Pages

Wednesday 2 February 2022

Genetic Mutations vs Differentially Expressed Genes (DEGs) in Autism

 

Genes make proteins and you need the right amount in the right place
at the right time.

I should start this post by confessing to not having carried out genetic testing on Monty, now aged 18 with autism.  When I did mention this to one autism doctor at a conference, I was surprised by her reply:- “ You did not need to.  Now there’s no point doing it”.

I got lucky and treated at least some of Monty’s Differentially Expressed Genes (DEGs) by approaching the problem from a different direction.

People do often ask me about what diagnostic tests to run and in particular about genetic testing.  In general, people have far too high expectations regarding such tests and assume that there will be definitive answers, leading to effective therapeutic interventions.

I do include an interesting example today where parent power is leading a drive towards an effective therapeutic intervention in one single gene type of autism.  The approach has been to start with the single gene that has the mutation and look downstream at the resulting Differentially Expressed Genes (DEGs). The intervention targets one of the DEGs and not the mutated gene itself.

This is a really important lesson.

It can be possible to repurpose existing drugs to treat DEGs quite cheaply.  Many DEGs encode ion channels and there are very many existing drugs that affect ion channels.

Entirely different types of autism may share some of the same DEGs and so benefit from the same interventions.

 

Genetic Testing 

Genetic testing has not proved to be the holy grail in diagnosing and treating autism, but it remains a worthwhile tool at a population level (i.e. maybe not in your specific case).  What matters most of all are Differentially Expressed Genes (DEGs), which is something different.

A paper was recently published that looked into commercially available genetic testing.  Its conclusion was similar to my belief that you risk getting a “false negative” from these tests, in other words they falsely conclude that there is no genetic basis for the person’s symptoms of autism. 

 

Brief Report: Evaluating the Diagnostic Yield of Commercial Gene Panels in Autism

Autism is a prevalent neurodevelopmental condition, highly heterogenous in both genotype and phenotype. This communication adds to existing discussion of the heterogeneity of clinical sequencing tests, “gene panels”, marketed for application in autism. We evaluate the clinical utility of available gene panels based on existing genetic evidence. We determine that diagnostic yields of these gene panels range from 0.22% to 10.02% and gene selection for the panels is variable in relevance, here measured as percentage overlap with SFARI Gene and ranging from 15.15% to 100%. We conclude that gene panels marketed for use in autism are currently of limited clinical utility, and that sequencing with greater coverage may be more appropriate.

 

To save time and money, the commercial gene panels only test genes that the company defines as autism genes.  There is no approved list of autism genes. 

You have more than 20,000 genes and very many are implicated directly, or indirectly, in autism and its comorbities. To be thorough you need Whole Exome Sequencing (WES), where you check them all.  

There are tiny mutations called SNPs ("snips") which you inherit from your parents; there are more than 300 million known SNPs and most people will carry 4-5 million.  Some SNPs are important but clearly most are not.  Some SNPs are very common and some are very rare. 

Even WES only analyses 2% of your DNA, it does not consider the other 98% which is beyond the exome.  Whole Genome Sequencing (WGS) which looks at 100% of your DNA will be the ideal solution, but at some time in the future.  The interpretation of WES data is often very poor and adding all the extra data from WGS is going to overwhelm most people involved. 

Today we return to the previous theme of treating autism by treating the downstream effects caused by Differentially Expressed Genes (DEGS).

Genetics is very complicated and so people assume that is must be able to provide answers. For a minority of autism current genetics does indeed provide an answer, but for most people it does not.

Early on in this blog I noted so many overlaps between the genes and signaling pathways that drive cancer and autism, that is was clear that to understand autism you probably first have to understand cancer; and who has time to do that!

Some people’s cancer is predictable. Chris Evert, the American former world No. 1 tennis player, announced that she has ovarian cancer.  Her sister had exactly the same cancer.  Examining family history can often yield useful information and it is a lot less expensive that genetic testing.  Most people’s cancer is not so predictable; sure if you expose yourself to known environmental triggers you raise its chances, but much appears to be random.  Cancer, like much autism, is usually a multiple hit process. Multiple events need to occur and you may only need to block one of them to avoid cancer. We saw this with a genetic childhood leukemia that you can prevent with a gut bacteria. 


Learning about Autism from the 3 Steps to Childhood Leukaemia


What is not random in cancer are the Differentially Expressed Genes (DEGs).

We all carry highly beneficial tumor suppressing genes, like the autism/cancer gene PTEN.  You would not want to have a mutation in one of these genes.

What happens in many cancers is that the individual carries two good copies of the gene like PTEN, but the gene is turned off. For example, in many people with prostate cancer, the tumor suppressor gene PTEN is turned off in that specific part of the body.  There is no genetic mutation, but there is a harmful Differentially Expressed Gene (DEG). If you could promptly turn PTEN expression back on, you would suppress the cancer.

Not surprisingly, daily use of drugs that increase PTEN expression is associated with reduced incidence of PTEN associated cancer.  Atorvastatin is one such drug.

 

DEGs are what matter, not simply mutations

 

In many cases genetic mutations are of no clinical relevance, we all carry several on average.  In some cases they are of immediate critical relevance.  In most cases mutations are associated with a chance of something happening, there is no certainty and quite often further hits/events/triggers are required.

A good example is epilepsy. Epilepsy is usually caused by an ion channel dysfunction (sodium, potassium or calcium) that is caused by a defect in the associated gene. Most people are not born with epilepsy, the onset can be many years later.  Some parents of a child with autism/epilepsy carry the same ion channel mutation but remain unaffected. 

 

Follow the DEGs from a known mutation 

There is a vanishingly small amount of intelligent translation of autism science to therapy, or even attempts to do so.  I set out below an example of what can be done.

 

Pitt Hopkins (Haploinsufficiency of TCF4) 

The syndrome is caused by a reduction in Transcription factor 4, due to mutation in the TCF4 gene.  One recently proposed therapy is to repurpose the cheap calcium channel blocker Nicardipine. Follow the rationale below.

 

  means down regulated

↑ means up regulated


1.     Gene/Protein TCF4 (Transcription Factor 4) ↓↓↓↓

2.     Genes SCN10a  ↑↑    KCNQ1 ↑↑

3.     Encoding ion channels  Nav1.8   ↑↑     Kv7.1   ↑↑

4.     Repurpose approved drugs as inhibitors of Kv7.1 and Nav1.8 

5.     High throughput screen (HTS) of 1280 approved drugs.

6.     The HTS delivered 55 inhibitors of Kv7.1 and 93 inhibitors of Nav1.8

7.     Repurposing the Calcium Channel Inhibitor Nicardipine as a Nav1.8 inhibitor 


           

The supporting science: 

Psychiatric Risk Gene Transcription Factor 4 Regulates Intrinsic Excitability of Prefrontal Neurons via Repression of SCN10a and KCNQ1

  

Highlights

•TCF4 loss of function alters the intrinsic excitability of prefrontal neurons 

TCF4-dependent excitability deficits are rescued by SCN10a and KCNQ1 antagonists 

TCF4 represses the expression of SCN10a and KCNQ1 ion channels in central neurons 

•SCN10a is a potential therapeutic target for Pitt-Hopkins syndrome

  

Nav1.8 is a sodium ion channel subtype that in humans is encoded by the SCN10A gene

Kv7.1 (KvLQT1) is a potassium channel protein whose primary subunit in humans is encoded by the KCNQ1 gene.

  

Transcription Factor 4 (TCF4) is a clinically pleiotropic gene associated with schizophrenia and Pitt-Hopkins syndrome (PTHS).  

SNPs in a genomic locus containing TCF4 were among the first to reach genome-wide significance in clinical genome-wide association studies (GWAS) for schizophrenia  These neuropsychiatric disorders are each characterized by prominent cognitive deficits, which suggest not only genetic overlap between these disorders but a potentially overlapping pathophysiology.

We propose that these intrinsic excitability phenotypes may underlie some aspects of pathophysiology observed in PTHS and schizophrenia and identify potential ion channel therapeutic targets.

Given that TCF4 dominant-negative or haploinsufficiency results in PTHS, a syndrome with much more profound neurodevelopmental deficits than those observed in schizophrenia, the mechanism of schizophrenia risk associated with TCF4 is presumably due to less extreme alterations in TCF4 expression at some unknown time point in development

The pathological expression of these peripheral ion channels in the CNS may create a unique opportunity to target these channels with therapeutic agents without producing unwanted off-target effects on normal neuronal physiology, and we speculate that targeting these ion channels may ameliorate cognitive deficits observed in PTHS and potentially schizophrenia.

 

 

Disordered breathing in a Pitt-Hopkins syndrome model involves Phox2b-expressing parafacial neurons and aberrant Nav1.8 expression

Pitt-Hopkins syndrome (PTHS) is a rare autism spectrum-like disorder characterized by intellectual disability, developmental delays, and breathing problems involving episodes of hyperventilation followed by apnea. PTHS is caused by functional haploinsufficiency of the gene encoding transcription factor 4 (Tcf4). Despite the severity of this disease, mechanisms contributing to PTHS behavioral abnormalities are not well understood. Here, we show that a Tcf4 truncation (Tcf4tr/+) mouse model of PTHS exhibits breathing problems similar to PTHS patients. This behavioral deficit is associated with selective loss of putative expiratory parafacial neurons and compromised function of neurons in the retrotrapezoid nucleus that regulate breathing in response to tissue CO2/H+. We also show that central Nav1.8 channels can be targeted pharmacologically to improve respiratory function at the cellular and behavioral levels in Tcf4tr/+ mice, thus establishing Nav1.8 as a high priority target with therapeutic potential in PTHS. 

 

Repurposing Approved Drugs as Inhibitors of Kv7.1 and Nav1.8 To Treat Pitt Hopkins Syndrome

Purpose:

Pitt Hopkins Syndrome (PTHS) is a rare genetic disorder caused by mutations of a specific gene, transcription factor 4 (TCF4), located on chromosome 18. PTHS results in individuals that have moderate to severe intellectual disability, with most exhibiting psychomotor delay. PTHS also exhibits features of autistic spectrum disorders, which are characterized by the impaired ability to communicate and socialize. PTHS is comorbid with a higher prevalence of epileptic seizures which can be present from birth or which commonly develop in childhood. Attenuated or absent TCF4 expression results in increased translation of peripheral ion channels Kv7.1 and Nav1.8 which triggers an increase in after-hyperpolarization and altered firing properties.

Methods:

We now describe a high throughput screen (HTS) of 1280 approved drugs and machine learning models developed from this data. The ion channels were expressed in either CHO (KV7.1) or HEK293 (Nav1.8) cells and the HTS used either 86Rb+ efflux (KV7.1) or a FLIPR assay (Nav1.8).

Results:

The HTS delivered 55 inhibitors of Kv7.1 (4.2% hit rate) and 93 inhibitors of Nav1.8 (7.2% hit rate) at a screening concentration of 10 μM. These datasets also enabled us to generate and validate Bayesian machine learning models for these ion channels. We also describe a structure activity relationship for several dihydropyridine compounds as inhibitors of Nav1.8.

Conclusions:

This work could lead to the potential repurposing of nicardipine or other dihydropyridine calcium channel antagonists as potential treatments for PTHS acting via Nav1.8, as there are currently no approved treatments for this rare disorder.

  

Repurposing the Dihydropyridine Calcium Channel Inhibitor Nicardipine as a Nav1.8 inhibitor in vivo for Pitt Hopkins Syndrome

Individuals with the rare genetic disorder Pitt Hopkins Syndrome (PTHS) do not have sufficient expression of the transcription factor 4 (TCF4) which is located on chromosome 18. TCF4 is a basic helix-loop-helix E protein that is critical for the normal development of the nervous system and the brain in humans. PTHS patients lacking sufficient TCF4 frequently display gastrointestinal issues, intellectual disability and breathing problems. PTHS patients also commonly do not speak and display distinctive facial features and seizures. Recent research has proposed that decreased TCF4 expression can lead to the increased translation of the sodium channel Nav1.8. This in turn results in increased after-hyperpolarization as well as altered firing properties. We have recently identified an FDA approved dihydropyridine calcium antagonist nicardipine used to treat angina, which inhibited Nav1.8 through a drug repurposing screen.

 

All of the above was a parent driven process.  Well done, Audrey!

Questions remain.

Is Nicardipine actually beneficial to people with Pitt Hopkins Syndrome? Does it matter at what age therapy is started? What about the Kv7.1 inhibitor?

 

Conclusion 

Genetics is complicated, ion channel dysfunctions are complicated; but just a superficial understanding can take you a long way to understand autism, epilepsy and many other health issues.

There is a great deal in this blog about channelopathies/ion channel dysfunctions.

https://epiphanyasd.blogspot.com/search/label/Channelopathy

Almost everyone with autism has one or more channelopathies. Most channelopathies are potentially treatable.

Parents of children with rare single gene autisms should get organized and make sure there is basic research into their specific biological condition.  They need to ensure that there is an animal model created and it is then used to screen for existing drugs that may be therapeutic.  I think they also need to advocate for gene therapy to be developed.  This all takes years, but the sooner you start, the sooner you will make an impact.

Very likely, therapies developed for some single gene autisms will be applicable more broadly.  A good example may be the IGF-1 derivative Trofinetide, for girls with Rett Syndrome. IGF-1 (Insulin-like growth factor 1) is an important growth factor that is required for proper brain development. In the brain, IGF-1 is broken down into a protein fragment called glypromate (GPE). Trofinetide is an orally available version of GPE.

The MeCP2 protein controls the expression of several genes, such as Insulin-like Growth Factor 1 (IGF1), brain-derived neurotrophic factor (BDNF) and N-methyl-D-aspartate (NMDA).  All three are implicated in broader autism. 

https://rettsyndromenews.com/trofinetide-nnz-2566/

In girls with Rett Syndrome the genetic mutation is in the gene MeCP2, but one of the key DEGs (differentially expressed genes) is the FXYD1; it is over-expressed. IGF-1 supresses the activity of FXYD1 and hopefully so does Trofinetide.  Not so complicated, after all!

Medicine is often driven by the imperative to do no harm.

In otherwise severely impaired people, perhaps the imperative should be to try and do some good.

In medicine, time is of the essence; doctors in the ER can be heard to say "Stat!", from the Latin word for immediately, statim.  

How about some urgency in translating autism science into therapy? But then, what's the hurry? Why rock the boat?

On an individual basis, much is already possible, but you will have to do most of the work yourself - clearly a step too far for most people.








   



 






37 comments:

  1. Well done by the parents driving the above process for Pitt-Hopkins, I'm impressed! :)
    When it comes to gene testing (trio sequencing with parents), I still think it is an avenue to follow up - and to redo it every 5th year. Geneticists are already looking at the areas in-between genes in the DNA, and I've seen examples of people getting a diagnosis that way.

    Anyway, Peter I realized you haven't written much about iron on your blog of what I recall.
    Ferritin (the iron storage protein) is important for both serotonin and dopamine synthesis and iron deficiency with/without anemia is very common world-wide.
    Iron deficiency in immune cells also plays a role in allergy as I learned recently and I'm curious about the latest buzz around Beta-Lactoglobulin and its so-called "farm effect", protecting against pollen and dust mite allergies. This is a supplement you already can find in Germany and Austria (ImmunoBon) and I just hope it could be another useful intervention in the anti-allergy toolbox...
    There's plenty of research out there to read on it, here's just an excerpt:

    Compensating functional iron deficiency in patients with allergies with targeted micronutrition

    "iron deficiency primes mast cells for degranulation, while an increase in their iron content inhibits their degranulation. Many allergens, especially those with lipocalin and lipocalin-like protein structures, are able to bind iron and either deprive or supply this trace element to immune cells. Thus, a local induced iron deficiency will result in immune activation and allergic sensitization. However, lipocalin proteins such as the whey protein β‑lactoglobulin (BLG) can also transport micronutrients into the defense cells (holo-BLG: BLG with micronutrients) and hinder their activation, thereby promoting tolerance and protecting against allergy
    ..
    In our recent murine studies, BLG only became an allergen when it was not loaded with micronutrients such as iron or vitamin A. However, once the BLG pocket was loaded with iron complexes, it prevented allergy development"
    https://link.springer.com/article/10.1007/s40629-021-00171-9

    /Ling

    ReplyDelete
    Replies
    1. Ling, the Farm Effect is interesting, but does it apply more to dairy farms or just any farm? I am a big believer in the hygiene hypothesis, which is based on beneficial bacteria from farms, pets and non-sterile life. Is the Farm Effect raw milk consumption driven or dirt/bacteria driven?

      It is interesting that Beta-Lactoglobulin is both a common cause of childhood milk allergy and also a potential anti-allergen therapy, in the presence of those micronutrients. Also of interest is that only fresh milk, not yogurts etc, is rich in Beta-Lactoglobulin.

      You wonder why children with a milk allergy problem are not given those extra nutrients to change the effect of Beta-Lactoglobulin?

      Delete
    2. β‑lactoglobulin was originally found both in milk and in farm dust. So both a dairy/hygiene hypothesis would fit here - either you eat it or inhale it and either way you get exposed to it. It's possible that the load carried by the β‑lactoglobulin is important in sensitization, it seems the researchers have tried different loads like vitamin D3, iron, quercetin...
      It's interesting and if I can get my hands on some I'll try it this season.

      /Ling

      Delete
    3. Actually, I just saw this easy to read mini-review that answers some of our questions (Fig 1 at the bottom for lazy readers):

      The farm effect revisited: from β-lactoglobulin with zinc in cowshed dust to its application
      https://link.springer.com/article/10.1007/s40629-021-00174-6

      "not all farms show the same protective effect: cattle and pig farms in particular provide a beneficial environment, demonstrating the allergy-preventive effect within a radius of up to 327 meters around the farm"

      Maybe we'll get inhalers with dust farm in the future?

      /Ling

      Delete
  2. Would that be seen as actually high ferritin in blood?

    ReplyDelete
    Replies
    1. Not sure I understand your question tpes, but ferritin levels in blood would be systemic, while my quotes are much about local iron stores or functional iron.

      Generally, it's worth knowing that inflammation can "mask" low ferritin levels and if hypothyroid you might need a higher ferritin level than the lower standard range to ease symptoms. When iron gets low, you might not first encounter anemia and fatigue but the neuronal symptoms: deficiency of dopamine (seen as restless legs or low motivation) and serotonin (depression or anxiety).

      /Ling

      Delete
  3. Hi Peter

    I’m unable to get a whole genome test or (WES) for my son on the NHS, he`s already had a microarray and ive since been fobbed off by GP & pediatrician after asking for one.

    The UK supposedly leads the world in genetic science, however a google search disappointingly reveals only a handful of commercial WGS places available for paying members of the public in the UK, most based overseas offering either standard 30x for around $300 or much more expensive 100x for $1000. They all have quite poor reviews for long delays in results.

    I think may be probably better than nothing & may show something useful, do you think its worth paying more for the 100x?

    ReplyDelete
    Replies
    1. Ross, some readers of this blog have found that they, or their child, carry a known mutation in a known autism or intellectual disability gene. This is most often found via whole exome sequencing (WES), by a company or university that is offering clinical services.

      There is now an entire industry offering services to individuals, often linked to selling them a myriad of supplements, many of which are likely to be of absolutely no benefit.

      I would suggest you use a service directed at clinicians. The one that has come up several times from readers is Gene DX, who look serious.

      They have a service which accepts either blood, or buccal (cheek) swabs.

      Autism/ID Xpanded Panel
      https://www.genedx.com/tests/detail/autism-id-xpanded-panel-849

      The problem with NHS WES testing in the UK is that the patient is not seen as the customer and so you do not receive the full results. You just get told if there any affected genes that the UK NHS thinks are causal; that is a very narrow list.

      It is a case of getting what you pay for. If it is free, you cannot really complain.

      Many people do send samples to the US for testing and that includes blood samples.

      I recall that our reader AJ negotiated a discount for his daughters testing at Gene DX, so it is always worthwhile asking.

      Even with “positive” results from genetic testing you are still in the situation that no autism/ID genetic mutations are regarded as treatable by the UK NHS.

      Delete
    2. Hi Ross,

      I was able to get Whole Exome sequencing done on the NHS through the medical genetics department. This was through a referral from the disabilities Psychiatrist. They took blood from me, my wife and my child. It takes about 3 months for the results. I do not think they give the full data to the patients.

      Delete
  4. Posting this from a friend involved in research in Germany:
    After a long compilation, I am trying to define a basics for screening for most often neuronal and glial alterations as a first step to understand (potentially) causality of the disorder on individual level. I have found company in Germany able to run some of these tests. My question is – are there any parents interested in running all of that together? It would require development of the induced pluripotent stem cells (also provided through Germany) and later on diagnostics:
    • size and amount of neuronal population(s)​​​​
    • neuronal maturation (neurite length - structural; MAP2 & SYP functional)​​​
    • action potential patterns​​​​
    • dendritic spine density and structure​​​​
    • lamination process​​​​
    • neurite outgrowth​​​​
    • neural network organization/activity​​​​
    • synaptogenesis​​​​
    • synaptic plasticity​​​​
    • Specific functional neuronal markers​​​​
    o βIII-tubulin (TUBB3), ​​​
    o Level of chloride (chloride homeostasis)​​​
    o Intracellular ion level homeostasis ​​​
    o Calcium signalling​​​
    • Metabolites​​​​
    o Gaba​​​
    o Glutamate​​​
    • Signalling pathways​​​​
    o mTOR​​​
    o MAPK​​
    I am in process of getting answer how much they can cover and what would be the price.

    So, you take blood from a child and magic it into a mini brain that in the lab can be analyzed to see whats up with it. Interested people should look for Renate Lukjanska.

    ReplyDelete
  5. Peter,

    Thanks very much for this interesting post. A couple years ago, my adult, autistic daughter had whole exome sequencing done. Initially, the testing turned up no "hits." But last summer we heard from her doctor that her DNA had been retested and she has a newly discovered disorder--Chopra-Amiel-Gordon Syndrome--associated with a mutation on the ANKRD17 gene, which is on chromosome 4. My question is this: is there anything we can do to identify DEGs associated with ANKRD17? You say above that we will need to do most of the work ourselves. That makes sense to me, given autism research's lack of focus on treatment. But we have no idea where to start. We've read the only paper that we've been able to find (https://pubmed.ncbi.nlm.nih.gov/33909992/) about the disorder and it certainly seems to fit our daughter, but we don't know where to go from there. Thanks for any help you can give.

    ~Mary

    ReplyDelete
    Replies
    1. Mary, as a first step, I would suggest you contact Dr Maya Chopra, of the Chopra-Amiel-Gordon Syndrome. I would suggest you ask her about plans to actually develop treatments. She may have it all planned out.

      Maya Chopra, Director of Translational Genomic Medicine at Boston Children’s Hospital / Harvard.
      maya.chopra@childrens.harvard.edu

      In her recent paper it concludes: “In the future, loss-of-function studies in an appropriate animal model may shed light on the precise cell types and transcriptional outputs regulated by ANKRD17”. Ask her what are her concrete plans and what are the limiting factors.

      Some researchers are very willing to respond to parents, at least initially, but some just ignore them. If no response then move on to Amiel and Gordon.

      As regards my thoughts on downstream effects of loss of function of your daughter’s gene ANKRD17, I will shortly put them in a dedicated post.

      In rare genetic disorders, what can happen is that nobody is interested in doing any research. Then parents have to do some fund raising and lobby for public funds to be made available. When funding is available then researchers become interested. With the advent of social media you can identify affected families worldwide relatively easily, via a Facebook group for example. Then you as a group form an association to pursue the development of therapies.

      As a group you can then push for the development of a gene therapy for ANKRD17 and/or to look at the downstream differentially expressed genes (DEGs). In the above comment from tpes, Renate Lukjanska mentions minibrains, this is potentially a very good way to see what is happening inside human brains lacking ANKRD17 expression. Personalized 'mini-brains' can be grown from stem cells generated from a sample of human hair or skin and could shed light on how brain disease progresses in an individual and how this person may respond to drugs.

      Having a minibrain with loss of ANKRD17 is not an unrealistic target. Gene therapy is also not unachievable, the hugely expensive part is the testing and approval process, but nothing stops you being in the trial group.

      Delete
  6. Hi Peter what fo yuo think about this article?
    https://www.nature.com/articles/s41467-021-26131-z

    ReplyDelete
    Replies
    1. You did not ask me, but still I will reply :-)))) I think I am sick of mouse studies.

      Delete
    2. Diego, mTOR is a key regulator of processes in the autistic brain, perhaps most importantly is synaptic pruning, which is how a child-like brain becomes an adult-like brain.

      It is a key regulator of how humans grow, age, get dementia and cancer etc.

      You can have too much mTOR activation (big heads/brains with too many synapses) and also too little mTOR (small heads/brains and too few synapses).

      Everolimus, an expensive mTOR inhibitor, is effective in very young children with TSC (Tuberous sclerosis complex) a single gene type of autism.

      mTOR is highly complex and does not offer a simple path to treatment for most autism.

      Delete
  7. Peter, I am wondering what you make of this article (admittedly another mouse study): https://pubmed.ncbi.nlm.nih.gov/33450274/

    My son was on 1 mg bumetanide for about 5 months, with moderate improvement. I was then able to get azosemide and switch him to that. I was giving him 60 mg azosemide. However, the diuretic effects were worse for him. The long-acting nature of azosemide made him much more likely to have accidents, while the bumetanide just made him pee frequently for a few hours. I then switched him back to 1 mg bumetanide. Since then, his teachers at school have noticed a significant uptick in aggression. There may be confounding factors, as his usual aide has been replaced by a substitute, but the timing lines up with the switch back to bumetanide. He is still quite small, so I do not want to go up to 2 mg bumetanide. For the time being, I will probably switch him back to the azosemide and see if that helps. However, in the longer term, I am wondering if torsemide would be another alternative to try. It would certainly be easier for us to access than azosemide.

    ReplyDelete
    Replies
    1. Sara, epilepsy is very complicated, in that study they did find that making the mice epileptic did increase NKCC1 expression, but the NKCC1 blockers did not block the seizures.

      It should be noted that Bumetanide/Azosemide/Torsemide taken orally are all very weak NKCC1 blockers, due to the blood brain barrier.

      In your son, I would stay with the bumetanide. Unless you manage the diuresis/toilet breaks very well, you may well see more aggression. The substitute may well not be as intuitive as the original aide. Some kids need to be prompted to go and pee. Not surprisingly, they will get agitated and the teachers do not know why.

      I have no experience with Torsemide. The response to these diuretics is very individual; in my son Azosemide is much less disruptive. In some people Bumetanide causes almost no diuresis - lucky them!

      The idea that came up from one paper was that the very cheap OTC supplement TMG/Betaine anhydrous may have a similar effect on NKCC1. The adult dose with this apparent effect was 10g. I have not tried this yet, but I will pick up a bulk pack and make my own trial.

      Delete
    2. Hello Sara, my son takes Bumetanide also and a Potassium Supplement, one time I didn't give him the supplement for days and I thought I'd compensate with banana and electrolytes but he was in a very bad mood until I returned to the supplement.

      Delete
  8. Hello Peter, recently a 14 year boy diagnosed with ADHD, intellectual disability and epilepsy (he looked like he had some type of syndrome, maybe Fragile X) that was in the state orphanage of my city was involved in a riot inside the institution and people say he was hit badly, he then was transfered to a shelter for immigrants and died there, he was cremated shortly after he died, so there was no autopsy. Today there was a letter published from the DIF (like child protective services from the state, they're in charge of the orphanage and shelter) and in short they said that due to his conditions he was taking meds and had lost sensitivity to pain, so they didn't know and when they tried to help him it was already too late, and they put on the report that the cause of death was Peritonitis. Many people are angry, but it seems it is more of a local news and soon it is forgotten. I think that if it's bad for children without disabilities, it's even worse for children that do have them.

    On another note, my son's ticks have been worsening, I think at times that it even looks like Touretttetes, he also has had ear pain and I stopped giving him folinic acid, maybe it affected him. So it is a bit confusing, he has more restrictive behaviour again, but seems ok in school, he's almost at the same level as his classmates. He is still on Bumetanide.

    ReplyDelete
  9. Hi Peter,
    My son has been toilet trained since age 4.All of a sudden since last month at age 10,he has been peeing in his pants everday at night and also during the day.The doctor has ruled out UTI.
    Any suggestion about what to do?
    Thanks
    SD

    ReplyDelete
    Replies
    1. SD, the onset of bedwetting is a symptom of PANS/PANDAS. Look for other symptoms. If it was PANS, or PANS-like, I would suggest asking for 5 days of Prednisone 1-2 mg/kg.

      Delete
  10. Another thing I would like to mention,could be coincidence.He was put on MUPIROCIN for skin lesion.The bedwetting started literally on the same day the ointment was applied.We stopped the ointment on the 4th day but the bedwetting did not stop

    ReplyDelete
  11. Hi! Thank you for your blog. I am learning to think here...

    β2 adrenergic agonists can also estimulate IGF-1, BDNF,...

    Here they studied Clenbuterol available in Hungry ttps://www.pnas.org/doi/full/10.1073/pnas.1309426111

    But it's possible to find safer over the counter alternatives with possibly a similar effect:
    https://www.sciencedirect.com/science/article/pii/S096999611530067X?via%3Dihub

    Any feedback is well come.

    I am a Rett caregiver.

    ReplyDelete
    Replies
    1. When I wrote about Rett Syndrome a long time ago I recall that reduced levels of NGF (nerve growth factor) is a key feature of Rett.

      NGF eye drops are now, or soon will be, commercially available. They were long ago suggested as a dementia prevention.

      IGF-1 has long been available via subcutaneous injection.

      Lions Mane mushrooms are supposed to increase NGF.

      Delete
  12. Hi Peter, I want to tell everyone who listens to us on this site that the combination of cromolyn sodium treatment (allergoval6capsule) + galavit4 cps \ 2zile + bacoflen 3 * 10mg, Nac if needed, is the best treatment method for Denis, it is happy, without aggression on us, try to relate more with the family. Who can help us with the purchase of Galavit to contact me on facebook, would be very helpful, thank you.

    ReplyDelete
    Replies
    1. Dragos, congratulations on finding an effective polytherapy for Denis.

      Galavit was recently suggested to me by another reader and I told her that it might indeed be helpful, but there is nothing written about its use in autism. Perhaps on Facebook people are discussing it.

      One of the effects of Galavit is on inflammatory messengers like TNF-alpha and IL-6. These are the target of another therapy I was recently contacted about. In that case it is a drug called Humira, which is given once every 2 months by injection. Humira is not cheap and is usually used for arthritis, psoriasis, Crohn’s disease etc.

      The fact that cromolyn sodium and Galavit are helpful does tell a lot about the type of autism Dennis is affected by.

      Galavit, being from Russia, may not be easy to acquire. There was a trend among some cancer patients to take Galavit, which then made it more expensive outside of Russia. There are various people selling Nootropic medicines from Russia on the internet and I expect they would sell you Galavit.

      Perhaps Galavit is available in Moldova?

      Delete
  13. Peter, they don't exist in Moldova, I asked in every pharmacy of theirs, it seems that it is only in Ukraine and Russia and the problem is that the war has blocked everything, but we are trying to buy, we need 2 boxes per month. ... Peter what kind of autism do you think Denis has ???

    ReplyDelete
    Replies
    1. Dragos, if cannot get it via a Russian doctor, you could ask the Russian online sites that sell nootropics if they can help you. I expect they are shipping to Romania, unless the international mail has stopped. Two such are rupharma.com and cosmicnootropic.com/

      Dennis clearly has a disturbed auto-immune system. This is not rare in autism. You may look for other people who respond to Galavit and see what other therapies they are using.

      Delete
  14. Hi Paul, thank you for such an informative blog. My son RT is 5 with severe autism (CARs score 40), we started noticing withdrawal and less eye contact at 8-9 months old, he had had several ear infections (still very common in wintertime for RT) in the 2 months leading to this. His twin sister (who is neurotypical) and him had been hospitalized for bronchitis at 2 months old and blood tests conducted then showed that his iron levels were low and had a transfusion done. RT and his twin were delivered through C section at 38 weeks. I also suffered a postpartum/ Peripartum Cardiomyopathy and a bout of Pupps post-delivery.
    RT is affectionate, shows interest in his older brother but not so much his twin sister; has been known to say single words but only if really motivated to do so; He has always been a bad sleeper and is partially toilet trained (doesn’t feel wet or uncomfortable if he has an accident) he does not have seizures. He was a chubby baby till around 3 years old and now at 5 only weigh 17 kg. I feel that RT has classic Autism. I am currently giving him Bacopa Syrup and noticed some improvement in cognition also supplemented by Fish oil Omega 3, B6, Vit D and a probiotic he also gets 3 drops of Amitriptyline for anxiety.
    Going through your blog has been an eye opener for us, as we were always told that the “only” way forward was therapy. Your blog has really help us join the dots. We are awaiting an order of Bumetanide and Broccoli powder and in the meantime (yesterday) I have started supplementing with 250mg of K and 100 mg of magnesium and it calmed him down to such an extent that he nearly fell asleep. We have also initiated genetic testing (which will have to be sent abroad) to cross out Fragile X syndrome, as he does have a wide forehead, very slight strabismus. I would like to have your thoughts on the dosage of Bumetanide and whether to discontinue the Bacopa, as I understand it is also a diuretic. Sorry for the long comment. Thanks Anj

    ReplyDelete
    Replies
    1. I meant Peter not Paul

      Delete
    2. Anji, Bacopa has some interesting properties that can be helpful in autism. If it works well, I would continue with it.

      In most people Bumetanide is a potent diuretic and this is why some people stop using it. I would try 1mg once a day at/before breakfast, that way you get the diuresis out of the way early in the day. You should expect a lot of urination in the two hours after Bumetanide. It is an urgent need, so he needs to be near a bathroom.

      I think you would expect some impact on the fetus from Peripartum Cardiomyopathy. The female twin is going to better protected than the male twin. This is all water under the bridge now, so I would not over-think it.

      Genetic testing is a good idea. It may tell you something useful, but do not be surprised if it does not.

      Delete
  15. This comment has been removed by the author.

    ReplyDelete
  16. Hello Peter, I did WES and the result was a mutation on the ASXL2 gene: "The patient is heterozygous for ASXL2 c2688>T"
    What treatment should I try, I kept reading the comments but it seems we don't fit in anywhere. He has always had a difficult evolution, I haven't noticed any big regression even though he has lost some purchases over time.

    ReplyDelete
    Replies
    1. Denisa, ASXL2 is an epigenetic regulator, which means it plays a role in how other genes get turned on and off. So you would expect there to be many resulting DEGs (differentially express genes).

      This gene plays an important role in neurodevelopment, but in older people it is known as a cancer gene. Cancer is very well studied and if you look up epigenetic drugs, you will see that they are generally cancer drugs.

      In some other single gene autisms, these epigenetic drugs (usually HDAC inhibitors) are beneficial in experimental models. Nobody tries in humans.

      There is a very cheap pediatric epilepsy drug called Valproic acid, which includes HDAC inhibition among its many modes of action.

      ASXL2 is also known to acts as coactivator for PPARG.
      There is quite a lot in this blog about PPARG.

      https://www.epiphanyasd.com/search/label/PPAR%CE%B3

      PPARG is a drug target to treat people with type 2 diabetes.
      Some readers of my blog found that Sytrinol, an OTC supplement that is a mild PPARG agonist to be helpful. But the effect only lasted a few days.

      Pioglitazone is a PPARG agonist that has been shown effective in children with autism. It has broad anti-inflammatory effects and has another effect of triggering biogenesis of mitochondria. It is a cheap diabetes drug.

      Understanding the phenotypic spectrum of ASXL-related disease: 10 cases and a review of the literature
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8842511/

      As you can see in the above paper, there are people collecting information about those with ASXL mutations. Take a look and see where your child fits in (or, mavbe he does not, anything is possible).

      If your child does fit the above descriptions, ideally you would find a helpful clinician willing to support you through some trials of epigenetic drugs.

      Generally speaking, clinicians do not take the logical next step and try and treat the patient. They see it as a big risk to themselves if they get it wrong and not much upside if they get it right. Parents expect the doctor to know what to do and in this kind of case the doctor has no definite path to follow.

      You might find an older senior doctor who thinks he has nothing to lose by helping you and his colleagues respect his seniority and will not report the unorthodox approach and get him into trouble.

      Delete
    2. Hi Peter, I went through the CT page for Pioglitazone dosing information. There they've administered the recommended doses 4 times a day. Whereas in the results publication, they are saying the same doses should be given only once per day. Not sure why this discrepancy. Which dosing you think is correct, 4 times a day or once a day?

      Delete
    3. Pioglitazone is taken once a day.

      In the 2018 autism trial even large doses of .75mg/kg were free of troubling side effects. I think the medium dose they trialed, 0.5 mg/kg is enough.

      Delete
  17. Hello, Peter! Thank you very much for the information! I am alone, I spoke, no one interferes, no one helps me

    ReplyDelete

Post a comment