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Wednesday 11 September 2019

DMF and MMF for Neuroprotection and Immunomodulation in MS, TBI, Parkinson’s and potentially much more




DMF is an inexpensive chemical and was used to stop mould growing on sofas shipped from China to Europe, until it was banned as a skin irritant. It is also an expensive drug, sold by Biogen.


DMF was discussed in an earlier post on ketones, because one of the anti-inflammatory effects of the ketone BHB can also be achieved using Dimethyl Fumarate (DMF). In the body DMF is converted to MMF by a chemical reaction with the body’s key antioxidant Glutathione (GSH). Surprisingly, DMF then goes on to improve GSH recycling and actually raise GSH levels.

Ketones and Autism Part 3 - Niacin Receptor HCA2/GPR109A in Autism, Colonic Inflammation, Psoriasis and Multiple Sclerosis


                       
DMF is a very cheap chemical that has been sold as an extremely expensive drug, first in Germany to treat Psoriasis and later Multiple Sclerosis (MS). I did explain in an earlier post how a person unable to afford $50,000 a year for the Tecfidera drug version could achieve the same result for a couple of hundred dollars.

The drug form of DMF is cheaper in Europe, but still very pricey.

The good news is that some of Biogen’s patents are expiring and so new cheaper drug versions will appear, including one for MMF itself that may greatly reduce the GI side effects experienced by some people.

I do think that DMF, at much lower doses than used today, has potential to treat a wide range of inflammatory conditions. This will almost inevitably include some types of autism.  In one of Biogen’s patents they refer to a long list of potential applications: -

“The pharmaceutical composition according to any one of the above aspects is for use in the treatment of psoriasis (including moderate to severe plaque psoriasis), psoriatic arthritis, neurodermatitis, inflammatory bowel disease, such as Crohn's disease and ulcerative colitis, polyarthritis, multiple sclerosis including relapsing—remitting multiple sclerosis (MS including RR-MS and progressive MS), juvenile-onset diabetes mellitus, Hashimoto's thyroiditis, Grave's disease, SLE (systemic lupus erythematosus), Cutaneous Lupus Erythematosus, Sjogren’s syndrome, Pernicious anaemia, Chronic active (lupoid) hepatitis, Rheumatoid arthritis (RA), lupus nephritis, myasthenia gravis, uveitis, refractory uveitis, vernal conjunctivitis, pemphigus vulgaris, scleroderma, optic neuritis, malignant melanoma, alopecia areata, cutaneous sarcoidosis, pain such as radicular pain, pain associated with radiculopathy, neuropathic pain or sciatica/sciatic pain, organ transplantation (prevention of rejection), sarcoidosis, necrobiosis lipoidica or granuloma annulare.”

An “overactive immune system” is a hallmark of much autism and Asperger’s.  I am thinking of all those Aspies with IBS, IBD, ulcerative colitis etc.  There is also the opposite group in autism with those people catching every possible virus and taking a long time to get better.

We have come across an ever-widening variety of anti-inflammatory drugs and do help in certain cases, including:-

·        Cheap NSAIDs, like Ibuprofen
·        The  cheap leukotriene receptor antagonist, Montelukast/Singulair, used to treat children with asthma
·        The Japanese PDE4 inhibitor Ibudilast, used to treat asthma and now MS
·        TSO parasites
·        Lipophilic Statins (Atorvastatin, Lovastatin etc)
·        Beta-lactam antibiotics, like Penicillin
·        Macrolide antibiotics, like Azithromycin (developed interestingly, Natasa, in Croatia by Pliva)
·        Biogaia Gastrus probiotic from Sweden
·        PEA (Palmitoylethanolamide) from Italy or alternatively CBD (Cannabidiol)
·        The ketone BHB (beta hydroxybutyrate)
·        Lenalidomide (an ultra-expensive idea trialed by Dr Chez, in Sacramento)

You will find case histories or small trials that support all of the above therapies, but nothing works for everyone.

Some of the above therapies have side effects, some are cheap and some are very expensive.

I have no doubt that some people with autism would respond to DMF and some will not. People who respond well to BHB ketone supplements could well respond to DMF, because they share one anti-inflammatory mode of action; they are both agonists of Niacin Receptor HCA2/GPR109A. BHB has other anti-inflammatory modes of action and so does DMF. DMF has potent anti-oxidant effects that act via Nrf-2.

We see today that DMF can treat Psoriasis, Multiple Sclerosis (MS) and possibly Parkinson’s Disease and Traumatic Brain Injury (TBI). There is a lot in this blog about COPD (Chronic Oppressive Pulmonary Disease) and via Nrf2, I think DMF looks quite likely to be therapeutic.  You may wonder how these totally different diseases can respond to the same drugs or similar drugs, but it is well known that they do. Otelzla/Apremilast is a very expensive PDE4 inhibitor approved to treat psoriasis; Daxas/Roflumilast is a much cheaper PDE4 inhibitor approved to treat COPD, both cause GI side effects because neither drug is sufficiently selective (there are sub-types of PDE4).

Biogen’s patent for DMF does mention neuropathy and I can say that a much lower dose than they suggest, it can be effective, (based on n=1 trial).

The problems with DMF

I think the main problem with the drug form of DMF is the price.  The active form of DMF, which is called MMF, is also being developed as a drug.

It is suggested that MMF will have less GI side effects than MMF, in part because you would need a lower dose.

DMF needs to be taken in an enteric capsule/coating and with food, or you may get quite extreme GI side effects.

I think low dose DMF (5-10mg) has great potential to treat minor chronic inflammatory conditions.   

The MS dosage of Tecfidera/DMF is usually 240mg twice a day and this brings in $1 billion a year to Biogen.  As usual it us far more expensive in the US than in Europe.

DMF as a chemical is extremely cheap.  You may even find a sachet of DMF inside your old sofa.

Immunomodulation vs Immunosuppression

Even people with an “over-active” immune system get sick and so any therapy to damp down an excessive immune response has to avoid suppressing the immune system.  Ideally you would just modulate the immune system to put it where it should have always been.

Immunomodulation is something that a clever immunologist may be able to help you with, but it is still an emerging area of medicine.


Effects of dimethyl fumarate on neuroprotection and immunomodulation


Background

Neuronal degeneration in multiple sclerosis has been linked to oxidative stress. Dimethyl fumarate is a promising novel oral therapeutic option shown to reduce disease activity and progression in patients with relapsing-remitting multiple sclerosis. These effects are presumed to originate from a combination of immunomodulatory and neuroprotective mechanisms. We aimed to clarify whether neuroprotective concentrations of dimethyl fumarate have immunomodulatory effects.

Findings

We determined time- and concentration-dependent effects of dimethyl fumarate and its metabolite monomethyl fumarate on viability in a model of endogenous neuronal oxidative stress and clarified the mechanism of action by quantitating cellular glutathione content and recycling, nuclear translocation of transcription factors, and the expression of antioxidant genes. We compared this with changes in the cytokine profiles released by stimulated splenocytes measured by ELISPOT technology and analyzed the interactions between neuronal and immune cells and neuronal function and viability in cell death assays and multi-electrode arrays. Our observations show that dimethyl fumarate causes short-lived oxidative stress, which leads to increased levels and nuclear localization of the transcription factor nuclear factor erythroid 2-related factor 2 and a subsequent increase in glutathione synthesis and recycling in neuronal cells. Concentrations that were cytoprotective in neuronal cells had no negative effects on viability of splenocytes but suppressed the production of proinflammatory cytokines in cultures from C57BL/6 and SJL mice and had no effects on neuronal activity in multi-electrode arrays.

Conclusions

These results suggest that immunomodulatory concentrations of dimethyl fumarate can reduce oxidative stress without altering neuronal network activity.

DMF protection involves glutathione recycling

DMF increased the mRNA abundance of various genes involved in the antioxidant response in HT22 cells including the enzymes glutamate-cysteine ligase (GCLC), NQO1, and peroxiredoxin 1, as well as the system Χc- subunit xCT while glutathione S-transferase 1 and heme-oxygenase 1 were downregulated. In primary cortical cultures, only xCT and NQO1 were upregulated by DMF (Figure 2A). We then asked whether inhibition of the function of the most upregulated transcripts, xCT and GCLC with S4-CPG and buthionine sulfoximine (BSO), respectively, abolished the protective activity of DMF. However, DMF was capable of protecting against both compounds (Figure 2B). DMF was also still able to raise glutathione levels when GCLC was inhibited or when system Χc- activity was abrogated by incubation in cysteine-free medium (Figure 2C). Therefore, DMF can still exert protection in neuronal cells when de novo glutathione synthesis is blocked, suggesting that it enhances glutathione recycling.
Our main finding is that DMF at low concentrations protects neuronal cells from oxidative stress by elevating cellular glutathione, and that similar concentrations also reduce production of proinflammatory cytokines from splenocytes. In our experiments, DMF protection needed less time to develop than protection induced by MMF. The induction of the antioxidant response leading to glutathione synthesis seems to be the consequence of an initial and short-lived oxidative stress, since DMF decreased the glutathione content immediately after its addition to the cells. Most likely DMF as an unsaturated carboxylic acid ester initially binds and sequesters glutathione. The long-term effect of DMF in neuronal cells is most probably mediated via Nrf2 as other reported mechanisms such as the inhibition of the nuclear translocation of NF-κB were not evident in these cells and because the increase in GSH synthesis was abolished in cells lacking Nrf2.
In summary, our findings demonstrate that DMF at low concentrations exerts protective effects on neuronal cells and diminishes the production of TNF-α, IL-2, and IL-17 in splenocytes from C57BL/6 mice and the production of all cytokines measured in splenocytes from SJL mice. Although higher concentrations of DMF can cause cell death of primary splenocytes, this is probably not necessary for its immunomodulatory effect. These observations might be relevant for understanding the drug’s presumed mechanism of action as we assume that the active metabolite MMF has similar effects that merely need a longer time to develop.
Here, we first investigated the concentration and time dependence of DMF-mediated protection in neuronal cells using a model of endogenous oxidative stress, oxidative glutamate toxicity, where extracellular glutamate blocks the glutamate-cystine antiporter system Χc-. This leads to deprivation of cystine and its reduced form cysteine, the rate-limiting substrate for the synthesis of glutathione. The subsequent glutathione depletion gives rise to the accumulation of reactive oxygen species and cell death by oxidative stress (recently reviewed [13]). We show herein that neuroprotective concentrations of DMF suppress cytokine production by splenocytes from two different mouse strains without effecting apoptosis and do not impact neuronal network activity studied with dissociated cortical cultures grown on multi-electrode arrays [14] which allows a highly sensitive and reproducible assessment of network activity. Our results suggest that low doses of DMF may promote cellular resistance against oxidative stress and cause immunomodulation independent of T cell apoptosis or alterations in endogenous brain activity.                                                     
Patent for Low Dose DMF
Below is an excerpt from one of Biogen’s patents for DMF.

They are talking about 400mg a day as a low dose, whereas I am talking about a dose of 5-10mg for chronic low-level inflammation.

Pharmaceutical composition containing dimethylfumarate for administration at a low daily dose

Abstract

The present invention relates to pharmaceutical compositions containing dimethyl fumarate (DMF), More specifically, the present invention relates to a pharmaceutical composition for oral use in treating hyperproliferative, inflammatory or autoimmune disorders by administering a low daily dosage in the range of 410 mg±5% or 400 mg±5% dimethyl fumarate, wherein the pharmaceutical formulation is in the form of an erosion matrix tablet.

0044]
The pharmaceutical composition according to any one of the above aspects is for use in the treatment of psoriasis (including moderate to severe plaque psoriasis), psoriatic arthritis, neurodermatitis, inflammatory bowel disease, such as Crohn's disease and ulcerative colitis, polyarthritis, multiple sclerosis including relapsing—remitting multiple sclerosis (MS including RR-MS and progressive MS), juvenile-onset diabetes mellitus, Hashimoto's thyroiditis, Grave's disease, SLE (systemic lupus erythematosus), Cutaneous Lupus Erythematosus, Sjögren's syndrome, Pernicious anemia, Chronic active (lupoid) hepatitis, Rheumatoid arthritis (RA), lupus nephritis, myasthenia gravis, uveitis, refractory uveitis, vernal conjunctivitis, pemphigus vulgaris, scleroderma, optic neuritis, malignant melanoma, alopecia areata, cutaneous sarcoidosis, pain such as radicular pain, pain associated with radiculopathy, neuropathic pain or sciatica/sciatic pain, organ transplantation (prevention of rejection), sarcoidosis, necrobiosis lipoidica or granuloma annulare.

Dimethyl fumarate treatment induces adaptive and innate immune modulation independent of Nrf2

Significance

Dimethyl fumarate (DMF) (BG-12, Tecfidera), a fumaric acid ester (FAE), is a commonly prescribed oral therapy for multiple sclerosis (MS), a CNS autoimmune inflammatory demyelinating disease that may result in sustained neurologic damage. It is thought that the benefit of DMF in MS therapy is mediated through activation of the antioxidative transcription factor nuclear factor (erythroid-derived 2)-like 2 (Nrf2) pathway. However, the role of Nrf2 in the antiinflammatory effects of DMF has not been fully elucidated. Here, we investigated the role of Nrf2 in DMF treatment of the MS model, experimental autoimmune encephalomyelitis (EAE), and demonstrated DMF can modulate T cells, B cells, and antigen-presenting cells, and reduce clinical and histologic EAE, independent of Nrf2.

Dimethyl fumarate (DMF) (BG-12, Tecfidera) is a fumaric acid ester (FAE) that was advanced as a multiple sclerosis (MS) therapy largely for potential neuroprotection as it was recognized that FAEs are capable of activating the antioxidative transcription factor nuclear factor (erythroid-derived 2)-like 2 (Nrf2) pathway. However, DMF treatment in randomized controlled MS trials was associated with marked reductions in relapse rate and development of active brain MRI lesions, measures considered to reflect CNS inflammation. Here, we investigated the anti-inflammatory contribution of Nrf2 in DMF treatment of the MS model, experimental autoimmune encephalomyelitis (EAE). C57BL/6 wild-type (WT) and Nrf2-deficient (Nrf2−/−) mice were immunized with myelin oligodendrocyte glycoprotein (MOG) peptide 35–55 (p35–55) for EAE induction and treated with oral DMF or vehicle daily. DMF protected WT and Nrf2−/− mice equally well from development of clinical and histologic EAE. The beneficial effect of DMF treatment in Nrf2−/− and WT mice was accompanied by reduced frequencies of IFN-γ and IL-17–producing CD4+ cells and induction of anti-inflammatory M2 (type II) monocytes. DMF also modulated B-cell MHC II expression and reduced the incidence of clinical disease in a B-cell–dependent model of spontaneous CNS autoimmunity. Our observations that oral DMF treatment promoted immune modulation and provided equal clinical benefit in acute EAE in Nrf2−/− and WT mice, suggest that the anti-inflammatory activity of DMF in treatment of MS patients may occur through alternative pathways, independent of Nrf2.

 

DMF probably has multiple therapeutic targets. In this regard, MMF is a potent agonist of the hydroxycarboxylic acid receptor 2 (HCAR2) (GPR109A). It was also observed that HCAR2 deficiency prevented the beneficial effects of DMF treatment in acute EAE in mice, suggesting that HCAR2 may, indeed, be a principal target in DMF therapy of EAE. Our results in this report, highlighting the importance of the Nrf2-independent immunologic and clinical effects of DMF, are complementary with studies that identified HCAR2 as a potential target for DMF. However, the clinical and immunologic effects of DMF treatment of EAE were not completely inhibited by HCAR2 deficiency, indicating that HCAR2 is not the sole target of DMF therapy. One should recognize that the therapeutic response to DMF in MS is dose dependent, and it is possible that individual targets may vary in their sensitivity to different levels of MMF exposure. In this study, the plasma MMF levels obtained in DMF treatment of mice were severalfold higher than those in healthy volunteers treated with DMF doses used in MS. Of interest, when DMF was administered in vivo at a higher dose than was used in either our investigation of Nrf2-deficient mice or the study that evaluated HCAR2-deficient mice, it was observed that a majority of genes induced in spleen cells by DMF treatment were Nrf2 dependent. Thus, in vivo DMF treatment likely mediates its effects through activation of both Nrf2 and HCAR2, and possibly additional targets. Just as MMF covalently attaches to cysteine 151 of Keap1, it also conjugates to other Keap1 cysteine residues and may therefore also modify other cysteine-containing proteins involved in immune regulation. Our results in this report should stimulate exploration for additional potential targets of DMF therapy.

 

DMF/MMF for Parkinson’s Disease?

I found it interesting that the Parkinson’s researchers took a different view of the potential of DMF and its metabolite MMF. They see the merit in using the active substance, the metabolite MMF, as the drug and in doing so reduce the potential for GI side effects.

In the Parkinson’s reality they seek to develop MMF as a drug.

This may well also have something to do with patents and the intellectual property held by Biogen. 

 

Metaboliteof multiple sclerosis drug could be safe, effective therapy for Parkinson's disease


The metabolite of a drug that is helping patients battle multiple sclerosis appears to significantly slow the onset of Parkinson's disease, researchers say.
The oral drug, dimethyl fumarate, or DMF, and its metabolite, monomethylfumarate, or MMF, both increase activity of Nrf2, a protein that helps protect the body from oxidative stress and inflammation, hallmarks of both diseases, said Rd. Bobby Thomas, neuroscientist in the Department of Pharmacology and Toxicology at the Medical College of Georgia at Augusta University.
But the new study provides the first evidence that the metabolite, which is essentially the active portion of the parent drug, more directly targets Nrf2, potentially reducing known side effects of the parent drug that include flushing, diarrhoea, nausea, vomiting, abdominal pain and the brain infection encephalopathy, said Thomas, corresponding author of the study in The Journal of Neuroscience.
Particularly, the gastrointestinal side effects can exacerbate some problems patients with Parkinson's already experience, said Dr. John Morgan, neurologist, neuroscientist and Parkinson's disease specialist in the MCG Department of Neurology. In addition to destroying neurons in the brain that produce dopamine, a neurotransmitter that enables movement and learning, Parkinson's causes nerve cell death in the gastrointestinal tract and related problems such as severe constipation.
"Nrf2 is a natural protective mechanism we have for oxidative stress," Thomas said. The fact that multiple sclerosis and Parkinson's have in common evidence of declining activity of the Nrf2 pathway has generated interest in the drug for Parkinson's and other neurodegenerative diseases.
DMF was approved for multiple sclerosis three years ago by the Food and Drug Administration. While its metabolite MMF is not quite as potent as the parent drug in increasing Nrf2 activity, the new study indicates that its action is sufficient to dramatically slow the loss of dopamine-producing neurons as well as the parent drug, in an animal model of Parkinson's.
In their model, mice given the neurotoxin MPTP experience a dramatic loss of dopamine-producing neurons, losing about half within a handful of days, and rapidly develop Parkinson's-like symptoms. Patients, on the other hand, slowly develop symptoms over many years. By the time they seek medical care, patients may have lost 30-50 percent of their dopaminergic neurons, said Morgan, a study coauthor. "Presentation is after the disease is kind of out of the gate."
To accommodate the very compressed timeline in their model and the fact that several daily doses are needed before the drug starts to work, the researchers first gave the mice either the drug or metabolite the day before they started the toxin.
Dopamine-producing neurons are located in a darker-pigmented central portion of the brain called the substantia nigra. Even in the absence of disease, making dopamine is a stressful job for these neurons that makes them generally more fragile and actually results in oxidative stress even in a healthy scenario, Morgan said. To make a difficult situation worse, increased oxidative stress can make dopamine toxic to neurons, he said.
To increase Nrf2 activity, the parent drug DMF also appears to first make bad matters worse. DMF increases oxidative stress by depleting the natural antioxidant, glutathione, and reduces the power of cell powerhouses, called mitochondria, by limiting their ability to use oxygen and glucose to make energy leading to reduced viability of dopamine-producing cells, Thomas said.
The metabolite MMF appears to more directly activate Nrf2, and actually increases glutathione and improves mitochondrial function, brain cell studies showed. While the parent drug ultimately produces a higher Nrf2 activation, the researchers found the MMF effect was sufficient to stop the dramatic neuron loss in the animal model.
Both DMF and MMF slowed neuron loss to a more normal level, and the neurons that survived continued to make dopamine. Inflammation and oxidative stress levels also were significantly reduced, the researchers said.
As a next step, they are working toward a clinical trial of MMF in patients with early Parkinson's disease. Although the metabolite could be easily formulated for humans, it has not yet been done, Thomas notes.

 

Repurposing the NRF2Activator Dimethyl Fumarate as Therapy Against Synucleinopathy in Parkinson's Disease

Aims: This preclinical study was aimed at determining whether pharmacological targeting of transcription factor NRF2, a master controller of many homeostatic genes, might provide a disease-modifying therapy in the animal model of Parkinson's disease (PD) that best reproduces the main hallmark of this pathology, that is, α-synucleinopathy, and associated events, including nigral dopaminergic cell death, oxidative stress, and neuroinflammation. Results: Pharmacological activation of NRF2 was achieved at the basal ganglia by repurposing dimethyl fumarate (DMF), a drug already in use for the treatment of multiple sclerosis. Daily oral gavage of DMF protected nigral dopaminergic neurons against α-SYN toxicity and decreased astrocytosis and microgliosis after 1, 3, and 8 weeks from stereotaxic delivery to the ventral midbrain of recombinant adeno-associated viral vector expressing human α-synuclein. This protective effect was not observed in Nrf2-knockout mice. In vitro studies indicated that this neuroprotective effect was correlated with altered regulation of autophagy markers SQTSM1/p62 and LC3 in MN9D, BV2, and IMA 2.1 and with a shift in microglial dynamics toward a less pro-inflammatory and a more wound-healing phenotype. In postmortem samples of PD patients, the cytoprotective proteins associated with NRF2 expression, NQO1 and p62, were partly sequestered in Lewy bodies, suggesting impaired neuroprotective capacity of the NRF2 signature. Innovation: These experiments provide a compelling rationale for targeting NRF2 with DMF as a therapeutic strategy to reinforce endogenous brain defense mechanisms against PD-associated synucleinopathy. Conclusion: DMF is ready for clinical validation in PDAntioxid. Redox Signal. 25, 61–77.
The global results of this study are presented in an idealized graph in Supplementary Figure S6. It is predicted that overexpression of human α-SYN leads to a rapid, less than 3-week, intoxication of nigrostriatal dopaminergic neurons of Nrf2+/+ and Nrf2−/− mice. This injury is slightly higher in the Nrf2−/− mice (Fig. 3). In parallel to neuron intoxication, we find microglial activation that will elicit an inflammatory response and remove neuronal debris but will cease once α-SYN intoxicated neurons have disappeared. Microglial activation will be lower in DMF-treated Nrf2+/+ mice, because they exhibit less neuron damage (Figs. 5 and 3, respectively). Astrocytes are activated in parallel to neuronal intoxication but contrary to the microglia, they remain detectable after the phase of injury, creating a scar in the damaged tissue (Fig. 4). The astroglial scar is smaller in the DMF-treated mice, because the death of dopaminergic neurons was attenuated by this drug. Further work may be required for obtaining a fine analysis of the participation of DMF and NRF2 in prevention of proteinopathy, but from a clinical perspective, DMF is now ready for clinical analysis for the treatment of PD.


SUPPLEMENTARY FIG. S6. DMF effects on PD mouse model. Diagram of the molecular events triggered by a-SYN and the protective way of action of DMF through NRF2 activation. PD, Parkinson’s disease.
Biogen, maker of Tecfidera, dismissed its lawsuit against Banner in September 2018, in which Biogen claimed that monomethyl fumarate would infringe on patents 7,320,999 and 8,399,514 related to Tecfidera. The FDA’s final approval of monomethyl fumarate is expected once Biogen’s current patent no. 7,619,001 for dimethyl fumarate expires on June 20, 2020.  
A key feature offered by monomethyl fumarate is its lower dose when compared to dimethyl fumarate. Whether a lower dose of a different application of this class of drug will result in fewer side effects is yet to be explored in a clinical trial.  


Immunometabolism as therapeutic target


Dimethyl fumarate (DMF) is an immunomodulatory compound used to treat multiple sclerosis and psoriasis whose mechanisms of action remain only partially understood. Kornberg et al. found that DMF and its metabolite, monomethyl fumarate, succinate the glycolytic enzyme GAPDH (see the Perspective by Matsushita and Pearce). After DMF treatment, GAPDH was inactivated, and aerobic glycolysis was down-regulated in both myeloid and lymphoid cells. This resulted in down-modulated immune responses because inflammatory immune-cell subsets require aerobic glycolysis. Thus, metabolism can serve as a viable therapeutic target in autoimmune disease.
Activated immune cells undergo a metabolic switch to aerobic glycolysis akin to the Warburg effect, thereby presenting a potential therapeutic target in autoimmune disease. Dimethyl fumarate (DMF), a derivative of the Krebs cycle intermediate fumarate, is an immunomodulatory drug used to treat multiple sclerosis and psoriasis. Although its therapeutic mechanism remains uncertain, DMF covalently modifies cysteine residues in a process termed succination. We found that DMF succinates and inactivates the catalytic cysteine of the glycolytic enzyme glyceraldehyde 3-phosphate dehydrogenase (GAPDH) in mice and humans, both in vitro and in vivo. It thereby down-regulates aerobic glycolysis in activated myeloid and lymphoid cells, which mediates its anti-inflammatory effects. Our results provide mechanistic insight into immune modulation by DMF and represent a proof of concept that aerobic glycolysis is a therapeutic target in autoimmunity.
  

Dimethylfumarate inhibits microglial and astrocyticinflammation by suppressing the synthesis of nitric oxide, IL-1β, TNF-α andIL-6 in an in-vitro model of brain inflammation

Background
Brain inflammation plays a central role in multiple sclerosis (MS). Dimethyl fumarate (DMF), the main ingredient of an oral formulation of fumaric acid esters with proven therapeutic efficacy in psoriasis, has recently been found to ameliorate the course of relapsing-remitting MS. Glial cells are the effector cells of neuroinflammation; however, little is known of the effect of DMF on microglia and astrocytes. The purpose of this study was to use an established in vitro model of brain inflammation to determine if DMF modulates the release of neurotoxic molecules from microglia and astrocytes, thus inhibiting glial inflammation.

Methods

Primary microglial and astrocytic cell cultures were prepared from cerebral cortices of neonatal rats. The control cells were treated with LPS, an accepted inducer of pro-inflammatory properties in glial cells, and the experimental groups with LPS and DMF in different concentrations. After stimulation/incubation, the generation of nitric oxide (NO) in the cell culture supernatants was determined by measuring nitrite accumulation in the medium using Griess reagent. After 6 hours of treatment RT-PCR was used to determine transcription levels of iNOS, IL-1β, IL-6 and TNF-α mRNA in microglial and astrocytic cell cultures initially treated with DMF, followed after 30 min by LPS treatment. Moreover, we investigated possible involvement of the ERK and Nrf-2 transduction pathway in microglia using western blot analysis.

Results

Pre-treatment with DMF decreased synthesis of the proinflammatory mediators iNOS, TNF-α, IL-1β and IL-6 at the RNA level in activated microglia and astrocytes in vitro, associated with a decrease in ERK phosphorylation in microglia.

Conclusions

Collectively, these results suggest that the neuroprotective effects of DMF may be in part functionally attributable to the compound's ability to inhibit expression of multiple neuroinflammatory mediators in brain of MS patients.


Systemic inflammation is associated with increased cognitive decline and risk for Alzheimer’s disease. Microglia (MG) activated during systemic inflammation can cause exaggerated neuroinflammatory responses and trigger progressive neurodegeneration. Dimethyl fumarate (DMF) is an FDA-approved therapy for multiple sclerosis. The immunomodulatory and anti-oxidant properties of DMF prompted us to investigate whether DMF has translational potential for the treatment of cognitive impairment associated with systemic inflammation.

Methods

Primary murine MG cultures were stimulated with lipopolysaccharide (LPS) in the absence or presence of DMF. MG cultured from nuclear factor (erythroid-derived 2)-like 2-deficient (Nrf2 −/−) mice were used to examine mechanisms of DMF actions. Conditioned media generated from LPS-primed MG were used to treat hippocampal neuron cultures. Adult C57BL/6 and Nrf2 −/− mice were subjected to peripheral LPS challenge. Acute neuroinflammation, long-term memory function, and reactive astrogliosis were examined to assess therapeutic effects of DMF.

Results

DMF suppressed inflammatory activation of MG induced by LPS. DMF suppressed NF-κB activity through Nrf2-depedent and Nrf2-independent mechanisms in MG. DMF treatment reduced MG-mediated toxicity towards neurons. DMF suppressed brain-derived inflammatory cytokines in mice following peripheral LPS challenge. The suppressive effect of DMF on neuroinflammation was blunted in Nrf2 −/− mice. Importantly, DMF treatment alleviated long-term memory deficits and sustained reactive astrogliosis induced by peripheral LPS challenge. DMF might mitigate neurotoxic astrocytes associated with neuroinflammation.

Conclusions

DMF treatment might protect neurons against toxic microenvironments produced by reactive MG and astrocytes associated with systemic inflammation.

Emerging Understanding of the Mechanism of Action for Dimethyl Fumarate in the Treatment of Multiple Sclerosis

Dimethyl Fumarate Attenuates Neuroinflammation and Neurobehavioral Deficits Induced by Experimental Traumatic Brain Injury


Traumatic brain injury (TBI) is a serious neuropathology that causes secondary injury mechanisms, including dynamic interplay between ischemic, inflammatory, and cytotoxic processes. Fumaric acid esters (FAEs) showed beneficial effects in pre-clinical models of neuroinflammation and toxic oxidative stress, so the aim of the present work was to evaluate the potential beneficial effects of dimethyl fumarate (DMF), the most pharmacologically effective molecules among the FAEs, in a mouse model of TBI induced by controlled cortical impact (CCI). Mice were administered DMF orally at the doses of 1, 10, and 30 mg/kg 1 h and 4 h after CCI. We performed histological, molecular, and immunohistochemistry analysis on the traumatic penumbral areas of the brain 24 h after CCI. DMF treatment notably reduced histological damage and behavioral impairments, reducing neurodegeneration as evidenced by assessments of neuronal loss, Fluoro-Jade C, and TUNEL staining; also, treatment with DMF blocked the apoptosis process increasing B-cell lymphoma 2 (Bcl-2) expression in injured cortex. Further, DMF treatment up-regulated antioxidant Kelch-like ECH-associated protein 1/nuclear factor erythroid 2-related factor pathway, inducing activation of manganese superoxide dismutase and heme-oxygenase-1 and reducing 4-hydroxy-2-nonenal staining. Also, regulating the NF-κB pathway, DMF treatment decreased the severity of inflammation through a modulation of neuronal nitric oxide synthase, interleukin 1, tumor necrosis factor, cyclooxygenase 2, and myeloperoxidase activity, reducing ionized calcium-binding adapter molecule 1 and glial fibrillary acidic protein expression. Our results support the thesis that DMF may be an effective neuroprotectant after brain trauma and warrants further study.


Dimethyl fumarate alters microglia phenotype and protects neurons against proinflammatory toxic microenvironments


Highlights

·         Pharmacokinetic study provides evidence for direct brain exposure of dimethyl fumarates (DMF).
·         DMF, but not monomethyl fumarate (the primary metabolite of DMF) significantly decreases proinflammatory cytokine/chemokine and nitric oxide levels in classically activated microglia culture.
·         The inhibitory effect of DMF on cytokine is NRF2-independent.
·         DMF reduces the toxicity of classically activated microglia towards primary naïve neurons.

Abstract

Delayed-release dimethyl fumarate (DMF) is an approved treatment for multiple sclerosis (MS). Microglia are considered central to MS pathophysiology, however the effects of DMF and the primary metabolite monomethyl fumarate (MMF) on microglia are not well characterized. We demonstrated that DMF and MMF altered transcriptional responses in primary microglia related to the nuclear factor (erythroid-derived 2)-like 2 pathway. Additionally, through an NRF2 independent manner, DMF, but not MMF significantly reduced production of proinflammatory mediators in classically activated microglia, and further rescued mitochondrial respiratory deficits in primary cortical neurons that were induced by activated microglia. These data suggest the mechanism of action of DMF may involve modulation of microglia inflammatory responses and attenuation of neurotoxicity.






Dimethylfumarate inhibits NF-κB function at multiple levels to limit airway smooth muscle cell cytokine secretion


The antipsoriatic dimethylfumarate (DMF) has been anecdotically reported to reduce asthma symptoms and to improve quality of life of asthma patients. DMF decreases the expression of proinflammatory mediators by inhibiting the transcription factor NF-κB and might therefore be of interest for the therapy of inflammatory lung diseases. In this study, we determined the effect of DMF on platelet-derived growth factor (PDGF)-BB- and TNFα-induced asthma-relevant cytokines and NF-κB activation by primary human asthmatic and nonasthmatic airway smooth muscle cells (ASMC). Confluent nonasthmatic and asthmatic ASMC were incubated with DMF (0.1–100 μM) and/or dexamethasone (0.0001–0.1 μM), NF-κB p65 siRNA (100 nM), the NF-κB inhibitor helenalin (1 μM) before stimulation with PDGF-BB or TNFα (10 ng/ml). Cytokine release was measured by ELISA. NF-κB, mitogen and stress-activated kinase (MSK-1), and CREB activation was determined by immunoblotting and EMSA. TNFα-induced eotaxin, RANTES, and IL-6 as well as PDGF-BB-induced IL-6 expression was inhibited by DMF and by dexamethasone from asthmatic and nonasthmatic ASMC, but the combination of both drugs showed no glucocorticoid sparing effect in either of the two groups. NF-κB p65 siRNA and/or the NF-κB inhibitor helenalin reduced PDGF-BB- and TNFα-induced cytokine expression, suggesting the involvement of NF-κB signaling. DMF inhibited TNFα-induced NF-κB p65 phosphorylation, NF-κB nuclear entry, and NF-κB-DNA complex formation, whereas PDGF-BB appeared not to activate NF-κB within 60 min. Both stimuli induced the phosphorylation of MSK-1, NF-κB p65 at Ser276, and CREB, and all were inhibited by DMF. These data suggest that DMF downregulates cytokine secretion not only by inhibiting NF-κB but a wider range of NF-κB-linked signaling proteins, which may explain its potential beneficial effect in asthma. 

Dimethyl Fumarate Reduces Inflammatory Responses in Experimental Colitis


Background and Aims:
Fumaric acid esters have been proven to be effective for the systemic treatment of psoriasis and multiple sclerosis. We aimed to develop a new treatment for colitis.

Methods:
We investigated the effect of dimethylfumarate [DMF, 10-30-100mg/kg] on an experimental model of colitis induced by dinitrobenzene sulphuric acid [DNBS]. We also evaluated the therapeutic activity of 7 weeks’ treatment with DMF [30mg/kg] on 9-week-old IL-10KO mice that spontaneously develop a T helper-1 [Th1]-dependent chronic enterocolitis after birth, that is fully established at 8–10 weeks of age. The mechanism of this pharmacological potential of DMF [10 μM] was investigated in colonic epithelial cell monolayers [Caco-2] exposed to H 2 O 2 . The barrier function was evaluated by the tight junction proteins.
Results:
The treatment with DMF significantly reduced the degree of haemorrhagic diarrhoea and weight loss caused by administration of DNBS. DMF [30 and 100mg/kg] also caused a substantial reduction in the degree of colon injury, in the rise in myeloperoxidase [MPO] activity, and in the increase in tumour necrosis factor [TNF]-α expression, as well as in the up-regulation of ICAM-1 caused by DNBS in the colon. Molecular studies demonstrated that DMF impaired NF-κB signalling via reduced p65 nuclear translocalisation. DMF induced a stronger antioxidant response as evidenced by a higher expression of Mn-superoxide dismutase. Moreover, DMF protected human intestinal epithelial cells against H 2 O 2 -induced barrier dysfunction, restoring ZO-1 occludin expression, via the HO-1 pathway.
Conclusions:
DMF treatment reduces the degree of colitis caused by DNBS. We propose that DMF treatment may be useful in the treatment of inflammatory bowel disease.


Dimethyl fumarate treatment induces adaptive and innate immune modulation independent of Nrf2 

Significance 

Dimethyl fumarate (DMF) (BG-12, Tecfidera), a fumaric acid ester (FAE), is a commonly prescribed oral therapy for multiple sclerosis (MS), a CNS autoimmune inflammatory demyelinating disease that may result in sustained neurologic damage. It is thought that the benefit of DMF in MS therapy is mediated through activation of the antioxidative transcription factor nuclear factor (erythroid-derived 2)-like 2 (Nrf2) pathway. However, the role of Nrf2 in the antiinflammatory effects of DMF has not been fully elucidated. Here, we investigated the role of Nrf2 in DMF treatment of the MS model, experimental autoimmune encephalomyelitis (EAE), and demonstrated DMF can modulate T cells, B cells, and antigen-presenting cells, and reduce clinical and histologic EAE, independent of Nrf2.

Abstract

Dimethyl fumarate (DMF) (BG-12, Tecfidera) is a fumaric acid ester (FAE) that was advanced as a multiple sclerosis (MS) therapy largely for potential neuroprotection as it was recognized that FAEs are capable of activating the antioxidative transcription factor nuclear factor (erythroid-derived 2)-like 2 (Nrf2) pathway. However, DMF treatment in randomized controlled MS trials was associated with marked reductions in relapse rate and development of active brain MRI lesions, measures considered to reflect CNS inflammation. Here, we investigated the antiinflammatory contribution of Nrf2 in DMF treatment of the MS model, experimental autoimmune encephalomyelitis (EAE). C57BL/6 wild-type (WT) and Nrf2-deficient (Nrf2−/−) mice were immunized with myelin oligodendrocyte glycoprotein (MOG) peptide 35–55 (p35–55) for EAE induction and treated with oral DMF or vehicle daily. DMF protected WT and Nrf2−/− mice equally well from development of clinical and histologic EAE. The beneficial effect of DMF treatment in Nrf2−/− and WT mice was accompanied by reduced frequencies of IFN-γ and IL-17–producing CD4+ cells and induction of antiinflammatory M2 (type II) monocytes. DMF also modulated B-cell MHC II expression and reduced the incidence of clinical disease in a B-cell–dependent model of spontaneous CNS autoimmunity. Our observations that oral DMF treatment promoted immune modulation and provided equal clinical benefit in acute EAE in Nrf2−/− and WT mice, suggest that the antiinflammatory activity of DMF in treatment of MS patients may occur through alternative pathways, independent of Nrf2.

Control of Oxidative Stress and Inflammation in Sickle Cell Disease with the Nrf2 Activator Dimethyl Fumarate


Aims: Heme derived from hemolysis is pro-oxidative and proinflammatory and promotes vaso-occlusion in murine models of sickle cell disease (SCD), suggesting that enhanced detoxification of heme may be beneficial. Nuclear factor erythroid-2-related factor-2 (Nrf2) transcription pathway is the principal cellular defense system responding to pro-oxidative and proinflammatory stress. Dimethyl fumarate (DMF), a drug approved for treatment of multiple sclerosis, provides neuroprotection by activating Nrf2-responsive genes. We hypothesized that induction of Nrf2 with DMF would be beneficial in murine SCD models. Results: DMF (30 mg/kg/day) or vehicle (0.08% methyl cellulose) was administered for 3-7 days to NY1DD and HbSS-Townes SCD mice. Vaso-occlusion, a hallmark of SCD, measured in sickle mice with dorsal skinfold chambers, was inhibited by DMF. The inhibitory effect of DMF was abrogated by the heme oxygenase-1 (HO-1) inhibitor tin protoporphyrin. DMF increased nuclear Nrf2 and cellular mRNA of Nrf2-responsive genes in livers and kidneys. DMF increased heme defenses, including HO-1, haptoglobin, hemopexin, and ferritin heavy chain, although plasma hemoglobin and heme levels were unchanged. DMF decreased markers of inflammation, including nuclear factor-kappa B phospho-p65, adhesion molecules, and toll-like receptor 4. DMF administered for 24 weeks to HbSS-Townes mice decreased hepatic necrosis, inflammatory cytokines, and irregularly shaped erythrocytes and increased hemoglobin F, but did not alter hematocrits, reticulocyte counts, lactate dehydrogenase, plasma heme, or spleen weights, indicating that the beneficial effects of DMF were not attributable to decreased hemolysis. Innovation: These studies identify Nrf2 activation as a new therapeutic target for the treatment of SCD. Conclusion: DMF activates Nrf2, enhances antioxidant defenses, and inhibits inflammation and vaso-occlusion in SCD mice. 


Dimethyl fumarate treatment after traumatic brain injury prevents depletion of antioxidative brain glutathione and confers neuroprotection.

 

Abstract

Dimethyl fumarate (DMF) is an immunomodulatory compound to treat multiple sclerosis and psoriasis with neuroprotective potential. Its mechanism of action involves activation of the antioxidant pathway regulator Nuclear factor erythroid 2-related factor 2 thereby increasing synthesis of the cellular antioxidant glutathione (GSH). The objective of this study was to investigate whether post-traumatic DMF treatment is beneficial after experimental traumatic brain injury (TBI). Adult C57Bl/6 mice were subjected to controlled cortical impact followed by oral administration of DMF (80 mg/kg body weight) or vehicle at 3, 24, 48, and 72 h after the inflicted TBI. At 4 days after lesion (dal), DMF-treated mice displayed less neurological deficits than vehicle-treated mice and reduced histopathological brain damage. At the same time, the TBI-evoked depletion of brain GSH was prevented by DMF treatment. However, nuclear factor erythroid 2-related factor 2 target gene mRNA expression involved in antioxidant and detoxifying pathways was increased in both treatment groups at 4 dal. Blood brain barrier leakage, as assessed by immunoglobulin G extravasation, inflammatory marker mRNA expression, and CD45+ leukocyte infiltration into the perilesional brain tissue was induced by TBI but not significantly altered by DMF treatment. Collectively, our data demonstrate that post-traumatic DMF treatment improves neurological outcome and reduces brain tissue loss in a clinically relevant model of TBI. Our findings suggest that DMF treatment confers neuroprotection after TBI via preservation of brain GSH levels rather than by modulating neuroinflammation.


Emerging Understanding of the Mechanism of Action for Dimethyl Fumarate in the Treatment of Multiple Sclerosis


Dimethyl fumarate (DMF) is an effective treatment option for relapsing–remitting multiple sclerosis (MS), but its therapeutic mechanism of action has not been fully elucidated. A better understanding of its mechanism will allow for the development of assays to monitor its clinical efficacy and safety in patients, as well as guide the development of the next generation of therapies for MS. In order to build the foundation for determining its mechanism, we reviewed the manner in which DMF alters lymphocyte subsets in MS patients, its impact on clinical efficacy and safety, as well as its molecular effects in cellular and animal models. DMF decreases absolute lymphocyte counts, but does not affect all subsets uniformly. CD8+ T-cells are the most profoundly affected, but reduction also occurs in the CD4+ population, particularly within the pro-inflammatory T-helper Th1 and Th17 subsets, creating a bias toward more anti-inflammatory Th2 and regulatory subsets. Similarly, B-lymphocyte, myeloid, and natural killer populations are also shifted toward a more anti-inflammatory stateIn vitro and animal models demonstrate a role for DMF within the central nervous system (CNS) in promoting neuronal survival in an Nrf2 pathway-dependent manner. However, the impact of DMF directly within the CNS of MS patients remains largely unknown.


Conclusion

I think DMF and MMF could have wide application in numerous inflammatory conditions and at much lower doses that those envisaged by Biogen.

No very low dose versions are produced as drugs, the lowest is the 30mg “starter” version for psoriasis. It is not cheap. This tablet can of course be subdivided and placed into enteric capsules to give whatever dose is required and taken after a large meal. Enteric capsules will not dissolve in the gastric acids of the stomach (pH ~3), but they will in the alkaline (pH 7–9) environment present in the small intestine. DMF is an irritant to the stomach and your skin.

Do some of the big-time responders to BHB salts and esters also respond to a tiny dose of DMF? My feeling is that some will.  

It looks like anyone who has oxidative stress and neuroinflammation might potentially benefit and that is most of "autism".  In our case all that is left of allergy-triggered summertime raging/SIB is some anxiety; increasing the NKCC1 blocking with a second daily dose improves cognition but may have a side effect of increasing this anxiety. I was recently asked to fix it. This anxiety disappears with 5mg of DMF, with no side effects. 

There has also been an increase in speech, somewhat reminiscent of what happened several years ago when starting sulforaphane/broccoli sprouts. Sulforaphane and DMF both activate Nrf-2, which functions like an antioxidant switch. The effect of sulforaphane/broccoli sprouts does fade.  

More speech in our case does not mean the social "chit-chat", which you might hope for, but it nonetheless is speech. I was just talking to Monty's assistant about this subject. She is working on developing more conversational speech during some of the free time at school. When your goal is conversational speech you may totally ignore the new speech the student does produce - better to engage in whatever subject he actually does want to "talk" about and build from there.

BHB does have multiple potentially helpful-to-autism modes of action, but so does DMF.

DMF accelerates wound healing, but only in diabetics (this is observed, but not fully understood). Diabetics do suffer foot ulcers that often lead to amputations, so DMF would have a very obvious application.

Neuralgia is a chronic problem affecting many people, DMF may well be an effective new therapy.

It looks like activating the Nrf-2 pathway should protect brains affected by Parkinson’s and maybe these researchers will push for DMF/MMF to get approved.  I do not think anyone has thought of using DMF to treat COPD (severe asthma).  I am glad that at least one paper does mention the potential to use DMF to reduce inflammation in Alzheimer’s.

I think some people with irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD) would very likely respond and MMF is the obvious choice, so as to avoid the GI side effects of DMF.

Even though it is usually stated that DMF is a prodrug while MMF is the active substance, it is clear that this is an over simplification. The effects of DMF and MMF are slightly different.  The effect on GSH (the antioxidant Glutathione) levels is very different, because GSH is consumed in the chemical transition from DMF to MMF, so in the short-term oxidative stress increases if you take DMF.  Perhaps people taking large doses of DMF for Multiple Sclerosis should indeed take NAC to avoid GSH being depleted and also be told not to take Paracetamol for pain (since it further depletes GSH).

For the time being the only commercial product available is DMF.  

Low dose DMF placed in an enteric capsule and taken after a main meal appears to have no GI side effects. It does indeed have an immunomodulatory effect even at a tiny dose of 5 to 8 mg.  Low dose DMF taken without an enteric capsule does have GI effects that you would rather avoid.  I looked up patient feedback from those taking the 100 time higher psoriasis dose of DMF and many report an awful time for the first 2-3 months, before things settle down.

DMF does cause dose dependent side effects. This is why doses far lower than envisaged by Biogen are interesting, if they do actually have a genuine clinical effect in that person. The daily dose for psoriasis is 720 mg. DMF/MMF crosses the blood brain barrier very easily.


DMF, at high psoriasis doses, has been widely used in Germany for many years.

As with many things mentioned in this blog, realistically I doubt much will be made of DMF/MMF in the near future beyond Multiple Sclerosis (MS) and Psoriasis; this is a shame, but not really a surprise.  It does get added to my list of options to modulate the immune system in autism.

·        Cheap NSAIDs, like Ibuprofen
·        The  cheap leukotriene receptor antagonist, Montelukast/Singulair
·        The Japanese PDE4 inhibitor Ibudilast (has less GI side effects than the Western drug Daxas/Roflumilast)
·        TSO parasites
·        Statins
·        Beta-lactam antibiotics, like Penicillin
·        Macrolide antibiotics, like Azithromycin
·        Biogaia Gastrus probiotic
·        PEA (Palmitoylethanolamide) or alternatively CBD (Cannabidiol)
·        The ketone BHB (beta hydroxybutyrate)
·        Lenalidomide (an ultra-expensive drug)
·        5mg DMF (Dimethyl Fumarate) taken in an enteric capsule just after a large meal


All of the above would raise eyebrows as autism therapies, but perhaps less so if you use the term autoimmune encephalopathy.  

The thing to bear in mind is that all the above immuno-modulating therapies have the potential to cause a negative reaction.  You have to match the therapy to the specific immune dysfunction, if indeed there is one at all. Hopefully the field of immunology will move forward and not leave you to ponder these issues yourself. 

I will pursue DMF further.






Thursday 5 September 2019

Cannabis Use and Potential Epigenetic Damage to Autism Genes


Today we consider another risk factor that may be contributing to the increase in prevalence of autism and it is about the father, for a change.  In the public's perception cannabis is a safe alternative way to treat all kinds of medical problems, many experts do not agree.




Fathers who use marijuana may be using it for two, suggests a study from Duke Medical Center. Although the study is small, encompassing just 24 men and 15 rats, it highlights a potential transgenerational effect of marijuana exposure—the passing on of sperm in which an autism-associated gene, DLGAP2, has accumulated extra epigenetic marks.
The Duke scientists, led by Susan Murphy, PhD, associate professor of obstetrics and gynecology, identified significant hypomethylation at DLGAP2 in the sperm of men who used marijuana compared to controls. A similar observation was made in the sperm of rats exposed to tetrahydrocannabinol (THC) compared to controls. This hypomethylated state was also detected in the forebrain region of rats born to fathers exposed to THC.
Murphy and colleagues said their findings do not establish a definitive link between cannabis use and autism, but the possible connection warrants further, urgent study, given efforts throughout the country to legalize marijuana for recreational and/or medicinal uses.
This study is the first to demonstrate an association between a man’s cannabis use and changes of a gene in sperm that has been implicated in autism,” she emphasized. “Given marijuana’s increasing prevalence of use in the United States and the increasing numbers of states that have legalized its use, we need more studies to understand how this drug is affecting not only those who smoke it, but their unborn children.
“There’s a perception that marijuana is benign. More studies are needed to determine whether that is true.”
The original paper:-

Parental cannabis use has been associated with adverse neurodevelopmental outcomes in offspring, but how such phenotypes are transmitted is largely unknown. Using reduced representation bisulphite sequencing (RRBS), we recently demonstrated that cannabis use is associated with widespread DNA methylation changes in human and rat sperm. Discs-Large Associated Protein 2 (DLGAP2), involved in synapse organization, neuronal signaling, and strongly implicated in autism, exhibited significant hypomethylation (p < 0.05) at 17 CpG sites in human sperm. We successfully validated the differential methylation present in DLGAP2 for nine CpG sites located in intron seven (p < 0.05) using quantitative bisulphite pyrosequencing. Intron 7 DNA methylation and DLGAP2 expression in human conceptal brain tissue were inversely correlated (p < 0.01). Adult male rats exposed to delta-9-tetrahydrocannabinol (THC) showed differential DNA methylation at Dlgap2 in sperm (p < 0.03), as did the nucleus accumbens of rats whose fathers were exposed to THC prior to conception (p < 0.05). Altogether, these results warrant further investigation into the effects of preconception cannabis use in males and the potential effects on subsequent generations.


Conclusion

I do not think anyone should be surprised that the THC in cannabis may leave an epigenetic tag on the DNA of the user and that it is passed down to following generations. We saw a long time ago that the same applies to people who smoke. It is just a question of which genes are most affected.  In the case of smoking it affected how your body deals with oxidative stress and this blocked how drugs for severe asthma (COPD) should work, so making COPD a very big problem for ex-smokers. Stopping smoking does not make the problem go away.

Any kind of prolonged chemical exposure may be a problem, the lead that was used in gasoline/petrol, current use of potent pesticides etc.  The same applies to electrical/magnetic exposure. Best not to live very close to high voltage power lines, or have a mobile phone mast on top of your building.

The concern is that these epigenetic markers are heritable and so accumulate over the generations, a kind of epigenetic pollution.

If great great grandpa worked down a coal mine or in a chemical factory, it may be recorded in your DNA.





Friday 30 August 2019

Cesarian Delivery and Autism – another inconvenient truth?


Brasil is the C-section capital of the world, with rates in the public sector of 35–45%, and 80–90% in the private sector.

A recent study from the Karolinska Institute in Sweden, analysing 61 previous studies, has again shown a connection between birth by Cesarian Section and an increased risk of autism or indeed ADHD. 

C-sections account for just 16% of births in Sweden, but 32% in North America.

This of course prompted a reaction to reassure future mothers that they have nothing to fear, from experts in obstetrics who of course know nothing about the etiology of autism.  Mothers should be reassured, but trashing the study helps nobody.  Instead of a 1% risk of non-trivial autism, it rises to 1.3%. You still have more than a 98% chance of having a neurotypical child, all other factors being equal.  Without a medically necessary C-section, death is a real possibility.

It was a couple of years ago that the Karolinska Institute highlighted the fact that those with severe autism currently have a life expectancy of under 40 years.  Another inconvenient truth.


Association of Cesarean Delivery With Risk of Neurodevelopmental and Psychiatric Disorders in the Offspring 

Question  Is birth by cesarean delivery associated with an increased risk of neurodevelopmental and psychiatric disorders in the offspring compared with birth by vaginal delivery?
Findings  In this systematic review and meta-analysis of 61 studies comprising more than 20 million deliveries, birth by cesarean delivery was significantly associated with autism spectrum disorder and attention-deficit/hyperactivity disorder.
Meaning  The findings suggest that understanding the potential mechanisms behind these associations is important, especially given the increase in cesarean delivery rates for nonmedical reasons.
Abstract
Importance  Birth by cesarean delivery is increasing globally, particularly cesarean deliveries without medical indication. Children born via cesarean delivery may have an increased risk of negative health outcomes, but the evidence for psychiatric disorders is incomplete. 
Conclusions and Relevance  The findings suggest that cesarean delivery births are associated with an increased risk of autism spectrum disorder and attention-deficit/hyperactivity disorder, irrespective of cesarean delivery modality, compared with vaginal delivery. Future studies on the mechanisms behind these associations appear to be warranted. 
Very many things are known to slightly increase the odds of a person having autism and the more risk factors you have the more severely autistic you may be.  This ranges from maternal stress (anything from experiencing a hurricane, work stress, life trauma) to maternal/paternal age, obesity, gestational diabetes, alcohol/drug abuse, illness during pregnancy etc. This combines with whatever is in the parents’ DNA and random mutations that are bound to occur.    

A more rational reaction might be to investigate further why there might be a link and how you could counter any risk to children born by cesarian section.  You only have to read the existing research, or this blog.

There are 2 very good reasons why there should be a link between autism and C section, both have been covered in this blog.

1.     The microbiome comes from the mother. Science is only recently starting to understand the role of bacteria in health, but we know that it plays a key role in conditioning/calibrating the immune system of babies.  Once the immune system has been calibrated it is set for life.  Early exposure to bacteria is necessary and humans evolved to expect it.  If your immune system is over/under sensitive there will be consequences. Birth via C-section avoids exposure to bacteria in the birth canal, unless the newly arrived baby is “seeded” with bacteria from the mother. Mother’s milk is another key source of transferring the mother’s microbiome to the baby. 

2.     We saw that the birthing hormone Oxytocin plays a key role in triggering the “GABA switch” in new-borns. This is the process which transforms immature neurons with high chloride to mature neurons with low chloride shortly after birth.  During natural birth there is a surge in the hormone Oxytocin that is transferred to the baby, this causes the chloride transporter KCC2 to be further expressed and the “opposing” transporter NKCC1 to fade away.  In many people with severe autism their neurons remain in the immature state their entire life.  Just as you can replace the bacteria transfer lost in birth via C-section, there would be absolutely no reason why you could not replicate the surge in Oxytocin to "flip the GABA switch".

The recent study showed that elective C-sections (where the baby is in perfect health and not distressed) are associated with the elevated risk of both Autism and ASD.

Regular readers of this blog would probably be surprised if C-section did not increase autism prevalence.

The important thing is to acknowledge this likely connection and mitigate it, rather than try and fault the numerous studies that have shown the same effect.

The same of course applies to reducing the very small risk from vaccines, rather than construct new studies in a contrived way to show there is zero risk.   If you can safely and cheaply reduce the risk of a negative reaction to vaccines, why wouldn’t you?  Just follow Johns Hopkins example and give Ibuprofen or Montelukast (Singular) for a few days before and after and remember to never give Paracetamol/Acetaminophen (Tylenol) in response to fever after a vaccine. Paracetamol/ Acetaminophen reduces the body’s key antioxidant GSH just when the baby/child may need its neuroprotection most.

Some conditions are associated with preterm births, a good example is Cerebral Palsy (CP), which is twice as common in babies born very early. CP is rarely genetic and is usually considered to be caused by a complication during pregnancy, birth or shortly thereafter. I think you would find a correlation between C-sections and CP, but in this case I doubt you would find it in elective C-sections.   In other words C-sections do not “cause” CP, but they may be associated with it. The ID/MR often found in CP might be elevated by C-section and, if so, would be treatable.


Conclusion

In order to halt the rise in incidence of the disabling kinds of autism there should be steps taken to reduce some of the very many factors that are driving the increase, albeit each one sometimes by a tiny amount.

This would be a good application of all those thousands of autism research papers, many of which have shown what factors contribute to increased risk, that now sit gathering dust.

We are not at the stage of wide scale gene editing, but many simple steps can be taken today to improve future health.  This does not mean do not vaccinate, or avoid medically necessary C-sections; vaccinations and C-sections have saved millions of lives. But, why would you not want to take a good thing and make it even better?  That is what we humans tend to be good at, like the Swedes and their Volvos.

Perhaps take your C-section with a generous smear of Mum's bacteria and a shot of synthetic oxytocin?  

There will be more on Cerebral Palsy in a later post on D-NAC (Dendrimer N-Acetyl Cysteine). 

                                                               



Thursday 22 August 2019

Bumetanide 5mg for Parkinson’s Disease?



I have been asked twice about off-label therapies for Parkinson’s, both times I mentioned Bumetanide, but having rechecked the literature, there is now plenty of supporting data, enough that a clinical trial has now been put in motion in France.

Parkinson’s disease is all about a lack of dopamine and bumetanide is all about making GABA work as inhibitory. You might wonder why is Peter suggesting people to talk to their doctor about giving their elderly parents a diuretic. Well the lack of dopamine goes on to cause a GABA dysfunction, which is treatable and does improve the symptoms of Parkinson’s.

So, Bumetanide will not cure Parkinson’s, but may reduce its severity.

In the case of the last person who asked me, her mother already takes a diuretic for other reasons, so all she would have to do is to switch drugs to Bumetanide. The doctor was only too happy, when given the evidence, to switch her to Bumetanide - a rare victory for common sense. 

What caught my attention was the dosage of Bumetanide used in the published case histories and the concern about polyuria. Polyuria is too much urination. The dose used was 5mg taken all in one go and that is a lot; you would have to run to the bathroom, which might cause falls in people with poor balance.

Since we recently discovered that Azosemide has the same effect on GABA as Bumetanide, but can have a less urgent effect as a diuretic, it may be that Azosemide is a better choice for Grandma with Parkinson’s.  Incontinence can be a feature of Parkinson’s disease.  The ideal drug will be the new one being developed by Neurochloré for autism.


Standard Parkinson’s Drugs

Since most symptoms of Parkinson’s disease (PD) are caused by a lack of dopamine in the brain, many PD drugs are aimed at either temporarily replenishing dopamine or mimicking the action of dopamine. These types of drugs are called dopaminergic medications. They generally help reduce muscle rigidity, improve speed and coordination of movement and lessen tremor.

L-DOPA, the standard treatment for Parkinson’s is actually also used in some people with autism, in particular people with Angelman Syndrome, although it failed in a clinical trial.


Bumetanide for Parkinson’s?

The clinical trial for Parkinson’s will use the standard rating scale (UPDRS) that is very much centered on motor skills. There is a tiny part on memory.

Cognition is affected in Parkinson’s and this might be another area that improves with Bumetanide; but someone has to bother to measure it.

Nobody has measured the effect of Bumetanide on IQ in those with autism, even though the effect can be substantial.

                                  


Four patients suffering from idiopathic PD at the stage of motor fluctuation were included. All of them gave their written informed consent to receive open-label bumetanide. Bumetanide was progressively titrated up to 3 mg/d (once daily) received for a month. After having verified the good tolerability of the treatment, bumetanide was increased to 5 mg/d (once daily) and received for another month. Bumetanide was added to the patient's usual antiparkinsonian treatment that was maintained stable the month before and unchanged during the study. The patients were assessed before and at 1 and 2 months after the initiation of bumetanide.
At each visit, the patient was asked about any side effects having occurred since the last visit. A Unified Parkinson's Disease Rating Scale (UPDRS)19 was performed before and after 2 months of treatment in a practical OFF stage (the patients came in the afternoon, having not taken antiparkinsonian drugs for 4 hours, and confirmed to be in an OFF stage). At the end of the study, the patient was also asked to give a global impression of change compared with baseline.

Case 3

The patient was a 58-year-old man with a 21-year history of
PD. After early development of disabling motor fluctuation and dyskinesia despite an optimized drug treatment, bilateral subthalamic electrodes were implanted 16 years ago for continuous deep brain stimulation (DBS). He got an excellent control of PD motor symptoms. However, after a year of DBS treatment, he started to develop freezing of gait and dysarthria. Despite many attempts of adjusting the treatment (DBS parameters, changes in drug treatment, and physiotherapy), these symptoms remained disabling and even slowly worsened with time. Motor fluctuation and dyskinesia were well controlled by both DBS (left side: case positive, electrode 2 negative, voltage 3.5 V; right side: case positive, electrode 1 negative, voltage 3 V; for both sides: pulse width 60 microseconds, frequency 100 Hz) and drug treatment. The latter consisted of L-DOPA, 1000 mg/d (5 intakes per day); ropinirole, 2 mg/d; and amantadine, 200 mg/d. The freezing of gait was highly disabling.

At home, the patient could walk a few steps alone with a high risk of falls. Most of the time, he was wheelchair bound. After a few days of bumetanide at a dosage of 5 mg/d, the gait dramatically improved. He was able to walk almost 1000 m without any help.

The voice was unchanged. The UPDRS III in the OFF stage was hardly changed (10% improvement), and the UPDRS II in the worst state improved by 15%. The UPDRS II in the best condition was unchanged (21 to 18). The patient and the caregiver assessed the general improvement at 50%. Despite the polyuria and the fatigue, he has decided to continue the bumetanide treatment.
After a few weeks, the improvement of gait was less dramatic but still noticeable.


GABAergic inhibition in dual-transmission cholinergic and GABAergic striatal interneurons is abolished in Parkinson disease 

We report that half striatal cholinergic interneurons are dual transmitter cholinergic and GABAergic interneurons (CGINs) expressing ChAT, GAD65, Lhx7, and Lhx6 mRNAs, labeled with GAD and VGAT, generating monosynaptic dual cholinergic/GABAergic currents and an inhibitory pause response. Dopamine deprivation increases CGINs ongoing activity and abolishes GABAergic inhibition including the cortico-striatal pause because of high [Cl]i levels. Dopamine deprivation also dramatically increases CGINs dendritic arbors and monosynaptic interconnections probability, suggesting the formation of a dense CGINs network. The NKCC1 chloride importer antagonist bumetanide, which reduces [Cl]ilevels, restores GABAergic inhibition, the cortico-striatal pause-rebound response, and attenuates motor effects of dopamine deprivation. Therefore, most of the striatal cholinergic excitatory drive is balanced by a concomitant powerful GABAergic inhibition that is impaired by dopamine deprivation. The attenuation by bumetanide of cardinal features of Parkinson’s disease paves the way to a novel therapeutic strategy based on a restoration of low [Cl]i levels and GABAergic inhibition.



Official Title:
A Randomized Double-blind Placebo-controlled Multicenter Proof-of-concept Trial to Assess the Efficacy and Safety of Bumetanide in Parkinson's Disease
Actual Study Start Date  :
April 26, 2019
Estimated Primary Completion Date  :
September 2020
Estimated Study Completion Date  :
August 2021



Conclusion

There is now a long list of neurological conditions that may respond to bumetanide:-

·        Autism
·        Fragile-X Syndrome
·        Down Syndrome
·        Schizophrenia
·        Huntington’s Disease
·        Parkinson’s Disease

In addition, it is obvious that some epilepsy will respond to Bumetanide. The original epilepsy drug from 150 years ago, KBr, has the same mechanism of action, lowering chloride within neurons.

Perhaps higher doses of Bumetanide need to be trialled in autism, 5mg all at once is far higher than what has been used so far in studies.




Thursday 15 August 2019

Wandering, Water, Sense of Danger and Accidents


We were recently at the seaside in Greece, where Monty was enjoying swimming in the sea. He is now a very competent swimmer and behaves in the water just like any other confident swimmer. Together with Mum he actually rescued a Russian swimmer in distress.  Monty does not get crazy ideas to swim to islands in the distance, or anything like that. Not so far, at least. 

Water is behind a shocking number of wanderings and deaths.

In the North American media, you can see that on a very regular basis children with autism and/or ID/MR (Intellectual Disability/Mental Retardation) wander off and get lost. Very often they are found in or beside water.

In Europe you hear much less frequently about children wandering. A high-profile case recently was an Irish teenage girl with MR/ID who disappeared while on holiday at a tiny jungle resort in Malaysia.  She left behind an open ground floor window and was found 10 days later beside a stream in a ravine a mile away. 

She had holoprosencephaly, which is an umbrella term for conditions relating to when the forebrain of the embryo fails to develop into two separate hemispheres, it includes Agenesis of the Corpus Callosum (ACC) when the part of the brain that is supposed to connect the two hemispheres fails to develop. Partial ACC and the exact opposite are features appearing in some severe autism.

People with MR/ID have no sense of danger and are usually enchanted by water. Wandering is far more likely than abduction.

Another case recently was an American teenager on a cruise arranged by his residential care home, it appears that he jumped over the deck railing at night to go for a swim in the ocean.

Even a bath tub can be dangerous, a young man with autism and epilepsy was left unattended in a bath at a UK care facility. He had a seizure and drowned.

I do think much more could be done to prevent wandering and water-related accidents. Firstly, people (parents) should be made more aware of who is at risk; anyone with a low IQ and unable to travel independently is at risk.

People with ID/MR often live in a world of cartoons, where all kinds of crazy things are possible, like jumping off a cruise ship and nobody ever gets hurt.  Going to a jungle retreat, like you are living in the Jungle Book cartoon, why wouldn’t you sneak downstairs in the night and enter your private jungle world?

Just because you have never been able to wander before does not mean you never will. 

The shortened life expectancy of people with severe autism is in large part down to preventable accidents, seizures and poor basic healthcare.

I do think that treating MR/ID would be much more socially acceptable than treating autism. Understanding the danger of crossing a road, or falling into a lake is more important than being able to tie your shoe laces.  If you can improve cognition with a pill, who could possibly object to that? 

It is no surprise that we have www.Treatable-ID.org but no www.Treatable-ASD.org 

In reality you will struggle to have treating ID taken seriously, although for many people it is possible.