Thursday 29 January 2015

Cinnamon and DJ-1 as a general Anti-Oxidant and perhaps Much More

I am shortly going to introduce a complicated sounding substance called DAAO (D-amino acid oxidase) to this blog.  DAAO seems to be important in some types of autism, most schizophrenia and bipolar.  This will take us back to Cinnamon and Sodium Benzoate that were discussed in earlier posts.

The connection to UCLA will come at the end of the post.  UCLA is home to the Lovaas Model of Applied Behavior Analysis (ABA), but this post is all about biochemistry.  Before the internet existed,  I used to use one of their libraries for some research.

Prior to DAAO, I just want to make the case again for the medical effects of Cinnamon in typical people.

Accepted medical wisdom is that there is currently no proof of any benefit from Cinnamon.  Cinnamon does have known and quantifiable anti-oxidant properties in vitro, but research has shown that what happens in vivo can be quite different.  The whole idea of the ORAC scale, which measures the relative power of antioxidants, has lost credibility and is no longer used by “serious science”.

In an earlier post we saw a study that showed in both people with type 2 diabetes and the control group, cholesterol and fasting glucose levels were reduced by cinnamon.  This implied an increase in insulin sensitivity (and reduction in insulin resistance).
I also found numerous people posting their before and after cinnamon blood test results, confirming this benefit.

However, there were other studies showing no effect on fasting glucose levels and insulin sensitivity, which looked odd.

Why does this matter?

I am trying to establish that one effect of cinnamon comes from being metabolized to sodium benzoate (“benzoate”).  Benzoate then upregulates production of a protein called DJ-1.  DJ-1 was discovered by researchers looking at Parkinson’s Disease.  DJ-1 is known to have anti-oxidant properties, both directly and in support of a clever substance called Nrf-2.  Nrf-2 is released by the body when it senses an oxidative attack and its job is to switch on the body’s anti-oxidant genes.  But Nrf-2 cannot do this without some help from DJ-1; if DJ-1 is lacking, the key genes stay switched off.

One well established effect of Sulforaphane (from broccoli) is that it activates the production of Nrf-2.  This seems to account for the anti-oxidant and chemo-protective effects.

One reader of this blog confirmed the increase in insulin sensitivity produced by Sulforaphane from broccoli.  For the doctors among you, 2.5ml of broccoli powder had 25% of the effect of 600 mg of Alpha lipoic acid (ALA).  600mg of ALA reduced the insulin requirement by 25%.

In some people they lack DJ-1.  This raises their risk of Parkinson’s Disease, likely also COPD and I suggested possibly Autism and any other condition associated with oxidative stress.

Then I came across a trial of sodium benzoate in schizophrenia:-

We know that a characteristic of anti-oxidants, in varying degrees, is that they also reduce cholesterol and increase insulin sensitivity.

So we should expect that eating cinnamon would quickly cause sodium benzoate to be produced, causing an up-regulation in DJ-1.  The first effect should be a reduction in oxidative stress and then an increase in insulin sensitivity and a reduction in fasting glucose levels. Reduced oxidative stress will affect the lipid metabolism and lower cholesterol.

Some clinical trials last for 12 weeks, some even longer, but many are shorter.  In the following cinnamon trial, blood parameters were measured at week 0, week 6 and week 12.

They happened to test people who were overweight (so at higher risk of developing type 2 diabetes), but I think it would apply to everyone.

They choose to measure several markers of oxidative stress, as well as fasting glucose and plasma insulin levels.
Therefore, this work was designed to investigate in people that are overweight or obese, with impaired fasting glycemia, the effects of a twelve week supplementation of the dried aqueous extract of cinnamon on oxidative stress markers including plasma malondialdehyde (MDA) levels, plasma thiol (SH) group oxidation, FRAP (Ferric Reducing Activity Plasma), antioxidant erythrocyte enzyme activities as superoxide dismutase (Cu-Zn SOD) and glutathione peroxidase (GPx), and the possible correlation with fasting glucose and plasma insulin levels.

The interesting thing is that while by week 6 the oxidative 3 of the 4 markers of oxidative stress were changing, glucose levels had not.

So if the trial had ended at week 6 we would conclude that cinnamon does not increase insulin sensitivity.

But all changed by the end of week 12, fasting glucose had gone down and fasting insulin had gone up.

This study did not measure cholesterol.  If it had done, we would have expected triglicerides down, LDL (bad) cholesterol down and HDL cholesterol increased.

Since cinnamon is a non standardized natural product, this might explain why in some studies the beneficial effects take longer to become established.

Cinnamon as a DAAO inhibitor

In the next post we will look at D-amino acid oxidase (known as DAAO and also DAO, OXDA, DAMOX).

DAAO is interesting because it is known to be elevated by a factor of two in the brains of people with schizophrenia.  The underlying gene is a probable susceptibility gene for schizophrenia and also bipolar disorder.  DAAO gene polymorphisms were found in boys with autism spectrum disorders in in Korea.

Risperidone and sodium benzoate are the well-known inhibitors of DAAO, but there are others.  Risperidone is an anti-psychotic drug approved for use in schizophrenia, bipolar and autism.  The usually claimed modes of action are that as a dopamine antagonist it possesses anti-serotonergic, anti-adrenergic and anti-histaminergic properties.

This will bring us back to the potential of cinnamon in autism/schizophrenia and whether the mode of action is antioxidant, DAAO inhibitor or both.  If it is just as an antioxidant, does it confer any additional benefit over NAC + Sulforaphane ?  I am interested to find out whether Nrf-2 will be more effective, with the increase in DJ-1; if you were deficient in DJ-1 this should be the case.

DJ-1 produced by cinnamon is one antioxidant, but there clearly are others since no DJ-1 would be produced by cinnamon in vitro.

DAAO inhibitors may produce allergic reactions in people with histamine intolerance.

This might explain one of the warnings for Risperidone:-

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Patent Search

I did a quick patent search to see if anybody else thinks that sodium benzoate might be useful in autism and related conditions.  Here is a small sample of the many patents.  In some cases benzoate is used to increase the effectiveness of other ingredients and others it is the claimed active ingredient.

In the UCLA patent below they combine a D-amino Acid Oxidase Inhibitor (DAAOI), a NMDA enhancer and a Glycine transporter inhibitor.

A method of treating autism in a patient. The method includes administering to the patient an effective amount of a glutamine level reducing agent, a glycine level reducing agent or combinations thereof. Representative glutamine level reducing agents are phenylbutyrate and phenylacetate, and a representative glycine level reducing agent is sodium benzoate. Optionally, an N-methyl-D-aspartate receptor antagonist can also be administered to the patient. A representative N-methyl-D-aspartate receptor antagonist is dextromethorphan.

The invention provides methods for treating neuropsychiatric disorders such as schizophrenia, Alzheimer's Disease, autism, depression, benign forgetfulness, childhood learning disorders, close head injury, and attention deficit disorder. The methods entail administering to a patient diagnosed as having a neuropsychiatric disorder or as at risk for a neuropsychiatric disorder administering to a D-amino Acid Oxidase Inhibitor (DAAOI); in conjunction with an NMDA enhancer and/or a glycine transporter inhibitor.

The invention describes novel methods for treating and preventing dementia caused by vascular diseases; dementia associated with Parkinson's disease; Lewy Body dementia; AIDS dementia; mild cognitive impairments; age-associated memory impairments; cognitive impairments and/or dementia associated with neurologic and/or psychiatric conditions, including epilepsy, brain tumors, brain lesions, multiple sclerosis, Down's syndrome, Rett's syndrome, progressive supranuclear palsy, frontal lobe syndrome, and schizophrenia and related psychiatric disorders; cognitive impairments caused by traumatic brain injury, post coronary artery by-pass graft surgery, electroconvulsive shock therapy, and chemotherapy, administering a therapeutically effective amount of at least one of the cholinesterase inhibitor compounds described herein. The invention also describes novel methods for treating and preventing delirium, Tourette's syndrome, myasthenia gravis, attention deficit hyperactivity disorder, autism, dyslexia, mania, depression, apathy, and myopathy associated with diabetes by administering a therapeutically effective amount of at least one of the cholinesterase inhibitor compounds described herein. The invention also describes novel methods for delaying the onset of Alzheimer's disease, for enhancing cognitive functions, for treating and preventing sleep apnea, for alleviating tobacco withdrawal syndrome, and for treating the dysfunctions of Huntington's Disease by administering a therapeutically effective amount of at least one of the cholinesterase inhibitor compounds described herein. A preferred cholinesterase inhibitor for use in the methods of the invention is donepezil hydrochloride or ARICEPT®. The invention also provides orally administrable liquid dosage formulations comprising cholinesterase inhibitor compounds, such as ARICEPT®.




Methods and compositions are provided for treating neuropsychiatric disorders such as schizophrenia, depression, attention deficit disorder, mild cognitive impairment, dementia, and bipolar disorder. The methods entail administering to a patient diagnosed as having a neuropsychiatric disorder (e.g., schizophrenia, depression, attention deficit disorder, mild cognitive impairment, dementia bipolar disorder, etc.) or as at risk for a neuropsychiatric disorder a benzoic acid, benzoic acid salt, and/or benzoic acid derivative, and/or a sorbic acid, sorbic acid salt, and/or sorbic acid derivative, in combination with a neuropharmacological agent (e.g., an antipsychotic, an antidepressant, medications for attention deficit and hyperactivity disorder, cognitive impairment, or dementia, etc.) where the benzoic acid, benzoic acid salt, or benzoic acid derivative, and/or a sorbic acid, sorbic acid salt, and/or sorbic acid derivative, is in an amount sufficient to increase the efficacy of the neuropharmacological agent.

[0062] Without being bound to a particular theory, it is believed that the DAAOI enhances the levels of both D-serine and D-alanine which are agonists of NMDA receptor and have been shown by the inventor to be beneficial for patients with schizophrenia and other disorders. It can help a wide variety of patients with cognitive impairment and other mental or behavioral symptoms. The combination therapies boost the NMDA and/or neuropharmaceutical activity and benefit subjects more than single agent treatments (e.g., antipsychotic drug, antidepressant, anxiolytic, mood stabilizer, psychotropic medication for attention deficit and hyperactivity disorder, drug for dementia, and the like).

[0063] Accordingly, in certain preferred embodiments, "combination" therapies are contemplated, where the subjects are administered a benzoic acid, a benzoic acid salt, a benzoic acid ester, or another benzoic acid derivative, and/or a sorbic acid, a sorbic acid salt, sorbic acid ester, or another sorbic acid derivative, in conjunction with a neuropharmaceutical (e.g., a therapeutic agent selected from the group consisting of an antipsychotic, an antidepressant, a phsychostimulant, a mood stabilizer, an anxiolytic, an Alzheimer's disease therapeutic, and/or other psychotropic for the treatment of a neuropsychiatric disorder).

[0072] In certain embodiments the combination formulation for the treatment of schizophrenia, bipolar disorder, and the like comprises a combination of benzoic acid, benzoic acid salt, benzoic acid ester, or other benzoic acid derivative, and/or sorbic acid, sorbic acid salt, sorbic acid ester, or other sorbic acid derivative and an antipsychotic drug. Suitable antipsychotic drugs include, but are not limited to the antipsychotic drugs described above.
[0073] In certain embodiments the combination formulation for the treatment of schizophrenia, bipolar disorder, and the like comprises a combination of depression, panic disorder, social phobial, GAD, and the like comprises a combination of benzoic acid, benzoic acid salt, benzoic acid ester, or other benzoic acid derivative, and/or sorbic acid, sorbic acid salt, sorbic acid ester, or other sorbic acid derivative and an antidepressant and/or mood stabilizer. Suitable antidepressants and mood stabilizers include, but are not limited to the antidepressants and mood stabilizers described above. [0074] In certain embodiments the combination formulation for the treatment of
ADD and/or ADHD, and the like comprises a combination of benzoic acid, benzoic acid salt, benzoic acid ester, or other benzoic acid derivative, and/or sorbic acid, sorbic acid salt, sorbic acid ester, or other sorbic acid derivative and an agent for the treatment of ADD and/or ADHD. Suitable agents for the treatment of ADD and/or ADHD include, but are not limited to the agents for the treatment of ADD and/or ADHD described above.

[0076] Typically, in various embodiments, the benzoic acid, benzoic acid salt, or derivative thereof (e.g., a benzoate), and/or sorbic acid, a sorbic acid salt, or a derivative thereof, is present in an amount sufficient to enhance therapeutic efficacy of the neuropharmaceutical rather than as a preservative, and/or melting point lowering agent, and/or stabilizer, and/or a lubricant, and/or a stabilizer, etc. In effect, the benzoic acid, benzoic acid salt, or derivative thereof, and/or sorbic acid, sorbic acid salt, or a derivative thereof, is an active agent. Thus, in various embodiments the benzoic acid, benzoic acid salt, benzoic acid ester, or other benzoic acid derivative, and/or sorbic acid, sorbic acid salt, sorbic acid ester, or other sorbic acid derivative, is not substantially present as an acid addition salt of the neuropharmaceutical (or at least the majority of the benzoic or sorbic acid or derivative thereof) is not present as an acid salt addition salt of the neuropharmaceutical.. Similarly, in certain embodiments the benzoic acid, benzoic acid salt, benzoic acid ester, or other benzoic acid derivative, and/or sorbic acid, sorbic acid salt, sorbic acid ester, or other sorbic acid derivative, (or at least the majority of the benzoic or sorbic acid or derivative thereof) is not present as a co-crystal of the neuropharmaceutical.

The various treatment strategies described herein can be applied to most if not all of them including, for example, learning disorder, attention deficit and hyperactivity disorder, schizophrenia, bipolar disorder, depression, Alzheimer's Disease, autism, benign forgetfulness, close head injury, dementia, mild cognitive impairment, ataxia, spinocerebellar degeneration, Parkinson's disease, obsessive compulsive disorder (OCD), phobia, social phobia, generalized anxiety disorder (GAD), panic disorder, substance abuse, and substance dependence. In addition to their benefits for human subjects, the treatments described herein can be used in veterinary applications (e.g., to canines, felines, equines, bovines, porcines, etc.) with treatment of household pets (e.g., canine, feline) being of considerable interest. In addition, the combination treatments described herein can improve cognition in animal models of learning and model of schizophrenia, depression, anxiety, and the like. [0080] In certain embodiments the treatment methods of the invention entail administering to a subject in need thereof (e.g., a patient diagnosed as having or at risk for a neuropsychiatric disorder) one or more a pharmaceutical compositions containing a therapeutically effective amount(s) of (i) an NMDA (N-methyl-D-aspartate)-Enhancer, and/or (ii) a glycine transporter inhibitor, and/or (iii) a D-amino Acid Oxidase Inhibitor (DAAOI). Where combinations of two or all three of these agents are utilized they can be administered separately (simultaneously or sequentially), in a single "combination" formulation, or in simultaneously or sequentially a combination formulation comprising two agents and a second formulation comprising a single agent. [0081] The effective doses of the active agent(s) (of an NMDA (N-methyl-D- aspartate) -Enhancer, and/or Glycine Transporter Inhibitor, and/or D-amino Acid Oxidase Inhibitor (DAAOI)) can vary, depending upon factors such as the condition of the patient, the severity of the symptoms of the disorder, and the manner in which the pharmaceutical composition is administered. In various embodiments, for human patients, the effective unit dose of typical compounds include: DAAOI (e.g., benzoate, range of 50 mg-150 grams), NMDA enhancers (D-serine, range of 50 mg-50 grams; D-alanine, range 1-150 grams), glycine transporter inhibitor (for example: sarcone, range 50 mg-50 grams); including DAAOI+NMDA enhancer, DAAOI+glycine transporter inhibitor, NMDA enhancers +glycine transporter inhibitor or three classes of compound together. [0082] In various embodiments, then, effective doses of each of the active agent(s) ranges from 1 mg, 10 mg, 50 mg, 100 mg, 250 mg, or 500 mg, 300 g, 20Og, 150 g, 100 g, 50 g, 25 g, 1Og, 5 g, or 1 g depending of factors including, but not limited to 150 g. In certain embodiments the compounds and compositions of the present invention can be administered to a patient at dosage levels in the range of about 0.1 to about 1,000 mg per day. For a normal human adult having a body weight of about 70 kilograms, it is estimated that a dosage in the range of about 0.01 to about 100 mg per kilogram of body weight per day is sufficient. The specific dosage used, however, can vary. For example, the dosage can depend on a numbers of factors including the requirements of the patient, the severity of the condition being treated, and the pharmacological activity of the compound being used. The determination of optimum dosages for a particular patient is well-known to those skilled in the art. The amount of active ingredient(s) that may be combined with the carrier materials to produce a single dosage form will vary depending upon the host treated and the particular mode of administration. It will be understood, however, that the specific dose level for any particular patient will depend upon a variety of factors including the activity of the specific compound(s) employed, the age, body weight, general health, sex, diet, time of administration, route of administration, and rate of excretion, drug combination and the severity of the particular disease undergoing therapy.


[0117] In the most accepted animal model of schizophrenia, which tests the sensory gating, we found that combination treatment improve the startle habituation and PPI significantly more than the individual agent alone. . The effect of benzoate was close to combination treatment in habituation.


I have convinced myself of the merits of Cinnamon  (the Cinnamomum verum variety, not the “cassia” variety) for typical people. 

I have been testing it myself for a month and then I will measure the effect.

For people with neurological conditions, it does seem that some clever people at UCLA, and elsewhere, seem to think there is potential.  Their suggested mode of action is not the same as mine, they think DAAOI and I was thinking DJ-1.

Monday 26 January 2015

Kvx.y-channelASD, Navx.y-channelASD, Cavx.y-channelASD and channelASD-channelepsy phenotype

Perugia is an ancient university city in Central Italy.  If you live in North America you may recall it in connection with a high profile murder trial.  You probably would not expect it to produce clever insights into autism.

In fact, Italy is a rare country outside the US that has leading autism researchers.

Today’s post is to draw your attention to very insightful paper about some of the ion channel dysfunctions in autism.  This paper is about those concerning potassium.

The nice touch was their suggestion that we could classify some people with ASD, some with epilepsy and some people with both, by their ion channel dysfunction.

So if like some people, you have a dysfunction of the L-type calcium channel Cav1.2, you would become:-


Somebody with Dravet Syndrome (epilepsy) with ASD, would become:-


The underlying assumption by the authors is that a type of single ion channel dysfunction, generally triggered by the underlying gene being dysfunctional, and may account for many cases of “autism”.

This is interesting, but I tend to believe that multiple ion channel dysfunctions (channelopathies) are present and in some cases the underlying gene itself is not the problem.  Ion channels and transporters are proteins and each type is indeed expressed by its gene, but the degree to which that gene is expressed is also determined by many other factors.  So over/under expression of, for example, an ion transporter might well not correspond to any genetic error.

We have already seen that in addition to ion channels there are also various types of ion transporter/exchangers. Two very important ones in autism are NKCC1 and KCC2, they determine the chloride concentration within brain cells.  Too many NKCC1 transporters and/or too few KCC2 transporters mean that the level of chloride is too high.  This then causes an ongoing dysfunction of the neurotransmitter GABA.  So in this case the route problem is not a dysfunction of the transporter rather there are just too many of them.

NKCC1 is also expressed in many regions of the brain during early development, but not in adulthood.[5] This change in NKCC1 presence seems to be responsible for altering responses to the neurotransmitters GABA and glycine from excitatory to inhibitory, which was suggested to be important for early neuronal development. As long as NKCC1 transporters are predominantly active, internal chloride concentrations in neurons is raised in comparison with mature chloride concentrations, which is important for GABA and glycine responses, as respective ligand-gated anion channels are permeable to chloride. With higher internal chloride concentrations, outward driving force for this ions increases, and thus channel opening leads to chloride leaving the cell, thereby depolarizing it. Put another way, increasing internal chloride concentration increases the reversal potential for chloride, given by the Nernst equation. Later in development expression of NKCC1 is reduced, while expression of a KCC2 K-Cl cotransporter increased, thus bringing internal chloride concentration in neurons down to adult values

So we could call this common autism phenotype NKCC1 over expression.

Then the type of autism I am interested in would become:-

Cav1.2-channelASD with NKCC1 over expression

This assumes that no potassium or sodium channels are affected.

Back to Potassium Ion Channelopathies

Here is the paper from Perugia:-

 .. a mounting body of evidence indicates that ion channel dysfunction may well enhance autism susceptibility also when other contributing alleles are coinherited.

Direct and indirect defects in K+  channels have been implicated in ASDs pathogenesis, likely altering crucial neural network processes in several brain areas including the cerebellum, a structure that emerges as critically involved in determining the core features of ASDs. Abnormal synaptic transmission and dendritic spine pathology play crucial roles in ASDs. Notably, the activity of many thousands synapses is controlled by a single astrocyte. Thus, aberrant astrocyte dependent synaptic functions and CNS development, induced by defective ion channels, represent an interesting causative hypotheses for ASDs

Kv4.2 – ChannelASD

The presence of Kv4.2 channels in hippocampus appears fundamental, mostly at early developmental stage when neuronal activity drives synaptic maturation and network refinement. At hippocampal synapses, the gradual reduction in GluN2B/GluN2A subunit ratio, during post-natal development, is correlated with AMPA expression and synaptic maturation. Ablation of Kv4.2 in mice abolished this phenomenon and resulted in a higher number of silent synapses in the adulthood.  Given the importance of Kv4.2 in brain development and functioning, defects of this channel have been unsurprisingly correlated with a broad spectrum of neurological disorders. Gene deletion in mice leads to increased susceptibility to convulsant stimuli  and truncating mutation of Kv4.2 in humans leads to temporal lobe epilepsy

Kv4.2 channel expression may also participate in establishing the conditions for the development of ASDs, given that Kv4.2 mRNA can bind to the fragile X mental retardation protein (FMRP), which is associated to fragile X syndrome (FXS), the most common monogenic cause of autism and inherited intellectual retardation

Kv7.3 – ChannelASD

KCNQ3 and KCNQ2 gene mutations segregate with various forms of Kv7.3/Kv7.2-channelepsies

KCa1.1 – ChannelASD

The calcium-activated K+ 230 (KCa) channels are highly conserved across species, and widely expressed in the human brain.
KCa1.1 loss-of function mutations likely alter pyramidal neurons excitability and result in impairment of neural networks in hippocampus, an area implicated in cognition, mood disorders and ASD. However, these mutations may also affect cerebellar PNs excitability, development, learning and memory processes, suggesting that KCa1.1 channels dysfunction may impact these crucial neurophysiological processes occurring within the cerebellum and result in the psychomotor development and cognition features of ASD

Recently, KCa1.1 channels have been implicated in ASD on a different ground, since their activity is regulated by FMRP, whose mutation produces FXS.

Notably, FMRP can also bind to Na+-activated K+ channel Slack  (i.e. KCa4.1), and thus regulate its activity.

Interestingly, intellectual disability only occurs in those patients who carry mutations in Slack channels, further suggesting a role for this channel type in both epilepsy and cognitive disorders

Inwardly-rectifying K+ channels

Inwardly-rectifying K+ (Kir) channels take their name from the greater conductance at potentials negative to EK, while at more positive values the outward flow of K+  ions is variably inhibited by cytoplasmic polyamines and Mg2+, by means of affinity dependent blockade

Kir2.1 – ChannelASD

Loss-of-function mutations in the KCNJ2 gene are responsible for the rare Andersen-Tawil syndrome a  condition characterized by long QT-syndrome, cardiac arrhythmia, skeletal abnormalities, periodic paralysis, mood disorders and seizures

genetically-induced Kir2.1 defects, beside causing SQT3 syndrome, may possibly result in functional impairment of neural networks where this channel type  resides and contribute to ASDs pathogenesis

I do think Kir2.1 is interesting because it seems to be related hypokalemic sensory overload, which if a key feature of many people’s ASD and indeed ADHD.

Interestingly, a reader with the above Andersen-Tawil syndrome and relatives with ASD, told me how many of them smoke and feel much better by doing so.

Nicotine has been shown to depolarize membrane potential and to lengthen action potential duration in isolated cardiac preparations. To investigate whether this is a consequence of direct interaction of nicotine with inward rectifier K(+) channels which are a key determinant of membrane potentials, we assessed the effects of nicotine on two cloned human inward rectifier K(+) channels, Kir2.1 and Kir2.2, expressed in Xenopus oocytes and the native inward rectifier K(+) current I(K1) in canine ventricular myocytes. Nicotine suppressed Kir2.1-expressed currents at varying potentials negative to -20 mV, with more pronounced effects on the outward current between -70 and -20 mV relative to the inward current at hyperpolarized potentials (below -70 mV). The inhibition was concentration dependent. For the outward currents recorded at -50 mV, the IC50 was 165 +/- 18 microM. Similar effects of nicotine were observed for Kir2.2. A more potent effect was seen with I(K1) in canine myocytes. Significant blockade ( approximately 60%) was found at a concentration as low as 0.5 microM and the IC50 was 4.0 +/- 0.4 microM. The effects in both oocytes and myocytes were partially reversible upon washout of nicotine. Antagonists of nicotinic receptors (mecamylamine, 100 microM), muscarinic receptors (atropine, 1 microM), and beta-adrenergic receptors (propranolol, 1 microM) all failed to restore the depressed currents, suggesting that nicotine acted directly on Kir channels, independent of catecholamine release. This property of nicotine may explain its membrane-depolarizing and action potential duration-prolonging effects in cardiac cells and may contribute in part to its ability to promote propensity for cardiac arrhythmias

Some people with ASD find nicotine patches helpful.  This could help for various reasons, but if they are Kir2.1 – ChannelASD, then likely it is blocking the misbehaving potassium channels.

Thursday 22 January 2015

ABA Strikes Again

This blog is mainly about clever pills and potions that may improve some people’s autism, but I do like to remind people of the power of behavioral interventions.

Monty, aged 11 with ASD, has had three behavioral consultants since we began his home ABA program when he was aged about four.  Since there are no ABA consultants in our part of the world, we have to fly them in.  We have our local therapists/assistants, who then work with some support from the foreign consultant.  The net result is a mixture of approaches, which admittedly becomes more “ABA” when the consultant comes to visit.  We now have a vast collection of ABA books, manuals and training materials.

Last week our excellent American-Greek behavioral consultant came for a two day visit and so it was a good opportunity to look at progress.

Monty went to the airport to wait for her and then we went home for some discussions and Monty showed off his piano playing.  Later everyone went out to a pizza restaurant; all went well and Monty quietly devoured his full-sized margarita pizza.

The next day the consultant went to school with Monty and his assistant, to see how things are handled there.  The last time she came, she pointed out that there was little interaction with the other kids.  Now things are much better in that area.  In class, she noted than he can now sit attentively and follow much of what the class teacher is saying/doing.

Then back home to see Monty’s afternoon home program with his other assistant.

Another school visit the next day and the visit was over.  Now we wait to find the suggested items to work on at home, as we work our way through one of the ABA bibles, which in our case is:-

We have lots of other material, but we still often use this book.

Academically and socially we have moved on a fair way since the last visit.  Back home our consultant runs more intensive clinic-based ABA programs and she was wondering out loud how come we are making all this progress.

“Our other kids have six times as much intervention”; I am not sure exactly how the six figure was picked, but I do get her point.

Near the end of the visit she did ask “are you giving him any drugs?”

The answer was “yes, but not any ones you will have heard of”.  I did then give a brief explanation of my "extra-curricular" activities.

I have learnt it is best not to mix messages with different audiences.  ABA people are great, but do tend to think nothing else can help.  Equally, people convinced that the problem is candida or vaccines, have also already made up their minds.

It is, of course, not a good idea to compare one child with ASD’s performance against another, but everybody still does it.

It looks like the kind of people our consultant works with now and encountered at a leading center in the US, where she trained until 10 years ago, are generally more affected by autism than Monty.  Most of the people I read about today with “autism” (mainly from the US) are clearly much less affected than Monty.  This does rather suggest that what passes for “autism” there has really changed a lot in 10 years.  Now that Asperger’s has ceased to exist in the US, under their latest DSM, this process will continue yet further.


My conclusion is that ABA works great and so does the Polypill.

Hopefully, next time we go to the airport to meet our ABA consultant, or even drop by her in Athens, we will again have moved forward nicely.

For now everyone is happy.

Tuesday 20 January 2015

Treatment of Autism with low-dose Phenytoin, yet another AED

I do like coincidences and I do like not struggling to find a picture for my posts. 

Phenytoin (Dilantin) is a drug that appeared in the novel and film, One Flew Over the Cuckoo's Nest, but then it was not used in low-doses.

Today’s post follows from a comment I received about using very low doses of anti-epileptic drugs (AEDs) in autism.

First of all a quick recap.

Clonazepam was discovered by Professor Catterall, over in Seattle, to have the effect of modifying the action of the neurotransmitter GABA to make it inhibitory, at tiny doses that would be considered to be sub-clinical (i.e. ineffective).

Valproate, another AED, was discovered by one of this blog’s readers also to have an “anti-autism” effect in tiny doses of 1 mg/kg.

A psychiatrist from Australia, Dr Bird, specialized in adults with ADHD has just published a paper about the benefit of low-dose phenytoin in adult autism.  The same psychiatrist has also earlier encountered the effect of low dose valproate in ADHD (autism lite).

Significantly, this beneficial effect of sodium valproate appeared to have a narrow therapeutic window, with the optimal range between 50 and 200mg daily. A complete loss of efficacy frequently occurred above a dose of 400mg.

Case presentation

My patient was a 19-year-old man diagnosed in early childhood with ADHD and ASD

a sublingual test dose of approximately 2mg phenytoin was administered

Within 10 minutes of taking the sublingual phenytoin he reported a reduction in the effort required to contribute to conversation and was able to sustain eye contact both when listening and speaking. He was surprised about the effortless nature of his eye gaze and also commented that he had never done this before.

The following day he started taking compounded 2mg phenytoin capsules in the morning in conjunction with his methylphenidate.

After two weeks both he and his mother stated that his communication with the family had improved and there had been no aggressive outbursts.

Over the next four weeks he became inconsistent in taking the phenytoin, and then ceased altogether. His behavior reverted to the previous pattern of poor social interaction; he became oppositional with outbursts of anger and physical violence.

Nine months later he resumed taking the phenytoin, this time as a single 4mg capsule in the morning. After his first dose there was an improvement of his social behavior similar to his previous response, although there was an apparent deterioration in the late afternoon. The dose was increased from 4mg to 5mg and a larger capsule formulated to try and prolong the release of the phenytoin. This appeared to achieve a more consistent improvement in behavior throughout the day, evident both at home and at work. Increases in the dose above 5mg were not associated with any additional benefit. He remained on the 5mg dose of phenytoin for over 18 months and reported that his work performance had consistently improved sufficient to increase his working hours and his level of responsibility. The violence and destruction at home abated. His confidence improved and for the first time he has established and sustained peer-appropriate friendships.

I hypothesize that, in a similar mechanism to the low-dose clonazepam in this animal model of autism, low-dose phenytoin may enhance GABA neurotransmission, thereby correcting the imbalance between the GABAergic and glutaminergic systems.


Now let us look at Phenytoin and see if we agree with Dr Bird's hypothesis that the mechanism is the same as low dose clonazepam. 

The accepted method of action is that working as a voltage gate sodium channel blocker.  GABA is not mentioned.

Phenytoin, by acting on the intracellular part of the voltage-dependent sodium channels, decreases the sodium influx into neurons and thus decreases excitability.

The antiepileptic activity of phenytoin was found during systematic research in animals: it suppresses the tonic phase but not the clonic phase elicited by an electric discharge and is not very active against the attacks caused by pentylenetetrazol.

Phenytoin was the first non-sedative antiepileptic to be used in therapeutics.
It decreases the intensity of facial neuralgia and has an antiarrhythmic effect.

 But as I dug a little deeper, I found from 1995:-

We report here that carbamazepine and phenytoin, two widely used antiepileptic drugs, potentiate gamma-aminobutyric acid (GABA)-induced Cl- currents in human embryonic kidney cells transiently expressing the alpha 1 beta 2 gamma 2 subtype of the GABAA receptor and in cultured rat cortical neurons. In cortical neuron recordings, the current induced by 1 microM GABA was enhanced by carbamazepine and phenytoin with EC50 values of 24.5 nM and 19.6 nM and maximal potentiations of 45.6% and 90%, respectively. The potentiation by these compounds was dependent upon the concentration of GABA, suggesting an allosteric modulation of the receptor, but was not antagonized by the benzodiazepine (omega) modulatory site antagonist flumazenil. Carbamazepine and phenytoin did not modify GABA-induced currents in human embryonic kidney cells transiently expressing binary alpha 1 beta 2 recombinant GABAA receptors. The alpha 1 beta 2 recombinant is known to possess functional barbiturate, steroid, and picrotoxin sites, indicating that these sites are not involved in the modulatory effects of carbamazepine and phenytoin. When tested in cells containing recombinant alpha 1 beta 2 gamma 2, alpha 3 beta 2 gamma 2, or alpha 5 beta 2 gamma 2 GABAA receptors, carbamazepine and phenytoin potentiated the GABA-induced current only in those cells expressing the alpha 1 beta 2 gamma 2 receptor subtype. This indicates that the nature of the alpha subunit isoform plays a critical role in determining the carbamazepine/phenytoin pharmacophore. Our results therefore illustrate the existence of one or more new allosteric regulatory sites for carbamazepine and phenytoin on the GABAA receptor. These sites could be implicated in the known anticonvulsant properties of these drugs and thus may offer new targets in the search for novel antiepileptic drugs.

So not only is it possible that phenytoin can modulate the behaviour of the GABAA receptor like Dr Catterall did with Clonazepam, but carbamazepine is yet another known AED with this effect.

So I expect someone will also go and patent low-dose carbamazepine for autism.

We potentially now have a wide range of low dose AEDs for autism.

·        Valproate (1000 to 2000 mg for adults as AED) at a dose of 1-2 mg/kg

·        Clonazepam (up to 20 mg for adults as an AED)   at a dose of 1.7mcg/kg

·        Phenytoin (up to 600 mg for adults as an AED) at a dose of 0.05 mg/kg

·        Carbamazepine (up to 1,200 mg for adults as an AED) no data for the low dose!

We also have two other drugs that are used as AEDs in high doses and have been used in autism with much lower doses.  I do not have any evidence to show that they affect GABAA receptors.  I think their method of action is unrelated to GABA, or sodium channels.
·        Piracetam (up to 24 g as an AED) at a dose of 400 to 800 mg

·        Vinpocetine (up to 45mg for adults as an AED)  at a dose of 1 to 5 mg

Both Piracetam and Vinpocetine are classed as drugs in Europe and supplements in the US.  Both are also used as cognitive enhancers. Both have numerous possible modes of action.  They may not help with behavioral problems, but may well improve cognition.

Interestingly, a clinical trial is underway to look at the cognitive effect of moderate doses of Vinpocetine in epilepsy.