autism is caused by genetic and epigenetic factors.  Those epigenetic factors would include all the accumulated environmental factors affecting that person and his ancestors.

As modern life becomes more distant from the village life of our ancestors, you can imagine a gradual build-up of environmental and stress factors.  If you cannot erase some of those marks, you will reach a point where the “tainted” DNA will produce aberrations.  Such aberrations might trigger cancer in one person and autism in another. 

Epigenetic Drugs

Cancer was identified very early as being a likely consequence of epigenetic changes.  Cancer research is very well funded and some epigenetic drugs are already available.  The idea is that epigenetic drugs should selectively target reversible epigenetic changes

A particular problem is that the drug has to act very selectively.

If you were able to erase all those chemical marks on someone’s DNA, there would most likely be some unwanted and unanticipated changes.

One pioneer in this field is a US firm called Acetyton Pharmaceuticals.

 

Epigenetic Research in Autism

The good news is that research has recently started in this area, and it might eventually lead to the possibility of reversing some of those unwanted epigenetic changes.

Here is rather heavy study from Kings College in London:-

Methylomic analysis of monozygotic twins discordant for autism spectrum disorder and related behavioural traits

 

Autism spectrum disorder (ASD) defines a group of common, complex neurodevelopmental disorders. Although the aetiology of ASD has a strong genetic component, there is considerable monozygotic (MZ) twin discordance indicating a role for non-genetic factors. Because MZ twins share an identical DNA sequence, disease-discordant MZ twin pairs provide an ideal model for examining the contribution of environmentally driven epigenetic factors in disease. We performed a genome-wide analysis of DNA methylation in a sample of 50 MZ twin pairs (100 individuals) sampled from a representative population cohort that included twins discordant and concordant for ASD, ASD-associated traits and no autistic phenotype. Within-twin and between-group analyses identified numerous differentially methylated regions associated with ASD. In addition, we report significant correlations between DNA methylation and quantitatively measured autistic trait scores across our sample cohort. This study represents the first systematic epigenomic analyses of MZ twins discordant for ASD and implicates a role for altered DNA methylation in autism.

 

For those of you who prefer some milk in your coffee, those helpful people at the MIND Institute in Sacramento have produced a series of video lectures on this very subject.

Here is the full list:

Environmental Epigenetics: New Frontiers in Autism Research

 and here is one particular video.

How might epigenetics relate to the etiology of ASD?


  

Conclusion

Epigenetics would help explain the increasing prevalence of ASD in the most developed countries.  It also opens the door to potentially highly effective treatment mechanisms to many currently incurable conditions.

Perhaps, by chance, one of the new epigenetic drugs developed for cancer will have a positive effect in ASD.

 
 

 

Long Term Bumetanide Use in Autism

This blog started life after I read about a clinical trial of the diuretic bumetanide to treat autism.  In the following 12 months the authors of that study, Ben-Ari and Lemmonier, have been busy building up their scientific case.  They published two further papers:-

 

 

Treating Fragile X syndrome with the diuretic bumetanide: a case report. 

We report that daily administration of the diuretic NKCC1 chloride co-transporter, bumetanide, reduces the severity of autism in a 10-year-old Fragile X boy using CARS, ADOS, ABC, RDEG and RRB before and after treatment. In keeping with extensive clinical use of this diuretic, the only side effect was a small hypokalaemia. A double-blind clinical trial is warranted to test the efficacy of bumetanide in FRX.

This single case report showed an improvement of the scores of each test used after 3 months of treatment. Double-blind clinical trials are warranted to test the efficacy of bumetanide in FRX.

 

Improving emotional face perception in autism with diuretic bumetanide: A proof-of-concept behavioral and functional brain imaging pilot study.

 

Clinical observations have shown that GABA-acting benzodiazepines exert  paradoxical excitatory effects in autism, suggesting elevated intracellular chloride (Cl-)i and excitatory action of GABA. In a previous double-blind randomized study, we have shown that the diuretic NKCC1 chloride importer  antagonist bumetanide, that decreases (Cl-)i and reinforces GABAergic  inhibition, reduces the severity of autism symptoms. Here, we report results from an open-label trial pilot study in which we used functional magnetic  esonance imaging and neuropsychological testing to determine the effects of 10 months bumetanide treatment in adolescents and young adults with autism. We show that bumetanide treatment improves emotion recognition and  enhances the activation of  brain regions involved in social and emotional perception during the perception of emotional faces. The improvement of emotion processing by bumetanide reinforces the usefulness of bumetanide as a promising treatment to improve social interactions in autism.

 

My experience after 12 months of Bumetanide

Bumetanide continues to have a positive effect on Monty, aged 10 with ASD, which I would summarize as a marked increase in awareness or “presence” or a lack of “absence” from the world.  Improved social interactions may have followed, but are secondary.

My own impression is that the effect peaks and then reduces somewhat.  This also appears to be the case with NAC and Atorvastatin.  I think the body is adjusting to the new treatments, via feedback loops.  This is inevitable, it is just a matter of human physiology.  If the above MRI study shows a long term change in brain function, then great.

I hope that my future therapies will be more disease changing, this does look to be possible.  Early signs are promising. 

 

My experience of 12 months blogging

My doctor mother asked me over Christmas how many people have been reading my blog and acting on it.  The answer is about 6,000 page views a month, but I suspect less than 10 people have even tried Bumetanide, nobody has tried Atorvastatin, and a few tens have tried NAC.

I think people are frightened of drugs.  Supplements are OK and any kind of unusual diet is great.

I think if I proposed a diet of baked beans, fried eggs and bacon I would have a much bigger following. Luckily that was not my objective.

With the advent of the internet, simple drugs like diuretics are as easy to buy as supplements like NAC; I doubt you are going to get into trouble for having an unauthorized diuretic in the bathroom cabinet.

Supplements are not subject to the same manufacturing standards as drugs and there are pretty strange things sold as “supplements”.

I will continue to develop my own therapy for classic early onset autism and when I finish, I will patent it and produce it as an orphan drug.  Orphan drugs are for rare diseases, where there is no other treatment.  They have less daunting regulatory requirements, meaning you do not need $25 million to develop them. In the EU you need a serious condition affecting fewer than 5 in 10,000 people; across the EU that equates to 250,000 people.  If you narrowly define my target autism phenotype, with biomarkers you end up within this limit.

Unfortunately, if you want to patent something, you have to keep it secret.  I did discuss all this with the venture capital firm that commercializes the intellectual property of my old university plus that of Cambridge, Oxford and UCL. The conclusion was to either give it to the world for free, or to commercialize it.  Giving it for free clearly has zero impact, so it has to be Plan B.

So the blog continues, but it will not contain all the clever stuff.

Next steps

I have also been busy in the last twelve months, having taken my inspiration from the Frenchmen, Ben-Ari and Lemmonier.  I have had my own “breakthroughs”, by applying the research and some imagination.

While you cannot totally cure genuine autism, you can go a long way, far further than I would have dared to believe possible.

You can treat the most difficult issues such as absence, anxiety, aggression and SIB.  Odd behavioural traits like obsessions and compulsions can be greatly reduced.  The combined effect is definitely a much happier person.

I think there is much more possible in areas like mood, confidence, creativity, sociability and indeed cognitive performance.

Bumetanide was a very important first step, but in itself it is far from a “cure”.  In combination with some other safe drugs, the result will indeed be remarkable.

The final element will be time itself.  The human brain does not come ready programmed; the first few years of childhood are used to establish full brain function.  In autism, during these important first few years the brain was running in “safe mode”, all sorts of important connections were never made and some were lost.  The brain does remain plastic throughout life and so it has the potential to make some of these missing connections.

The drug treatment has to deal with oxidative stress, neuro-inflammation, several ion channel/transporter dysfunctions and the tricky area of central hormonal hypofunction/dysfunction.

Note that not all people with autism respond to Bumetanide. Only a large clinical trial will show what percentage are responders.  In the same way, I expect only a minority of those diagnosed with ASD by current psychiatric measures will respond to my drug; but it would be possible to identify them based on biomarkers and case histories.