UA-45667900-1

Saturday 22 February 2014

Human Growth Factors, Autism and the Centenarian Nobel Laureate

 
 
 


































This post is another one of those long complicated ones, but should be worth reading.

We will look at Human Growth Factors, of which several have been identified by science and quite possibly more remain to be discovered.  Much of the science is well understood and overlaps with areas of interest to autism and another condition called Retts syndrome.
As often seems to be the case, elements of the science has been used by the anti-aging, athletic and body-building fraternities.
A surprise to me is that the science leads back to mast cells and that there some interesting therapeutic avenues already in existence.
We will even involve the seemingly obscure subject of amyloids that I introduced in a recent post.  In that post we discovered that in autism there were strange things going on with Amyloid Precursor Protein (APP).  I will postulate that perhaps amyloid-induced neuroinflammation might be a factor in the neuroinflammation found in autism.  In this post we will learn a potential strategy to control amyloid-induced neuroinflammation, which appears never to have tested in autism.
For a change we have some human interest, in the form of the Centenarian Nobel Laureate from Turin, Nerve Growth Factor and self-treated herself with it for 30 years, until she died aged 103, outliving her twin sister by 13 years.
We will look at:-

·        Human Growth Hormone (GH) and its replacement therapy

·        GABA and Baclofen that stimulate GH

·        Insulin-like Growth Factor 1 (IGF-1) and its replacement therapy

·        Nerve Growth factor (NGF) and its replacement therapy

·        Palmitoylethanolamide (PEA)

·        Brain-Derived Neurotropic Factor  (BDNF)

·        Neurotrophin-3

·        Neurotrophin-4

·        Why Rett Syndrome should not be confused with classic autism
 
That is quite a lot to digest in one post, but it is all interrelated and so should be together.

Basic Biology
As we have already discovered, the version of human biology in the textbooks is often a gross simplification of the reality.  Even in the up to date research papers it is clear that the understanding of human biology is constantly being revised.
For most people Human Growth Hormone, known as GH or HGH is the growth hormone.
Secretion of growth hormone (GH) in the pituitary is regulated by the neurosecretory nuclei of the hypothalamus. These cells release the peptides Growth hormone-releasing hormone (GHRH or somatocrinin) and Growth hormone-inhibiting hormone (GHIH or somatostatin) into the hypophyseal portal venous blood surrounding the pituitary. GH release in the pituitary is primarily determined by the balance of these two peptides, which in turn is affected by many physiological stimulators (e.g., exercise, nutrition, sleep) and inhibitors (e.g., free fatty acids) of GH secretion.

Somatotropic cells in the anterior pituitary gland then synthesize and secrete GH in a pulsatile manner, in response to these stimuli by the hypothalamus.

 
Source: Wikipedia


Main pathways in endocrine regulation of growth.

Effects of growth hormone on the tissues of the body can generally be described as anabolic (building up). Like most other protein hormones, GH acts by interacting with a specific receptor on the surface of cells.

Increased height during childhood is the most widely known effect of GH. Height appears to be stimulated by at least two mechanisms:

1.     Because polypeptide hormones are not fat-soluble, they cannot penetrate cell membranes. Thus, GH exerts some of its effects by binding to receptors on target cells, where it activates the MAPK/ERK pathway. Through this mechanism GH directly stimulates division and multiplication of chondrocytes of cartilage.

2.     GH also stimulates, through the JAK-STAT signaling pathway, the production of insulin-like growth factor 1 (IGF-1, formerly known as somatomedin C), a hormone homologous to proinsulin. The liver is a major target organ of GH for this process and is the principal site of IGF-1 production. IGF-1 has growth-stimulating effects on a wide variety of tissues. Additional IGF-1 is generated within target tissues, making it what appears to be both an endocrine and an autocrine/paracrine hormone. IGF-1 also has stimulatory effects on osteoblast and chondrocyte activity to promote bone growth.

Supplemental GH
Since 1995 Norditropin has been used in children and adults who have a natural deficiency in GH.  Usually it is used to treat a growth failure caused by low or no growth hormone.
 
In the 1990s it was popular in certain circles to use GH to look good and create a leaner body.  Harvard reported estimates that in 2004 20,000 to 30,000 Americans used GH as anti-aging therapy and another that 100,000 people received GH without a valid prescription in 2002.
The problem is that this seems to have been accompanied with side effects, ranging from strange growth effects in various parts of the body, to very early death.   It is much less popular today.


Safer ways to stimulate GH
There are numerous supplements sold that claim to stimulate GH and IGF-1.  These include GABA, Glutamine, Creatine and even Magnesium.

That the neurotransmitter GABA stimulates GH is a scientifically established fact.
Exercise itself stimulates the release of GH.

Some drugs are analogues of GABA, such as Gabapentin and Baclofen.  The GH stimulatory effect of Baclofen in particular has been well studied. 

Here is a recent study still unpublished:-



For GABA to bind to GABAB receptors   it is reported to depend on the presence of calcium or magnesium.  Magnesium is known to bind to and active GABAB receptors  .
This might be another explanation for how magnesium supplements have a profound effect in some people with autism.  They comment on the affect of Mg on sensory overload.  In these people the activation of   GABAB receptors  would explain this effect.

Quite possibly magnesium might increase/decrease the potency of Baclofen to stimulate GH; this perhaps should be tested.

Too much Baclofen or too much GH?
Baclofen is an analogue of the neurotransmitter GABA.  It is also an agonist for the GABAB receptors.  As a drug it is primarily used to treat spasticity.

It now gets a little complicated, because within Baclofen are two isomers in equal amounts, R-Baclofen and S-Baclofen.
Isomers have the same chemical formula  C10H12ClNO2 ,  but the physical arrangement of the molecule is different and as a result their effect as a drug differs.
It appears that while R-baclofen is potent, the effect of S-Baclofen actually reduces the potency of R-baclofen.
The currently available forms of Baclofen, like Lioresal, from Novartis, is 50% R-Baclofen and 50% S-Baclofen.  So in a 10mg tablet you get 5mg of R-baclofen.  If you had a 5mg tablet of R-baclofen it would be many times more potent  than 10 mg of Lioresal.

This is all interesting, as is the development of Arbaclofen Placarbil, a Novel R-Baclofen prodrug.  This clever drug gets around the short half-life of R-Baclofen.  Drugs like Lioresal have to be taken 2-3 times a day, because the effect wears off fast.  Arbaclofen Placarbil slowly converts into R-Baclofen in the body and allows a much more even dose to be achieved.

Why so much detail?  Well, there was a very high profile trial in the US of Arbaclofen (R-Baclofen) in autism.  Overall the trial was seen as a failure, by sponsor Roche.  Among the trial group of children, there were some great responders, but there were others whose autism got much worse.
I really wonder if they monitored the level of GH in those kids.  Here is some data:- 

They were randomized 1:1 to Arbaclofen or placebo for 12 weeks. Drug doses ranged from 5 to 15 mg two or three times daily, with doses titrated to maximize CGI improvement. Most patients in the 5 to 11 age range ended up at 10 mg three times daily or, in the placebo group, the equivalent number of pills; most older patients received 15 mg three times daily or the placebo equivalent.
 

The older kids had 45mg a day of Arbaclofen.
In the literature the relative potency of R-Baclofen over Baclofen varies, but it is around 5+ times more strong.

This would equate to a dosage of 225mg of baclofen.  This is a HUGE dose.  Assuming it is only the R-Baclofen that stimulates GH, there would have been a massive increase in GH and the IGF-1.
There is something called “too much of a good thing”.  Perhaps the Arbaclofen non-responders were just suffering from a GH overdose.

In Fibromyalgia, the daily dose of Baclofen for adults recommended by Dr Jay Goldstein is 10 mg; so in a child with ASD, who either exhibited signs of Fibromyalgia or indeed spasticity (tense claw fingers or strange gait are quite common features in autism) such a dose would not seem unreasonable.  225g might seem excessive.


IGF-1
IGF-1 is a hormone similar in molecular structure to insulin. It plays an important role in childhood growth and continues to have anabolic effects in adults. A synthetic analog of IGF-1, mecasermin, is used for the treatment of growth failure.

IGF-1 is produced primarily by the liver as an endocrine hormone as well as in target tissues in a paracrine/autocrine fashion.

Not so simple.
So according to the textbooks IGF-1  is produced in the liver in response to GH.  IGF-1 can freely cross the BBB so therefore IGF-1 levels should be pretty much the same throughout the body and an increase in GH should always produce an increase in IGF-1;  only is does not always.

 
"Our results demonstrated that hippocampal IGF-1 protein concentrations during adolescence are highly regulated by circulating IGF-1, which were reduced by GH deficiency and restored by systematic GH replacement
 

Importantly, IGF-1 levels in the cerebral spinal fluid (CSF) were decreased by GH deficiency but not restored by GH replacement. Furthermore, analysis of gene expression using microarrays and RT-PCR indicated that circulating IGF-1 levels did not modify the transcription of IGF-1 or its receptor in the hippocampus but did regulate genes that are involved in microvascular structure and function, brain development, and synaptic plasticity, which potentially support brain structures involved in cognitive function during this important developmental period."

So the role and behavior of IGF-1  is much more complex than the textbook suggests.
How can low levels of IGF-1 in spinal fluid not be restored by GH replacement?

The above study was nothing related to autism, but it shows that the relationship between GH and IGF-1 in the brain, CSF and blood can be different.  Further it means that measuring IGF-1 in the blood does not necessarily indicate the level in the brain or the CSF. 
It appears that IGF-1 is very important to support normal brain function, but just because IGF-1 may be elevated in the blood actually tells you little with certainly about the level in the brain.

 
IGF-1 levels in autism
We already noted in previous post that IGF-1 levels are often elevated in autism.  Does this mean IGF-1 levels are also high in the brain?  It does  not.



 IGF-1 is already a trial therapy in autism and Retts syndrome; but Retts syndrome is very different to autism.  It is caused by is caused by mutations in the gene MECP2.  It affects almost exclusively girls.  Most important of all is that the growth factor most connected to Retts syndrome is not IGF-1, but its cousin Nerve growth Factor (NGF).


"We observed significant beneficial effects of IGF-1 in a mouse model of ASD and of developmental delay. Studies in mouse and human neuronal models of Rett syndrome also show benefits with IGF-1, raising the possibility that this compound may have benefits broadly in ASD and related conditions, even with differing molecular etiology. Given the extensive safety data for IGF-1 in children with short stature due to primary IGF-1 deficiency, IGF-1 is an attractive candidate for controlled clinical trials in SHANK3-deficiency and in ASD."
 

"The proposed project will pilot the use of IGF-1 as a novel treatment for core symptoms of autism. We will use a double-blind, placebo-controlled crossover trial design in five children with autism to evaluate the impact of IGF-1 treatment on autism-specific impairments in socialization, language, and repetitive behaviors. We expect to provide evidence for the safety and feasibility of IGF-1 in ameliorating social withdrawal in children with Autistic Disorder. Further, we expect to demonstrate that IGF-1 is associated with improvement on secondary outcomes of social impairment, language delay, and repetitive behavior, as well as on functional outcomes of global severity."

You can supplement your natural IGF-1 with Increlex.  This is an approved therapy for growth delay.
It does appear that IGF-1 therapy looks safer than GH therapy.  There are very many stories of terrible consequences of GH abuse.
 
Nerve growth factor (NGF)
Professor Rita Levi-Montalcini discovered Nerve Growth Factor (NGF) in 1954 and she received the Nobel Prize in Physiology or Medicine in 1986 for the discovery.  She died in 2012 at the age of 103, having had a remarkable life.  She was also a pioneer in the area of mast cells, which it turns out are closely linked to NGF.

She spent much of her very long life researching the brain and concluded that to preserve her own mental capacity in old age she would need a little help. For her final the last 30 years she treated herself with home-made NGF eye drops, which she claimed restored her brain function to that of her youth.  It is notable that she outlived her twin sister by 12 years.  She never retired and in her 90s founded the European Brain Research Institute.
It seems many people have tried to copy her, but NGF is not so easy to obtain.



 


Nerve Growth factor (NGF) is a small secreted protein that is important for the growth, maintenance, and survival of certain target nerve cells. It also functions as a signaling molecule.  Other members of the neurotrophin family that are well recognized include Brain-Derived Neurotrophic Factor (BDNF), Neurotrophin-3 (NT-3), and Neurotrophin 4/5 (NT-4/5).

NGF is critical for the survival and maintenance of sympathetic and sensory neurons. Without it, these neurons undergo apoptosis.  Nerve growth factor causes axonal growth. Studies have shown that it causes axonal branching and a bit of elongation. NGF binds with at least two classes of receptors: the p75 LNGFR (for "low-affinity nerve growth factor receptor") neurotrophin receptor (p75(NTR)) and TrkA, a transmembrane tyrosine kinase. Both are associated with neurodegenerative disorders.
There is evidence that NGF circulates throughout the entire body and is important for maintaining homeostasis.
 

“Normal” in autism but very low in Rett's
When researchers compared the level of NGF in spinal fluid in children with autism and Rett's Syndrome they found normal levels in autism by near negligible values in Rett's Syndrome, they even suggest that NGF be used as a test to discriminate Autism and Retts syndrome.


Abstract


Autism and Rett syndrome (RS) are both developmental disorders of unknown origin. Autism is a behaviorally defined syndrome. RS, which affects girls only, is characterized by a profound learning disability following early normal development, with a consistent cluster of clinical features. Differentiation of RS from infantile autism in the very early stages of the disorders is not always easy. Both syndromes still lack discriminative laboratory markers for accurate diagnosis and differentiation. We decided to compare the CSF nerve-growth factor (NGF) levels of children with infantile autism and children with RS using enzyme-linked immunosorbent assay (ELISA). Our findings of mainly normal CSF NGF in autism and low to negligible values in RS are in agreement with the different morphological and neurochemical findings (brain growth, affected brain areas, neurotransmitter metabolism) in the two syndromes. CSF NGF could be used as a biochemical marker for differentiation of patients with autism from those with RS.

This finding is confirmed when postmortem brain tissue from Retts was analysed. 



One therapy currently being trialed in Rett's Syndrome is to give IGF-1 injections; perhaps they should also be trialing NGF injections. 

Normal in autism?  Not so fast
No studies have actually looked at NGF over time in autism and indeed the picture is far from simple. Research in 2013 looked at links between non-verbal communication deficits in people with autism and the gene that controls NGF.  The conclusion of the study was:-
 NGF is a promising risk gene for Non-verbal communication deficits.
Here is the full study:- 
 
"With regards to previously published genetic evidence supporting a role for NGF in ASD, none of the published GWAS or studies of structural variation have identified clear pathogenic variants in NGF in patients with ASD. However, a hypothesis-driven candidate-gene association study focusing on a variety of neuronal signaling pathways did identify evidence for association in the gene NTRK1, which is the canonical receptor for NGF. Remarkably, NTRK1 was one of only 2 out of approximately 60 genes that survived significance thresholds in the two cohorts investigated in that study. Combined with the current study, these data suggest the involvement of the NGF signaling pathway in ASD pathogenesis."

Also when children with ADHD were examines in research they were found to have elevated levels of NGF.


"Attention deficit/hyperactivity disorder (ADHD) is the most commonly diagnosed neurobehavioral disorder of childhood. The etiopathogeny of ADHD has not been totally defined. Recent reports have suggested a pathophysiological role of neurotrophins in ADHD. In this study, we evaluated serum levels of nerve growth factor (NGF) in patients with ADHD. The sample population consisted of 44 child or adolescent patients diagnosed with ADHD according to DSM-IV criteria; 36 healthy subjects were included in the study as controls. Venous blood samples were collected, and NGF levels were measured. The mean serum NGF levels of the ADHD patients were significantly higher than those of the controls. Age and gender of the patients were not correlated with serum NGF levels. There were no significant differences in NGF levels among the combined and predominantly inattentive subtypes of ADHD. Our study suggests that there are higher levels of serum NGF in drug naive ADHD patients, and that increased levels of NGF might have an important role in the pathophysiology of ADHD." 
This would imply to me that NGF is indeed very much implicated in autism.  In one piece if research NGF was normal in autism, but the authors of the QTL are suspicious of this.  Since ADHD is so overlapping with autism, the above paper really points to the need to go back and do a more rigorous study on NGF and autism.  For now, I will assume that NGF is indeed elevated in autism at some point. 

Here is rather complex paper that goes into great depth regarding the therapeutic potential of NGF and BDNF:- 



"Thus, it was remarkable to discover that treatment of newborn rats with NGF caused a systemic increase in the number of mast cells Today there is compelling evidence that NGF, in addition to its neurotropic function, enhances survival and activity of a large number of nonneuronal cells, including immune cells, pancreatic beta cells, vascular smooth muscle cells, cardiomyocytes, endothelial cells, epithelia cells, and adipocytes.


The secretory proforms of NGF and BDNF, pro- NGF and pro-BDNF (40), respectively, are cleaved extracellularly through the tissue type plasminogen activator (tPA)-serine protease plasmin pathway; note that today’s widely administrated cholesterol-lowering drugs, collectively named statins, can induce tPA
 
Indeed, NGF and BDNF initially discovered as neural growth factors are also affecting (i) immune cells, (ii) blood vessels/angiogenesis , (iii) synaptic plasticity and consolidation  involved in learning and memory , (iv) wound healing and tissue repair, and (v) glucose, lipid, antioxidant and energy metabolism.
 

Therapy Insight

NGF- and BDNF-based therapeutic pipeline for neuropsychiatric diseases discussed herein (except migraine, cluster headache, and probably epilepsy) may

include (i) applying NGF itself , (ii) targeting the secretory and signaling pathways using existing or novel drugs, (iii) TrkB transactivation , (iv) ampakines, small molecules that stimulate Alpha-amino-3-hydroxy-5-Methyl-4-isoxazole Propionic Acid (AMPA)-type glutamate receptors , (v) selective deacetylase inhibitors, and (vi) “brain food”, that is, neuroprotective nutrients including calorie restriction, also physical activity .Whereas a high-fat diet reduces brain BDNF levels and declines cognitive capacity. Accordingly, the above mentioned classes of drugs, including calorie restriction mimetics – see, for example,O’Brian and Chu and Nikolova  for resveratrol –, require a novel research evaluation as possible pharmaceuticals and nutraceuticals also for cardiometabolic diseases. Meanwhile, NGF and BDNF could be reasonable targets for resveratrol’s therapeutic effects in both neuropsychiatric and cardiometabolic diseases. Further, recent findings have discovered that free fatty acids may influence brain development through binding to G protein- coupled receptor-40 expressed in the hippocampus (151). Interestingly, some widely used drugs for cardiometabolic diseases such as the cholesterol-lowering statins and peroxisome proliferatoractivated receptor gamma agonists as well as two novel common players, acetylcholine and glucagon like peptide-1, have been introduced into diabetes-obesity-dementia link . Another crossroad of nerves and adipose tissue may be adipose-derived mesenchymal stem cells, which can differentiate into neurons in BDNFenriched cultures, and thus representing useful tool to treat neuropsychiatric disorders. Note that pro-NGF can be cleaved proteolytically at dibasic residues and liberates two other peptides beside NGF, LIP1, a 29 amino acid (aa) peptide, and LIP2, a 38 aa peptide; their synthetic forms may be targets for new drugs in NGF-related diseases.

The challenge for the future is to understand to what extent the effects of NGF and BDNF are interrelated with regards to their neuro-, synapto-, vasculoand metabotrophic potentials. Further studies should provide answers to the questions of when and how NGF-BDNF/TrkA,B dysfunction appears and leads to both neuropsychiatric and cardiometabolic diseases. It  is hope that by bringing the datasets together in these seemingly diverse disorders we can help develop a conceptual novel basis for future studies in the field.
 

So NGF can be both good and bad.  It looks like statins will stimulate bother NGF and BDNF. Older people and anyone with Retts Syndrome are likely to benefit from more NGF.  In autism it appears possible that there was too much NGF and BDNF at a very early age, with levels then changing.  High levels of NGF and BDNF look a bad idea.  A lot more research is needed to understand what determines  NGF and BDNF levels.  It appears that BDNF may stay high in autism, but NGF levels.
 
NGF therapy
You will naturally be wondering if you can order some NGF with your PayPal account, sadly not.
Rita probably made here NGF eye drops in her kitchen.
An Italian firm called Dompé has recently succeeded in developing a process for the industrial production of recombinant human NGF (rhNGF) at its biotech plant in Italy, and they are in the process of getting NGF eye drops approved as a drug for the treatment of disorders of both the anterior and posterior segments of the eye, including dry eye and glaucoma.
We all know that Rita had entirely different reasons to use her NGF eye drops.
I do like it when scientists/doctors very occasionally doing interesting things like self-experimentation; it shows they have ultimate faith in their own ideas.  I also like it when they use novel methods to deliver the drug into the body.  Eye drops and nasal sprays mean no loss via gut and no issue with passing through into the blood supply and are much more favorable than injections.  It also seems, from both Rita, the Nobel Laureate and Jay Goldstein, the Fibromyalgia doctor, that mixing up your nasal spray or eye drops is simple, effective and cheap.

Back again to Rita - Countering the pro-inflammatory actions of NGF

Mast cells
First Professor Rita Levi-Montalcini discovered that Mast cells synthesize, store, and release nerve growth factor and then her group discovered in 1993 that Palmitoylethanolamide (PEA) acts as a natural modulator of hyperactive mast cells, counteracting the pro-inflammatory actions of NGF.
 

Professor Levi-Montalcini’s focus was on NGF, and already as early as 1977 she pointed out that NGF was an irritative compound inducing mast cell degranulation . The relation between mast cell and NGF, also related to their interactive function in diseases, were topics Rita Levi-Montalcini worked on for many years

“...Unregulated mast-cell activation constitutes a considerable risk to the health of the organism, and it is not unreasonable to expect that nature should have devised a means for the host to defend itself against such damage. It has recently been proposed that saturated N-acyl-ethanolamides like palmitoylethanolamide, which accumulate in tissues following injury and which down modulate mast-cell activation in vitro, exert a local, autacoid, and anti-injury function via mast cells. Palmitoylethanolamide is orally active in reducing tissue inflammation and mast cell degranulation in vivo, in decreasing hyperalgesia that accompanies peripheral nerve compression, and in limiting the neurological deficits of experimental allergic encephalomyelitis. Moreover, palmitoylethanolamide appears to project against excitotoxic neuronal death in vitro and to be produced by cultured CNS neurons upon excitatory amino acid receptor activation. The mechanism of this action of N-acylethanolamides has been termed autacoid local injury antagonism (ALIA).”
 
Based on her work in the 90s PEA is now available as a nutraceutical for indications related to chronic pain and chronic inflammation. PEA has been explored in a variety of indications such as sciatic pain, diabetic pain, neuropathic pain, pain due to arthritis and pain in multiple sclerosis in the period 1992-2010 and around 20 clinical trials have documented its safety and efficacy in these chronic pain states. In the period 1970-1980 its safety and efficacy was already documented in a series of double blind clinical trials in flu and respiratory infections. PEA is therefore most probably the best-documented nutraceutical around, with pharmacological profile described in more than 350 scientific papers 

“...palmitoylethanolamide may behave as local autacoids capable of negatively modulating mast cell activation (ALIA mechanism). In keeping with this hypothesis, palmitoylethanolamide reduces mast cell activation associated with inflammatory processes. With these considerations in mind, the described pharmacological effects of palmitoylethanolamide could be mediated by interactions with CB2 receptors on mast cells.”
 
Professor Levi-Montalcini’s focus was on NGF, and already as early as 1977 she pointed out that NGF was an irritative compound inducing mast cell degranulation. The relation between mast cell and NGF, also related to their interactive function in diseases, were topics Rita Levi-Montalcini worked on for many years

“...Unregulated mast-cell activation constitutes a considerable risk to the health of the organism, and it is not unreasonable to expect that nature should have devised a means for the host to defend itself against such damage. It has recently been proposed that saturated N-acyl-ethanolamides like palmitoylethanolamide, which accumulate in tissues following injury and which down modulate mast-cell activation in vitro, exert a local, autacoid, and anti-injury function via mast cells. Palmitoylethanolamide is orally active in reducing tissue inflammation and mast cell degranulation in vivo, in decreasing hyperalgesia that accompanies peripheral nerve compression, and in limiting the neurological deficits of experimental allergic encephalomyelitis. Moreover, palmitoylethanolamide appears to project against excitotoxic neuronal death in vitro and to be produced by cultured CNS neurons upon excitatory amino acid receptor activation. The mechanism of this action of N-acylethanolamides has been termed autacoid local injury antagonism (ALIA).”

 "Prof. Rita Levi-Montalcini is widely known for her work on NGF. Much less is known about two other formidable chapters she added to neurobiology: the central role of the mast cell in much pathology, and the modulating role of the endogenous lipid PEA via the mast cell. Based on her work in the 90s PEA is now available as a nutraceutical for indications related to chronic pain and chronic inflammation. PEA has been explored in a variety of indications such as sciatic pain, diabetic pain, neuropathic pain, pain due to arthritis and pain in multiple sclerosis in the period 1992-2010 and around 20 clinical trials have documented its safety and efficacy in these chronic pain states. In the period 1970-1980 its safety and efficacy was already documented in a series of double blind clinical trials in flu and respiratory infections. PEA is therefore most probably the best-documented nutraceutical around, with pharmacological profile described in more than 350 scientific papers"
 

Reducing Amyloid-Related Brain Damage
In an earlier posts we looked at Amyloids in the brain in autism and Alzheimer’s.  There was a distinct difference in what was going on and definitely worse things were happening in Alzheimer’s, but things were far from normal in autism.


Several papers have demonstrated that an imbalance of the endocannabinoid system (ECS) and alterations in the levels of PEA occur in acute and chronic inflammation. For instance during β-amyloid-induced neuroinflammation the deregulation of cannabinoid receptors and its endogenous ligands accompanies the development and progression of disease.


The study strongly suggests that people with Alzheimer’s would benefit from the neuroprotective effects.  PEA also reduced Amyloid-Induced Oxidative Stress.
 

PEA as an anti-epileptic
Anticonvulsant activity of N-palmitoylethanolamide, a putative endocannabinoid, in mice

Abstract


PURPOSE:


The purpose of this study was to evaluate in mice the anticonvulsant potential of N-palmitoylethanolamide, a putative endocannabinoid that accumulates in the body during inflammatory processes.

METHODS:


N-palmitoylethanolamide was injected intraperitoneally (i.p.) in mice and evaluated for anticonvulsant activity [in maximal electroshock seizure (MES) and chemical-induced convulsions] and for neurologic impairment (rotorod). It was compared with anandamide and with different palmitic acid analogues as well as with reference anticonvulsants (AEDs) injected under the same conditions.

RESULTS:


The MES test showed, after i.p. administration to mice, that N-palmitoy]ethanolamide had an median effective dose (ED50) value comparable to that of phenytoin (PHT; 8.9 and 9.2 mg/kg, respectively). In the subcutaneous pentylenetetrazol test and in the 3-mercaptropropionic acid test, it was effective only against tonic convulsions. N-palmitoylethanolamide was devoid of neurologic impairment < or = 250 mg/kg, yielding a high protective index.

CONCLUSIONS:


N-palmitoylethanolamide, an endogenous compound with anti-inflammatory and analgesic activities, is a potent AED in mice. Its precise mechanism of action remains to be elucidated.
 
 
Disease-Modifying Agent in Peripheral Neuropathy
We have found before that what is good for treating Peripheral Neuropathy, can also be useful in treating autism.  Anybody remember those posts on antioxidants?  The antioxidants helped reduce diabetic neuropathy and even reduced the amount of insulin people needed, which means something must have happened to improve pancreatic function.  Some people’s autism is apparently linked to pancreatic dysfunction, if you did not know.

 
All in all  PEA has been shown to have anti-inflammatory, anti-nociceptive, neuroprotective, and anticonvulsant properties.  Where can I get some?

 
PEA (palmitoylethanolamide) levels in autism and ADHD
Very helpfully, some researchers in Japan have already done a study to measure the levels of PEA in autism and ADHD.
Decreased beta-phenylethylamine inurine of children with attention deficit hyperactivity disorder and autistic disorder




Beta-phenylethylamine (PEA), a biogenic trace amine, acts as a neuromodulator in the nigrostriatal dopaminergic pathway and stimulates the release of dopamine. To clarify the mechanism of neurochemical metabolism in attention deficit hyperactivity disorder (ADHD), we measured the urine levels of PEA using gas chromatography-chemical ionization-mass spectrometry. The urinary levels of 3-methoxy-4-hydroxyphenyl glycol (MHPG), homovanillic acid (HVA), and 5-hydroxy-indoleacetic acid (5-HIAA) were determined by high performance liquid chromatography. Urine samples were collected in a 24 hour period. Findings were compared with those obtained from controls (N = 15), children with ADHD (N = 15), and children with autistic disorder (AD) (N = 5). The mean urinary levels of MHPG, HVA, and 5-HIAA in the children with ADHD were not significantly different from those of the controls or those with AD, whereas PEA levels were significantly lower in children with ADHD (11.23 +/- 13.40 micrograms/g creatinine) compared with controls (56.01 +/- 52.18 micrograms/g creatinine). PEA and MHPG levels in children with AD (14.75 +/- 14.37 micrograms/g creatine, 1.10 +/- 0.61 micrograms/mg creatine, respectively) were significantly decreased compared to controls (MHPG, 2.2 +/- 0.9 micrograms/mg creatine). The decreased urine PEA in children with ADHD and AD may suggest a common underlying pathophysiology. The decreased urine MHPG in children with AD might indicate the existence of an alteration in central and peripheral noradrenergic function.

This is pretty much as expected and of course does prompt the question of how to raise PEA levels, if PEA is such a handy and helpful molecule.

Boosting the level of PEA
Some of the literature suggests that oral administration of PEA will be rather ineffective, since not much will reach the brain.  On the other hand there are plenty of studies showing PEA is more effective than conventional pain killers, so it must be reaching the brain.

Research indicates that PEA is deactivated by a special protein (N-acylethanolamine-hydrolyzing acid amidase) and it is possible to block the action of this protein and hence raise the level of PEA.addition, they found that PEA - also present in foods like eggs and peanuts - is deactivated by a protein called N-acylethanolamine-hydrolyzing acid amidase, which is an enzyme that breaks down molecules controlling cell inflammation
In addition, they found that PEA - also present in foods like eggs and peanuts - is deactivated by a protein called N-acylethanolamine-hydrolyzing acid amidase, which is an enzyme that breaks down molecules controlling cell inflammation.
The full paper is here:-


A cynic would point out that since PEA cannot be patented – it is naturally occurring substance – the pharmaceutical industry would prefer to find a patentable substance, to be the adopted therapy, rather than PEA itself.
In the meantime the logical way forward would be just to eat some.  Well, dark chocolate is rich in PEA, but you might have to eat quite a lot of it.  The alternative is a pill.  There is quite a choice:-
http://palmitoylethanolamide4pain.com/about-2/

If you want to buy in bulk you get a discount:-
Brain-Derived Neurotrophic Factor  (BDNF)
Unusually high levels of the signaling peptide BDNF, or brain-derived neurotropic factor, have been detected in blood samples from children with autism

During brain development, BDNF regulates the birth and differentiation of brain cells, or neurons. Some of BDNF’s target cells, such as cortical interneurons, which transmit information between different layers of the brain cortex, have been implicated in autism. BDNF is also a regulator of brain growth, and children with the disorder tend to have abnormally large brains during early development. What’s more, MeCP2, a gene in which mutations are known to cause the autism-related Rett syndrome, directly regulates the expression of BDNF.

If high BDNF levels do prove to be a cause of the disorder, drugs that block its production or signaling might be an effective treatment for autism.


BDNF is down regulated by stress and up regulated by learning, antidepressants, histone deacetylase inhibitors, physical activity, and dietary calorie restriction
 
 

Neurotrophin-3

Although the vast majority of neurons in the brain are formed prenatally, parts of the adult brain retain the ability to grow new neurons from neural stem cells; a process known as neurogenesis. Neurotrophins are chemicals that help to stimulate and control neurogenesis.

NT-3 is unique in the number of neurons it can potentially stimulate, given its ability to activate two of the receptor tyrosine kinase neurotrophin receptors (TrkC and TrkB - see below).
 

Autism is a neurodevelopmental disorder characterized by social and language deficits, ritualistic-repetitive behaviors and disturbance in motor functions. Data of imaging, head circumference studies, and Purkinje cell analysis suggest impaired brain growth and development. Both genetic predisposition and environmental triggers have been implicated in the etiology of autism, but the underlying cause remains unknown. Recently, we have reported an increase in 3-nitrotyrosine (3-NT), a marker of oxidative stress damage to proteins in autistic cerebella. In the present study, we further explored oxidative damage in the autistic cerebellum by measuring 8-hydroxydeoxyguanosine (8-OH-dG), a marker of DNA modification, in a subset of cases analyzed for 3-NT. We also explored the hypothesis that oxidative damage in autism is associated with altered expression of brain neurotrophins critical for normal brain growth and differentiation. The content of 8-OH-dG in cerebellar DNA isolated by the proteinase K method was measured using an enzyme-linked immunosorbent assay (ELISA); neurotrophin-3 (NT-3) levels in cerebellar homogenates were measured using NT-3 ELISA. Cerebellar 8-OH-dG showed trend towards higher levels with the increase of 63.4% observed in autism. Analysis of cerebellar NT-3 showed a significant (p = 0.034) increase (40.3%) in autism. Furthermore, there was a significant positive correlation between cerebellar NT-3 and 3-NT (r = 0.83; p = 0.0408). These data provide the first quantitative measure of brain NT-3 and show its increase in the autistic brain. Altered levels of brain NT-3 are likely to contribute to autistic pathology not only by affecting brain axonal targeting and synapse formation but also by further exacerbating oxidative stress and possibly contributing to Purkinje cell abnormalities.
 
Neurotrophin-4
Neurotrophin-4 (NT-4), also known as neurotrophin-5 (NT-5), is a protein that in humans is encoded by the NTF4 gene.

It seems that NT-4 levels are elevated in cases of mental retardation and not in cases of autism. 

Abstract
To evaluate the availability of the serum neurotrophins for the diagnosis of the patients with neurodevelopmental disorder, we measured the serum concentration of brain-derived neurotrophic factor (BDNF) and neurotrophin-4 (NT-4) in the patients diagnosed with autism (n=18) and mental retardation (n=20), or healthy controls (n=16), using enzyme-linked immunosorbent assay. There tended to be a higher concentration of serum BDNF found in the autistic group (P<0.05 by analysis of variance (ANOVA)) and the mental retardation group (P<0.001 by ANOVA) compared to the control group. Serum NT-4 concentration tended to be increased in the mental retardation group (P<0.05 by ANOVA). We conclude that measuring the serum concentration of two neurotrophins, BDNF and NT-4, might be helpful to diagnose or classify disorders such as autism or mental retardation.
 

 
Conclusion (finally)
After all that information there are some useful conclusions. Slightly raising GH by stimulating the body to produce more, looks much smarter than GH therapy, unless it is absolutely necessary.  The extra GH in most cases should stimulate more IGF-1, but not necessarily where it is needed.  IGF-1 therapy itself looks interesting but currently involves needles.  An oral IGF-1 related analogue has Orphan Drug status in the US and Europe and that may prove very useful, when it becomes available.

If Rett’s Syndrome is the concern, it looks like NGF really is needed ASAP. Rita Levi-Montalcini found a way to treat herself with NGF more than 30 years ago.
As a treatment for cognitive decline, NGF looks very interesting.  I wonder what the effect would be on apparent Mental Retardation, if given young enough.  Perhaps NGF should be measured in cases of suspected MR?
PEA looks very interesting for those who believe Theoharides’ Autism as an Allergy of the Brain hypothesis.  It also looks interesting as a safe pain reducing therapy to test in fibromyalgia and mastocytosis.  PEA also has anti-epileptic properties and in this blog we have seen a great deal can be learnt from thinking about the comorbidities of autism.  PEA might well eventually find a place in my “Autism Toolkit”, if it stabilizes mast cells.  It is quite strange that nobody has investigated the benefit of PEA in a controlled trial on kids with ASD, there are several possible mechanisms whereby it could be helpful.  PEA does not need a doctor’s prescription.
It looks like high NT-3 levels are a result of autism and ongoing oxidative stress in the brain; another reason to treat oxidative stress.
It appears likely that autism is accompanied by an excess of Brain-Derived Neurotropic Factor and if ongoing research proves this, then therapies that block its production or signaling might be an effective treatment for autism.

 

 

 

 

 

 













 

Wednesday 19 February 2014

Is a Subtype of Autism an Allergy of the Brain?

 
 


I am actually in the middle of writing up my ideas about autism and the various human growth factors, but I just came across a paper worthy of its own post.  It is by one of those researchers already on my Dean's List, Dr Theoharis Theoharides from Tuft's University.


Is a Subtype of Autism an Allergy of the Brain?

You may recall that Theoharides works in the very small world of the mast cell.  These cells play a key role in allergies.  They contain histamine, serotonin and various other inflammatory agents.

The allergy causes the mast cells to "degranulate" and all the contents is released into the blood supply.  This then starts a chain reaction of events all over the body.

I was just reading about Nerve Growth Factor (NGF) which appears to behave strangely in autism.  It turns out that mast cells synthesise, store and release NGF.

NGF is very important for the brain, but it can also be highly neuro-inflammatory.  In autism NGF levels are elevated, just like Serotonin levels usually are.

What is the connection between NGF, Serotonin and Autism?  The degranulation of the mast cell.

Well, Theoharides knows everything about mast cell stabilizers.  These are agents that stop the mast cells emptying their contents into the blood stream.

But perhaps he has actually missed a connection.  In my forthcoming post on Human Growth Factors, we will find out about palmitoylethanolamide (PEA), a natural substance found in body that counters the inflammatory effect of NGF.  According to the Nobel Laureate who discovered TNF, PEA itself has mast cell stabilzing properties.

And one other strange thing, in people with autism and ADHD, they have low levels of PEA.

Put all the pieces together and then reconsider:-

        Is a subtype of autism an allergy of the brain?

I think the answer is of course yes; but more than that, I think it may well affect all subtypes of autism, just not all the time.

In some people they may have this "allergy" and nothing else.  In other people there are other issues like ion channel dysfunctions, but when their autism suddenly flares up, think over-activated immune system in Peter-speak or allergy of the brain in Theoharis-speak.

I think we are in effect speaking the same language.



 

 

Friday 14 February 2014

Bumetanide Dosage & Effectiveness in Autism & Asperger's



The clinical trial of Bumetanide in autism, published in 2012, was what triggered my interest in using drugs to treat autism.


In that trial on children aged 3-11 years, the dosage used was 1mg a day, split in two doses.

In my trial, I found 1mg in the morning effective, while splitting the dose rendered it ineffective. 
I was surprised to hear that the French researchers find the treatment effective in 90% of cases of autism, including Asperger’s.  The reason is that while Monty, now aged 10 with ASD, is a responder, it seems that most people I know who have tried it have not responded.  Only one did respond, and that was when the father upped the dosage.

Now I hear that Lemmonier’s standard dosage has doubled to 2mg a day, with 1mg in the morning and 1mg at 5pm.  He tries for three months, before assuming the drug to be ineffective.
So to anyone who tried Bumetanide without success, maybe it is time to try again at the revised dosage and see if you are in the 90%.

The researchers are also suggesting Bumetanide is given from a very early age, as soon as autism is suspected.


 

Thursday 13 February 2014

The Matryoshka in Autism - Revealing the Child Within


  
 
Matryoshka dolls are Russian stacking dolls, often mistakenly called Babushka dolls
Picture Source: Wikipedia

This post coincides with the first week of Putin’s Winter Olympics in Sochi.  All is going well so far and Russia has shown it can put on quite a spectacle.  Russia has no shortage of clever scientists, but rarely does their research make it into English language journals.  No doubt, much gets lost to the non-Russian speaking world.
Russia is famous for its Matryoshka dolls.  Remove the outer layer and see what is underneath.

Treating your child’s autism can also be like un-stacking your Matryoshka doll  for the first time.  You may be surprised what lies underneath. 
 

моя матрешка (My Matryoshka)

This week for me was another surprising one.
Monty, aged 10 with ASD, has an Assistant with him in the mornings at school.  “Has Monty ever been to Disneyland?” she asked me.  It turns out one of his classmates had been telling his friends about a family holiday to Disneyland Paris.  Six years ago we took Monty to Disneyland Paris.  All I remember was pushing him around the theme park in a pushchair, while his elder brother enjoyed the rides.  In the very many gift shops, Monty enjoyed reorganizing the stock into nice neat rows; but that was about it.  After that experience, we limited ourselves to Legoland; the best one is the original in Billund, Denmark, which is great for all kids.  I doubt Disneyland was a memorable experience.

So it was a great surprise to hear that Monty had joined the conversation at school and said that he too had been to Disneyland. Until very recently, he had never been able to join in any, unprompted, natural conversation.  Perhaps this was just his imagination, but when I asked him later who he had been to Disneyland with, he gave the right answer and I had structured the question to make the easy response the wrong answer. 
We also now have a lot of speech and much is directed at humour.  Monty is taking an observation and reinventing it, to make it more memorable and amusing.  So, Martin breaking his tooth at school playing football, when he collided into another boy, with the teacher Mr Keith looking on, transitioned through:-

Martin hit his teeth   (what happened?)
Martin was playing football with Mr Keith  (really, and then what?)
Martin was playing football with Mr Keith and broke his teeth
And finally
“Mr Keith broke Martin’s teeth”, which was repeated many times.

By which time he was in fits of laughter.  As long as we don’t tell Martin’s mother, all will be OK.
Yesterday, Monty informed me of the news about his 8 year old classmate:  
“Alexia has got married”   (Martin has been busy) 
Is this NT behaviour? No, possibly not, but it is unlike any autistic behaviour I have seen to date.

Today, a little girl at school stopped me and said “Monty talks funny; and I don’t know why”. 

Finally, the Head Teacher came up to me and says she keeps meaning to write us a note, to tell us how great Monty is doing this year, so happy and joyful.  Now he greets everyone spontaneously and no longer with any prompting.
So it looks like the outer shell of the Matryoshka has been consigned to history.    Long live the Polypill, and not to forget 12,000 hours of 1:1 therapy.

What lies deeper inside remains to be seen.



 

 

Sunday 9 February 2014

Who Pays the Piper? Off-Label or Polypill





It seems that autism is not the only “untreatable disease”, that does appear to be treatable.  At least twenty years ago, one apparently related condition was extensively treated off-label.  I am reading an intriguing book about the off-label treatment of Fibromyalgia in the 80s and 90s.

 

Off-label
In medical-speak “off-label” is when a drug is use for a purpose it was never actually approved for.  If you have straight forward diseases, you would never need to use a drug “off label”.

In some countries off-label prescribing by doctors is totally discouraged, in others, it is quite common.
The problem occurs when it comes to paying for expensive drugs and, of course, who is to blame if things go wrong.
Since many drug discoveries are actually stumbled upon by chance, off-label drug use is not as crazy as it may sound.


Socialized Healthcare, Private Insurance and Lawsuits
In the developed world, healthcare is provided either via some kind of private insurance as in the US, or it is via the State, as in Europe.  If your insurer is unwilling to pay for off-label treatments, you will not get them (unless you pay yourself).  In the UK, if the treatment is not endorsed by NICE (in effect, the State), you are not going to get it.  In the old days, the doctor might have been willing to try some off-label drugs, but now they are likely to be more worried about being struck of the medical register for malpractice, or, in the US, being sued.

So, all over the world off-label prescribing is getting rarer.  Certain states in the US are more liberal, Florida I believe is one.
Your healthcare is really in the hands of big brother; in general, this is not a bad thing.  If you have some rare, “untreatable” condition, then the problems start.  Even if you know what off-label drug you want, you will struggle to get it.  You will even struggle to get any unusual blood tests done.

In some countries the system is much more liberal.  If you want to measure potassium in your blood or maybe IGF-1 or serotonin, the process is akin to having your dry cleaning done.  You pay and it gets done.
 

Off-Label in the US
Before insurers tightening things up in the 1980s, doctors in the US seemingly were able to prescribe pretty much what they wanted.  If you read about some of the things prescribed for severer cases of Fibromyalgia, you would be amazed at the things they used (IVIG, Baclofen, Oxytocin etc.) and how the underlying principle was one of trial and error.

Due to the unusual position of osteopathic medicine in the US, where osteopaths have the same drug prescribing rights as medical doctors, there are many “alternative” doctors practising what they call “holistic medicine”.  Then there is a small army of DAN doctors, some of whom are medical doctors and some are not.  You also have a large number of chiropractors in the US; graduates of chiropractic schools receive the degree Doctor of Chiropractic (DC), as I was told by a reader of this blog, US  Chiropractors do not prescribe drugs, but they do treat kids with autism (I am not sure how).
So it looks like, while the golden days are over, off-label drug prescribing is alive and well in the US.

 
From Off-Label to On-Label
You would think that once an off-label therapy gets established, it would be able to transition to on-label, and become an accepted mainstream therapy.  This does not happen very often.  The doctors using off-label widely, are seen as quacks by some established doctors and by much of the public.  If they are treating unusual, hard to define conditions, it is hard to carry out controlled clinical trials, and nobody has an interest to pay for them anyway.

So, off-label tends to stay off-label and for most people, untreatable conditions remain untreatable.


Polypill
I am wary of my ideas being seen as risky, off-label, quack nonsense.  They certainly are off-label uses.

I think you should be able to transition from off-label to on-label.  If the disease is just a cluster of symptoms and pathologies, it will be hard to identify the sub-type for which the therapy is effective.  This applies to both autism and indeed fibromyalgia.
To move away from the very unscientific, and indeed wasteful, trial and error approach, you have to be able to use reliable biomarkers or diagnostic tests.  You would have to prove to a very cynical public, that you are not spouting nonsense.

Then faced with a therapy which can be shown effective consistently, albeit for a rare, very well defined, condition (based on blood tests etc.), there is no good reason why the therapy should not go on-label.
The question now with the Polypill is to be able to identify with >75% certainly for whom it will be effective.  I also need to understand, and indeed predict, when it might stop working.  This may sound very strange, but can happen.

Predicting when it might stop working, as well as suggesting what to do should that occur, makes things tricky. To do it perfectly you would really need the old school off-label doctor, and a vast amount of consultation time, that will not be available.
I live in a country where access to lab tests is very open and they are inexpensive, so I have come up with a testing strategy to accompany the Polypill, using tests that are inexpensive.

The idea of the tests is twofold; to identify the sub-group of children who will benefit from the Polypill therapy and to establish a baseline of markers to later understand any cases, should the Polypill “stop working”

Blood tests
·        IGF-1

·        Serotonin

·        Free T3

·        Cholesterol LDL & HDL

·        Histamine

·        Inflammatory markers CRP and   IL-6

·        Potassium

I would also use the TRH stimulation test, except it is not available where I live and requires several blood draws.  It shows central hypothyroidism to be common in autism (as it is, interestingly, in fibromyalgia).
I am expecting any loss in efficacy of the Polypill to be accompanied by a surge in histamine and/or the easy to measure inflammatory markers, C - reactive protein (CRP) and Interleukin-6.

The trials would take place in winter (no pollen) and would exclude people with food allergies, digestive disorders, IBD, IBS, pancreatic enzyme deficiency etc.  The trial would be exclusively for early onset autism, no regression.
People with seizures would be very welcome and might form a separate subgroup within the test; I expect the incidence of seizure and epilepsy to be reduced by the Polypill.

Having created a trial based on children with elevated IGF-1, Serotonin, Free T3 and Cholesterol, I would then continue to measure all the above indicators on a monthly basis.

Assessing Success
Since the Polypill has several active ingredients, I would expect a marked reduction in autistic behaviours, based on any established autism rating scale.  I would expect parents, teachers and therapists to be really impressed by the effect.

Using the above screening biomarkers to select the trial group, I would hope to achieve a successful outcome in a great majority of cases.  This success rate has to be measured.  Perhaps the screening exclusions and biomarkers are too restrictive, or not restrictive enough.  If it was 100% effective, they should be relaxed; if it was 50% they should be tightened.
What intrigues me are the cases where the Polypill may stop working after a period of success.  If this is understood, it will be another step in understanding the dynamic nature of autism.  If the loss in effect can be correlated to an increase in histamine, in some cases, I will know what to do.  If in some cases CRP and IL-6 rise but histamine and serotonin do not, we would know that the immune system had been activated, but mast cells have not degranulated.  In these cases it would require the, currently under development, “Autism Toolkit”, to provide some immuno-modulatory therapy.

Just as abruptly as the Polypill might stop working in a child, I expect it will start working again, when the external stimulation (whatever it might be) has been withdrawn.
In children who have a permanent state of over-activation of their immune system, they should have sky high CRP and IL-6 and the Polypill will never start to work in the first place.  High inflammatory markers are seen in regressive autism, according to Ashwood, who is on my Dean’s List.


EMA
Having rationalised my objectives, I am finalizing my initial submission to the European Medicines Agency, to see whether the Polypill should remain Peter’s off-label curiosity, or become an Orphan Drug, to share with others.

 
 

 

Saturday 1 February 2014

Updated Conceptual Map of Behavioural Homeostasis in Autism



Ten months ago I decided to invent my own, admittedly subjective, autism scale to map the progress of Monty, aged 10 with ASD; a lot has changed since then, so I decided to update it.
For background to the scale, read the earlier post.


 

 



 
The chart above is an update of the original; I added the bright yellow line to reflect events since April 2013 and a future prediction.  I decided that predicting more than three years is pointless.

The orange line shows that autism was very present from birth, with a second wave hitting causing more symptoms and then a nice shallow decline.  Aged 8 and half, emotional stress causes a huge regression and he enters into the world of SIB and aggression.  The situation is gradually recovered using exclusively an ABA approach.  The new homeostasis is at a higher plateau.  I expect some epigenetic change occurred.
At 17 December 2013, we switch to the red line; this is the point when he started taking Bumetanide (BU), courtesy of Ben-Ari and Lemmonier, and then we see a sharp step change in improvement.  This was followed shortly thereafter by another step down, following the start of NAC.  This takes us to April 2013.  Now we switch to the yellow line.
In April 2013, 10 months ago, I started to look for further help in the form of "agent X".  I gave myself a year to find it, but it came much faster; statin therapy had arrived.
Come summer, everything goes sharply into reverse, with a big spike in the yellow line back up into the danger zone.  The spike seems to have been caused by over-activation of the immune system caused by pollen, of all things.  Using mast cell stabilizers the situation was fully recovered.  There was no net loss (no epigenetic damage).

Then in January, the experimental Polypill takes shape and we see another sharp drop in the autism rating on the yellow line.
Now we are on the verge of “nerd cloud”, which separates kids with serious autism from the regular kids below it.  The top end of the cloud might be called high functioning autism and the lower part Asperger’s.  When I was a child this cloud existed, but people were just called odd or weird; in the US they were already called nerds.  In 1950 the word nerd was created by Dr Seuss, in his book, If I Ran the Zoo.
It is of course a pejorative term, but nowadays there are some very successful and wealthy nerds, so maybe it should not be.

Time will tell whether we can continue to descend through the nerd cloud.  What is going to happen in a few months when the pollen returns?  Will the Polypill be mightier than the re-activated immune system?  Perhaps mast cell stabilizers should be in the Polypill?
 
It is clear that more work is going to be needed and, perhaps, in addition to an Autism Polypill, there is a need for an Autism Toolkit.  The Toolkit is what you need when the Polypill stops working, and perhaps, before it can start working in some people.