Wednesday 29 June 2022

Bumetanide - Biomarkers from Shanghai for Autism responders


“three cytokine levels, namely the IFN-γ, MIG and IFN-α2  … These cytokine levels at the baseline could improve the prediction of the bumetanide responders”

“… cytokines had a potential to construct a blood signature for predicting and monitoring the bumetanide treatment in young children with ASD.”

“a significant part of the clinical heterogeneity in the treatment effect of bumetanide for ASD is associated with the differences in the immune system of patients”


Autism is a very heterogeneous family of conditions and this is a big part of the reason why all clinical trials to date have failed.  Ideally, there would be a diagnostic test to identify which person will respond to which therapy.  Then you can have a successful clinical trial, because you are only including people likely to respond.

Researchers from China have just published their results that suggest that a blood test measuring three inflammatory markers can predict who will respond to bumetanide.  This is good news and where it is coming from is also very notable.

Autism research has been very fragmented, some of it is very sophisticated and insightful but much is very amateur and some is quite trivial.  There is usually a real lack of common sense among these people and no sense of urgency whatsoever.

China is a very organised country; plans are made and then they are implemented.  Forget political correctness.

This kind of approach is what is required to move along with autism treatment.

In addition, there is also another new study from China, this time on the microbiota in autism that compared those with and without GI problems (it found it is equally disturbed in both groups). Hopefully, that Chinese group will do the next common sense step and compare the microbiota of autistic people with and without restrictive diets. To what extent to people give themselves a microbiota problem through poor diet.


Disentangling the relationship of gut microbiota, functional gastrointestinal disorders and autism: a case–control study on prepubertal Chinese boys

The altered gastrointestinal microbiota composition in ASD appeared to be independent of comorbid functional gastrointestinal disorder


The bumetanide researchers are from Fudan University in Shanghai, one of the 3 ultra-selective Chinese Universities alongside Tsinghua University and Peking University in Beijing.

The paper, not surprisingly, may look complicated, but there are a great deal of interesting things in it.

In their words:-

An immuno-behavioural covariation was identified between symptom improvements in the Childhood Autism Rating Scale (CARS) and the cytokine changes among interferon (IFN)-γ, monokine induced by gamma interferon and IFN-α2. Using this covariation, three groups with distinct response patterns to bumetanide were detected

The three groups were: best responders, least responders and medium responders.

It should be noted that the dosage used in their trials was 0.5mg of bumetanide twice a day.

Chinese children tend to be smaller than Western children and this might help explain why the results were more positive than in Servier’s failed phase 3 clinical trial in Europe. I also imagine the Chinese children were more severely autistic than the European group.

The dosage used is selected to minimize the diuresis rather than to maximize the impact on the autism. This is understandable, but I think it is a mistake.


The immuno-behavioural covariation associated with the treatment response to bumetanide in young children with autism spectrum disorder 

Bumetanide, a drug being studied in autism spectrum disorder (ASD) may act to restore gamma-aminobutyric acid (GABA) function, which may be modulated by the immune system. However, the interaction between bumetanide and the immune system remains unclear. Seventy-nine children with ASD were analysed from a longitudinal sample for a 3-month treatment of bumetanide. The covariation between symptom improvements and cytokine changes was calculated and validated by sparse canonical correlation analysis. Response patterns to bumetanide were revealed by clustering analysis. Five classifiers were used to test whether including the baseline information of cytokines could improve the prediction of the response patterns using an independent test sample. An immuno-behavioural covariation was identified between symptom improvements in the Childhood Autism Rating Scale (CARS) and the cytokine changes among interferon (IFN)-γ, monokine induced by gamma interferon and IFN-α2. Using this covariation, three groups with distinct response patterns to bumetanide were detected, including the best (21.5%, n = 17; Hedge’s g of improvement in CARS = 2.16), the least (22.8%, n = 18; g = 1.02) and the medium (55.7%, n = 44; g = 1.42) responding groups. Including the cytokine levels significantly improved the prediction of the best responding group before treatment (the best area under the curve, AUC = 0.832) compared with the model without the cytokine levels (95% confidence interval of the improvement in AUC was [0.287, 0.319]). Cytokine measurements can help in identifying possible responders to bumetanide in ASD children, suggesting that immune responses may interact with the mechanism of action of bumetanide to enhance the GABA function in ASD.


The use of bumetanide as a potential drug to improve symptoms in ASD is based on a hypothesised pathoetiology of ASD, namely the delayed developmental switch of the gamma-aminobutyric acid (GABA) functioning from excitatory to inhibitory [10,11,12]. In the valproate and fragile X rodent models of autism, this GABA-switch can be facilitated by the reduction of intracellular chloride concentration, which is mediated by a sequential expression of the main chloride transporters, such as the potassium (K)-Cl co-transporters 2 (KCC2) and the importer Na-K-Cl cotransporter 1 (NKCC1) [12]. Therefore, bumetanide as an NKCC1 inhibitor has been tested for its ability to restore GABA function in ASD [5,6,71314]. However, these transporters can also be influenced by other molecules, such as cytokines, which are a number of small cell-signalling proteins closely interacting with each other to modulate the immune reactions. The cytokines have been implicated not only in brain development [15], but also in GABAergic transmission [16,17,18]. It has been reported that the interferon (IFN)-γ can decrease the levels of NKCC1 and the α-subunit of Na+-K+-ATPase, contributing to the restore of inhibitory GABA function [16]. In mice subjected to maternal deprivation, the interleukin (IL)-1 has also been found to reduce the expression of KCC2, delaying the developmental switch of the GABA function and thereby possibly contributing to the pathophysiology of developmental disorders such as ASD [1718]. Therefore, a question naturally arises that whether the treatment effect of bumetanide for ASD can be affected by the immune responses in the patients.

Indeed, compared with healthy controls, changes of the cytokine levels have already been reported in patients with ASD [19,20,21,22]. Recent meta-analyses showed that the levels of anti-inflammatory cytokines IL-10 and IL-1 receptor antagonist (Ra) were decreased [20], while proinflammatory cytokines IL-1β, IL-6 and anti-inflammatory cytokines IL-4, IL-13 were elevated in blood of patients with ASD [21]. The levels of IFN-γ, IL-6, tumour necrosis factor (TNF)-α, granulocyte-macrophage colony-stimulating factor (GM-CSF) and IL-8 were observed to be elevated [22] in postmortem brain tissues of ASD patients, and increased level of IFN-γ, monocyte chemotactic protein (MCP)-1, IL-8, leukaemia inhibitory factor (LIF) and interferon-gamma inducible protein (IP)-10 were found in another study [23]. These widely spread changes suggest that the cytokine signalling in ASD may be better characterised by multivariate patterns of cytokines. In literatures, many associations had been reported between the levels of cytokines (e.g., MCP-1, IL-1β, IL-4, IL-6, etc.) and both core symptoms and adaptive functions in children with ASD [24,25,26]. Therefore, it has been suggested that cytokines may be used as biomarkers to identify different subsets within ASD. In each of these subsets the patients with ASD may share a commonly immune-related pathoetiology and therefore may have similar profiles of response to treatment [27].

Based on these previous findings, we analysed data acquired through the Shanghai Xinhua ASD registry, China, that began in 2016 to test the hypothesis that the immune activity of patients might help to identify the best responders to bumetanide in ASD.


Between May 1st, 2018, to April 30th, 2019, a total of 90 ASD children, aged 3–10 years old, under a 3-month stable treatment of bumetanide without behavioural interventions and any concomitant psychoactive medications had both blood draws and behavioural assessments. Among these patients, 11 of them were further excluded due to the lack of the follow-up data at month 3. A group of 37 children, under 3-month stable treatment of placebo without behavioural interventions and any concomitant psychoactive medications had both blood draws and behavioural assessments. Therefore, the current analysis used a subsample of 116 young children with ASD, whose blood samples were available both before and after the treatment. The blood samples were sent in three batches (Discovery Set: n = 37 on December 4, 2019; Validation Set: n = 42 on May 22, 2019; and Control Set: n = 37 on January 5, 2022) to measure the serum levels of 48 cytokines for the immune response (Table S1), and the clinical symptoms were assessed using CARS, ADOS and the Social Responsiveness Scale (SRS). 

In this study, we observed a significant improvement of clinical symptoms with bumetanide treatment in children with ASD, and such improvement was associated with a pattern of changes in three cytokine levels, namely the IFN-γ, MIG and IFN-α2 (r = 0.459 in the Discovery Set and r = 0.316 in the Validation Set). These cytokine levels at the baseline could improve the prediction of the bumetanide responders compared with using the behavioural assessments alone, and the best predictor achieved an AUC of 0.83 in the independent test data set (Table S8). The implications of these findings may be twofold: (1) a significant part of the clinical heterogeneity in the treatment effect of bumetanide for ASD is associated with the differences in the immune system of patients, and (2) the component score of cytokines had a potential to construct a blood signature for predicting and monitoring the bumetanide treatment in young children with ASD.

Following the protocols of previous studies [8], bumetanide treatment consisted of two 0.5 mg tablets per day for three months, given at 8:00 a.m. and 4:00 p.m. The tablet size is 8 mm diameter x 2 mm thickness, which is quite small. Each time, the patient took half of a tablet, which was not difficult for most of the patients. However, the careers were recommended to grind the half-tablet into powder and give the powder in water, if necessary. Possible side effects were closely monitored during the treatment. Blood parameters (serum potassium and uric acid) were monitored via laboratory tests (Table S2) and symptoms (thirst, diuresis, nausea, vomiting, diarrhoea, constipation, rash, palpitation, headache, dizziness, shortness of breath, and any other self-reported symptoms) were telephone interviewed (Table S3), and both of them were reported to the research team by telephone at 1 week and 1 month after the initiation of treatment and at the end of the treatment period. The cytokine levels of the children with gastrointestinal problems were compared with those without such problems (Table S4).

The supplemental table S4 shows that GI problems had no effect on cytokine levels.

Changes after the administration of bumetanide

Seventy-nine patients were treated with bumetanide for 3 months, and the CARS total score decreased after the treatment (effect size Cohen’s d = 1.26, t78 = 11.21, p < 0.001). The treatment effect showed no difference between the Discovery Set and the Validation Set (ΔCARS_total: mean(±SD): 1.54 (±1.40) vs. 1.90 (±1.34)). Consistent to the previous studies of the low-dose bumetanide for ASD, the side effects were rarely reported (Tables S2 and S3). No significant difference in the cytokine levels between the children with and without the gastrointestinal problems at the baseline (Table S4). A number of cytokine levels were changed significantly after the treatment of bumetanide, but none of them was changed significantly after the treatment of placebo (Table S6). No significant pairwise association could be identified in the Discovery Set, the Validation Set and the Control Set among four groups of variables, including the baseline CARS total score, the baseline cytokine levels, the change of CARS total score, and the changes of cytokine levels (Fig. S2).


In this study, we observed a significant improvement of clinical symptoms with bumetanide treatment in children with ASD, and such improvement was associated with a pattern of changes in three cytokine levels, namely the IFN-γ, MIG and IFN-α2 (r = 0.459 in the Discovery Set and r = 0.316 in the Validation Set). These cytokine levels at the baseline could improve the prediction of the bumetanide responders compared with using the behavioural assessments alone, and the best predictor achieved an AUC of 0.83 in the independent test data set (Table S8). The implications of these findings may be twofold: (1) a significant part of the clinical heterogeneity in the treatment effect of bumetanide for ASD is associated with the differences in the immune system of patients, and (2) the component score of cytokines had a potential to construct a blood signature for predicting and monitoring the bumetanide treatment in young children with ASD.

Accumulating evidences support that IFN-γ can inhibit chloride secretion [38] and down-regulate both the NKCC1 expression [1638] and the Na+-K+-ATPase expression [16], which had been implicated in the GABAergic dysfunction in ASD [1039].


The cytokine-symptom association was identified in the changes after the treatment of bumetanide but not before the treatment, suggesting that bumetanide might interact with the cytokines and the changes of which contributed to the treatment effect of bumetanide. Animal studies showed a rapid brain efflux of bumetanide, but a number of clinical trials have shown a significant treatment effect for neuropsychiatric disorders, including ASD, epilepsy and depression [4142]. These findings may suggest the possible systemic effects of bumetanide as a neuromodulator for these neuropsychiatric disorders. Considering its molecular structure, bumetanide has been recently identified by an in vitro screen of small molecules that can act as an anti-proinflammatory drug via interleukin inhibition [43]. This anti-proinflammatory activity of bumetanide might alter the blood levels of cytokines outside the brain-blood-barrier (BBB).

Our findings may suggest that the identified canonical score of cytokines had a potential to construct a blood signature for predicting and monitoring the bumetanide treatment in young children with ASD. Accurately identifying patients who are likely to respond positively to bumetanide can facilitate the precision medicine for ASD. Our prediction model based on the cytokine levels before the treatment may provide a potentially new tool for the precision medicine of ASD. 


In summary, we identified an association between the changes of the cytokine levels and the improvements in symptoms after the bumetanide treatment in young children with ASD, and found that the treatment effect of bumetanide can be better characterised by an immuno-behavioural covariation. This finding may provide new clinically important evidence supporting the hypothesis that immune responses may interact with the mechanism of bumetanide to restore the GABAergic function in ASD. This finding may also have relevance for determining enriched samples of ASD children to participate in novel drug treatment studies of drugs with a similar mode of action to bumetanide, but with potentially greater efficacy and fewer side effects.



I think we can give the Shanghai researchers 10 out of 10 for their paper.

Monty, aged 18 with ASD, has been to Shanghai twice. It is a vast city, but well worth a visit. With the high speed train network it is now very easy to travel around China, quite different to when I visited as a teenager.

Hopefully the Chinese will continue in their pursuit of precision medicine for autism. They do not have much competition.

My perspective is a little different because I know that a bumetanide responder can cease to be a responder when affected by an inflammatory condition like allergy, which increases pro-inflammatory cytokines like IL-6. This suggests that some people with elevated cytokines are potential responders, you just have to use an anti-inflammatory therapy before you start bumetanide therapy. The inflammatory cytokines shift the balance between NKCC1 and KCC2 towards NKCC1 and so increasing intracellular chloride.  We also know that some people need a dose higher than 0.5mg twice a day to see a large benefit; I have been using 2mg once a day for several years.

The Chinese researchers have established biomarkers for who is likely now to respond to bumetanide. This certainly is a big step forward, if it can be replicated. This is not the same as identifying who could respond to bumetanide, if their current inflammatory condition was moderated. The levels of specific cytokines might indeed mark someone as both a current non-responder, but also as a potential future responder.

Autism is all about n=1, it is about the exceptions being more important than the average.

Unlike the Shanghai researchers, I do not really see Bumetanide as an anti-inflammatory therapy in my son’s Polypill, but I do have therapies included that are.

Understanding inflammation will be a key to treating autism using precision medicine.  That is less simple that it sounds. When it comes to preventing autism, inflammation in the mother is a key part of the equation. This also gets complicated, maternal antibodies damage the brain of the fetus, no genetic mutations were needed.

Wednesday 15 June 2022

Repurposing Autism Drugs to treat Alzheimer’s – Bumetanide for APOE4 Alzheimer’s and Clemastine for all Alzheimer’s

The Gladstone Center for Translational Advancement was formed in 2017, and focuses on drug repositioning; repurposing already-approved drugs for new uses and clinical trials, to speed up (and lower the cost of) drug development.


Our neurologist reader Eszter commented recently on the overlap between experimental therapies for Alzheimer’s and those for autism. She was mentioning GHK-Cu, which is a naturally occurring peptide in our bodies that looks interesting in the research on both Alzheimer’s and Parkinson’s.  There will be post on GHK-Cu, but this is a potential therapy that would require injections, so it has a big drawback

In the early days of this blog we looked at the repurposing of Alzheimer’s drugs like Memantine, Donepezil and Galantamine for some autism.

Roll forward a few years and we now have quite a handful of autism drugs in the portfolio. Today we look again at how some of these autism drugs can be repurposed for Alzheimer’s.

We have come full circle.

In a previous post we saw that Fenamate NSAIDs, like Ponstan, reduce the incidence of Alzheimer’s.  Only a low dose seems to be required for Alzheimer's and this drug is extremely cheap in countries like Greece. A low dose seems to have a broad effect on autism.  All in all very interesting, I believe.

We saw that Agmatine improves cognitive dysfunction and prevents cell death in a Streptozotocin-Induced Alzheimer rat model.

We saw that the ketone BHB inhibits inflammasome activation to attenuate Alzheimer's disease pathology.

I have mentioned the interest to repurpose Verapamil to treat Huntington’s disease, via its effect on autophagy, but there is also interest to use it in Alzheimer’s.

Repurposing verapamil for prevention of cognitive decline in sporadic Alzheimer’s disease

Today we will look at why Bumetanide and Clemastine may be beneficial in Alzheimer’s. 


A quick summary of Alzheimer’s Disease 

Alzheimer’s disease features prominently plaques (amyloid plaques) and fibers (tau tangles) that are visible within the brain.

It is thought that inhibiting the aggregation and accumulation of amyloid plaques and tau in the brain is the key to treating Alzheimer’s Disease.

We did see that that the red pigment in beetroot has been shown to block the formation of amyloid plaques and no prescription is required for that superfood.

In addition, we know that there is reduced glucose uptake across the blood brain barrier via the GLUT1 and GLUT3 transporters.  In effect the brain is left starving. There is also impaired insulin signalling within the brain, this led to the idea of intranasal insulin as a treatment.  The insulin dependent glucose transporter GLUT4 plays a central role in hippocampal memory processes, and reduced activation of this transporter may underpin the cognitive impairments seen in Alzheimer’s disease and more generally in those who develop insulin resistance. (more insulin inside the brain, please)

We also did look at the recently discovered lymphatic drainage system of the brain. It was seen that this waste clearing system is impaired in Alzheimer’s and perhaps some autism. This then takes us back to the autophagy process within the brain, where cellular waste is collected. It is thought that autophagy itself is impaired in autism. Collecting and disposing of brain garbage does not function as it should.

Over a decade or so, the brain gradually shrinks away and loses functions.  I think in reality Alzheimer’s initially develops slowly, years before diagnosis.

The currently prescribed drugs do not alter the course of the disease and often provide only minimal benefit. Donepezil increases acetylcholine concentrations at cholinergic synapses and upregulates nicotinic receptors. Memantine blocks NMDA receptors.  Much more appears to be possible.

This is an autism blog so let’s be aware of the research on the overlaps with Alzheimer’s. 

Alzheimer’s protein turns up as potential target for autism treatments 

Lowering the levels of a protein called tau, best known for its involvement in Alzheimer’s disease, eases autism-like traits in mice, according to a study published today in Neuron.

Tau regulates a gene called PTEN, according to a 2017 study4. PTEN accounts for 2 to 5 percent of autism cases and is known to modulate the PI3K pathway; without it, the pathway becomes overactive, in some cases leading to autism.

Mucke’s team found that knocking out PTEN in neurons blocks the effect of lowering tau on the mice’s behaviors. 

Proteomics of autism and Alzheimer’s mouse models reveal common alterations in mTOR signaling pathway

 Bumetanide for APOE4 Alzheimer’s?

Certain genes can increase the risk of developing dementia, including Alzheimer’s disease. One of the most significant genetic risk factors is a form of the apolipoprotein E gene called APOE4. About 25% of people carry one copy of APOE4, and 2 to 3% carry two copies. APOE4 is the strongest risk factor gene for Alzheimer’s disease, although inheriting APOE4 does not mean a person will definitely develop the disease.

The APOE gene comes in several different forms, or alleles. APOE3 is the most common and not believed to affect Alzheimer’s risk. APOE2 is relatively rare and may provide some protection against Alzheimer’s disease.

The reason APOE4 increases Alzheimer’s risk is not well understood. The APOE protein helps carry cholesterol and other types of fat in the bloodstream. Recent studies suggest that problems with brain cells’ ability to process fats, or lipids, may play a key role in Alzheimer’s and related diseases.

Regular readers of this blog will be familiar of the remarkable effects of statin drugs. So from the mention of cholesterol we take a brief diversion to see how people who start taking statins before older age get yet another benefit.,in%20Alzheimer's%20disease%20%5B70%5D.


"Additionally, statins could reduce dementia risk by directly affecting Alzheimer’s disease pathology. A study in transgenic mice models of Alzheimer’s disease found that atorvastatin reduced Aβ formation [69], and atorvastatin can attenuate some the damage from neuroinflammation in Alzheimer’s disease [70].

Much of the evidence supporting statins in the prevention of dementia and AD are in persons exposed to statins at mid-life as opposed to late life. This suggests that statins benefits may be limited to the vascular prevention stage of AD and dementia. "


Back to Bumetanide.


The easy to read article:-


Can an Already Approved Drug Treat Alzheimer’s Disease?  

An Alternative Approach to Drug Discovery 

Developing new, targeted drugs for complex conditions like Alzheimer’s disease is a notoriously long and expensive process. In 2017, with the goal of bringing safe treatments to patients more quickly, Huang launched the Gladstone Center for Translational Advancement to repurpose FDA-approved drugs for new uses.


Huang’s approach centers around the idea that patients with Alzheimer’s disease may have different underlying causes of neurodegeneration, and therefore, the efficacy of specific treatments may differ among patients—a strategy called precision medicine. However, in the large clinical trials required for new drugs, it can be hard to pinpoint whether a drug is effective in only a subpopulation of the patients.


Therefore, the research team used a computational approach to identify unique gene expression profiles (or the level to which genes are turned on or off) associated with Alzheimer’s disease in brain tissues from specific subgroups of patients. They then screened a database of existing drugs to find the ones most likely to reverse the altered gene expression profiles in each subgroup.


In the new study, the researchers first analyzed a publicly available database of 213 brain samples from people with and without Alzheimer’s disease, including people with different versions of a gene called APOE, the major genetic risk factor for the disease.

The team identified nearly 2,000 altered gene expressions in the brains of people with Alzheimer’s disease. While roughly 6 percent of the altered genes were similar between people with different APOE versions, the vast majority of them were unique to people with specific combinations of the APOE3 or APOE4 versions, the latter conferring the highest genetic risk of Alzheimer’s disease.

The researchers next queried a database of more than 1,300 existing drugs to look for those able to change the altered gene expressions they had identified for subgroups of Alzheimer’s patients. They zeroed in on the top five drugs that might reverse the altered gene expressions found in Alzheimer’s patients carrying two copies of the high-risk APOE4 version.


“This unbiased approach allowed us to find which drugs might be able to flip the altered gene expression associated with APOE4-related Alzheimer’s disease back to the normal state,” says Alice Taubes, PhD, lead author of the study and former graduate student in Huang’s lab at Gladstone and co-mentored by Marina Sirota at UCSF. “It gave us important clues in solving the puzzle of which drugs could be effective against APOE4-related Alzheimer’s disease.”


After looking at the known mechanisms and previous data on the drugs in their top-five list, the researchers homed in on bumetanide, a diuretic that reduces extra fluid in the body caused by heart failure, liver disease, and kidney disease. Bumetanide is known to work by changing how cells absorb sodium and chloride—both important not only for maintaining appropriate levels of water throughout the body, but also for electrical signaling of neurons in the brain.


Huang and his team tested the effect of bumetanide on mice genetically engineered to have human APOE genes. Mice with two copies of the human APOE4 version typically develop learning and memory deficits around 15 months of age—the equivalent of roughly 60 years in humans. But when the researchers treated the mice with bumetanide, they no longer developed such deficits. In addition, the drug rescued alterations in electrical brain activity that can underlie these cognitive deficits.


The scientists also studied a second mouse model of Alzheimer’s disease, in which two copies of APOE4 coexist with amyloid plaques—a major pathological sign of Alzheimer’s disease in the brain. In these mice, bumetanide treatment decreased the number of amyloid plaques and restored normal brain activity.


Lastly, when the researchers studied the effect of the drug on human neurons derived from skin cells of Alzheimer’s patients carrying the APOE4 gene, they found that bumetanide reversed the gene expression changes associated with the disease.


the researchers evaluated two large electronic health record databases—one from UCSF containing information on 1.3 million patients seen from 2012 through 2019, and another from the Mount Sinai Health System covering 3.9 million patients seen from 2003 through 2020. They narrowed in on more than 3,700 patients who had taken bumetanide and were over the age of 65, and compared them to patients of similar age and health who had taken different diuretic drugs. Strikingly, the patients who had taken bumetanide were 35 to 75 percent less likely to be diagnosed with Alzheimer’s disease.




The full paper:-


It gets a bit heavy, so just skip through it.


Experimental and real-world evidence supporting the computational repurposing of bumetanide for APOE4-related Alzheimer’s disease


The evident genetic, pathological and clinical heterogeneity of Alzheimer’s disease (AD) poses challenges for traditional drug development. We conducted a computational drug-repurposing screen for drugs to treat apolipoprotein E4 (APOE4)-related AD. We first established APOE genotype-dependent transcriptomic signatures of AD by analyzing publicly available human brain databases. We then queried these signatures against the Connectivity Map database, which contains transcriptomic perturbations of more than 1,300 drugs, to identify those that best reverse APOE genotype-specific AD signatures. Bumetanide was identified as a top drug for APOE4-related AD. Treatment of APOE4-knock-in mice without or with amyloid β (Aβ) accumulation using bumetanide rescued electrophysiological, pathological or cognitive deficits. Single-nucleus RNA sequencing revealed transcriptomic reversal of AD signatures in specific cell types in these mice, a finding confirmed in APOE4 induced pluripotent stem cell (iPSC)-derived neurons. In humans, bumetanide exposure was associated with a significantly lower AD prevalence in individuals over the age of 65 years in two electronic health record databases, suggesting the effectiveness of bumetanide in preventing AD. 

Bumetanide exposure is associated with a significantly lower AD prevalence in individuals over the age of 65. We hypothesized that, if bumetanide is efficacious against AD, we would observe a lower prevalence of AD diagnosis in individuals exposed to bumetanide than in a matched control cohort of individuals over the age of 65 years. To test this hypothesis in humans, we analyzed two independent EHR databases (Fig. 7a). One is an EHR database from the University of California at San Francisco (UCSF), which contains complete medical records for 1.3 million patients from outpatient, inpatient and emergency room encounters as part of clinical operations from June 2012 to November 2019. The UCSF EHR database was filtered using the medication order table for patients on the drug of interest, and we found 5,526 patients who had used bumetanide (other names, Bumex or Burinex). Among them, 1,850 patients (1,059 men (57.2%) and 791 women (42.8%)) were over the age of 65. The other EHR database was from the Mount Sinai Health


Fig. 7 | Bumetanide exposure is associated with a significantly lower AD prevalence in individuals over the age of 65 in two independent EHR databases.

Bootstrapped χ2 tests40 confirmed a significantly lower AD prevalence in bumetanideexposed individuals than that in non-bumetanide-exposed individuals in both EHR databases (Fig. 7b,c). Together, these data suggest that bumetanide may be effective in preventing AD in individuals over the age of 65 years, warranting further tests in prospective human clinical trials.



This study represents an attempt to apply a precision medicine approach to computational drug repurposing for AD in an APOE genotype-directed manner. The efficacy of a top predicted drug, bumetanide, for APOE4 AD was validated in vivo in both aged APOE4-KI (without Aβ accumulation) and J20/E4-KI (with Aβ accumulation) mouse models of AD for rescue of electrophysiological, pathological or behavioral deficits. Importantly, by leveraging real-world data, bumetanide exposure was associated with a significantly lower AD prevalence in individuals over the age of 65 years in two independent EHR databases, suggesting the potential effectiveness of bumetanide in preventing AD in humans.

Bumetanide exposure is associated with a significantly lower AD prevalence in individuals over the age of 65 in two independent EHR databases.


Clemastine for Alzheimer’s 

The research suggests multiple possible benefits from the use of the cheap antihistamine Clemastine in Alzheimer’s.


Clemastine Attenuates AD-like Pathology in an AD Model Mouse via Enhancing mTOR-Mediated Autophagy

Background: Alzheimer’s disease (AD) is a neurodegenerative disorder with limited available drugs for treatment. Enhancing autophagy attenuates AD pathology in various AD model mice. Thus, development of potential drugs enhancing autophagy may bring beneficial effects in AD therapy. Methods: In the present study, we showed clemastine, a first-generation histamine H1R antagonist and being originally marketed for the treatment of allergic rhinitis, ameliorates AD pathogenesis in APP/PS1 transgenic mice. Chronic treatment with clemastine orally reduced amyloid-β (Aβ) load, neuroinflammation and cognitive deficits of APP/PS1 transgenic mice as shown by immunohistochemistry and behavioral analysis. We further analyzed the mechanisms underlying the beneficial effects of clemastine with using the combination of both in vivo and in vitro experiments. We observed that clemastine decreased Aβ generation via reducing the levels of BACE1, CTFs of APP. Clemastine enhanced autophagy concomitant with a suppression of mTOR signaling. Conclusion: Therefore, we propose that clemastine attenuates AD pathology via enhancing mTORmediated autophagy.


Clemastine Ameliorates Myelin Deficits via Preventing Senescence of Oligodendrocytes Precursor Cells in Alzheimer’s Disease Model Mouse 

Disrupted myelin and impaired myelin repair have been observed in the brains of patients and various mouse models of Alzheimer’s disease (AD). Clemastine, an H1-antihistamine, shows the capability to induce oligodendrocyte precursor cell (OPC) differentiation and myelin formation under different neuropathological conditions featuring demyelination via the antagonism of M1 muscarinic receptor. In this study, we investigated if aged APPSwe/PS1dE9 mice, a model of AD, can benefit from chronic clemastine treatment. We found the treatment reduced brain amyloid-beta deposition and rescued the short-term memory deficit of the mice. The densities of OPCs, oligodendrocytes, and myelin were enhanced upon the treatment, whereas the levels of degraded MBP were reduced, a marker for degenerated myelin. In addition, we also suggest the role of clemastine in preventing OPCs from entering the state of cellular senescence, which was shown recently as an essential causal factor in AD pathogenesis. Thus, clemastine exhibits therapeutic potential in AD via preventing senescence of OPCs.


Reversing Alzheimer's disease dementia with clemastine, fingolimod, or rolipram, plus anti‐amyloid therapy

A few anti‐amyloid trials offer a slight possibility of preventing progression of cognitive loss, but none has reversed the process. A possible reason is that amyloid may be necessary but insufficient in the pathogenesis of AD, and other causal factors may need addressing in addition to amyloid. It is argued here that drugs addressing myelination and synaptogenesis are the optimum partners for anti‐amyloid drugs, since there is much evidence that early in the process that leads to AD, both neural circuits and synaptic activity are dysfunctional. Evidence to support this argument is presented. Evidence is also presented that clemastine, fingolimod, and rolipram, benefit both myelination and synaptogenesis. It is suggested that a regimen that includes one of them plus an anti‐amyloid drug, could reverse AD. 

Note that Rolipram is a selective PDE4 inhibitor that never made it to use in humans. Roflumilast is very similar and counts as an autism drug in this blog, alongside Pentoxifylline, which is a non-selective PDE inhibitor (if affects more than just PDE4). 


It looks like if you were an enlightened neurologist treating autism you would have the drugs needed to make a fair crack at treating, or preventing, Alzheimer’s.  Unfortunately, once they are established, you are not going to cure either disease; nonetheless, fully treating autism will carry forward the person further than their ABA therapist would ever have dreamed possible. Treating Alzheimer's successfully will depend on when you start, best to start as soon as the signs appear on an MRI or CT scan, not a few years later.

Prevention is better than cure; indeed an older person’s multipurpose Polypill looks to be in order. This could go beyond the usual cardiovascular concerns and include prevention/mitigation of dementia and diabetes (e.g. statin, low dose ponstan, verapamil and a mix of betanin, spermidine, agmatine with ALA or NAC)

Just because you might carry the APO4 gene does not mean you will develop Alzheimer’s, but it is a good reason to take steps to prevent it.

There is a long list of factors that increase the incidence/severity of autism, so there are is an equal number of steps that can be taken to reduce it.

The gene expression study showed that Bumetanide has wide ranging effects within the brain that counter the defects found in APO4 mice and humans who have developed Alzheimer’s.  This suggests that bumetanide’s effects go well beyond blocking the NKCC1 cotransporter.  This may explain why some bumetanide responders with autism have a paradoxical reaction to GABA agonists, like benzodiazepines, and some people do not. They are receiving different beneficial effects.

We will look at the anti-inflammatory benefits of bumetanide suggested in very recent Chinese research in the next post.  This might provide biomarkers for likely responders. 

You might have thought that clemastine would not be good for dementia, because it is anticholinergic, as are many antihistamines and even drugs commonly given to older people like Nexium. The neurotransmitter acetylcholine is good for cognition and it has been suggested that depleting it might lead to dementia.

It looks like our off-label MS drugs, clemastine, Ibudilast and Roflumilast are going to be good for dementia, not to forget our new reader Bob and his Pentoxifylline.

It is notable that Gladstone Center for Translational Advancement exists. There are clearly very many existing drugs that can be repurposed to treat all kinds of medical issues. I keep discovering more, which is good for me. Bob discovered Pentoxifylline, which is good for him and his patients.  Other people are free to make their own choices.