Folate Metabolism, the Folate Trap, and finding the right therapy for your specific autism

  

Most of the folate and folic acid we eat must be converted into the active form, known as L-methylfolate or 5-MTHF. However, some dietary folate is already in the active form when we eat it and therefore does not rely on MTHFR.

In treating autism, folate metabolism is a key area of therapeutic focus. While folate supplementation seems simple on the surface, the biology behind it is complex — and, if misunderstood, you may even worsen symptoms.

This post explains how folate metabolism works, what the methyl folate trap is, and how different folate and B12 formulations affect outcomes in children and adults with autism, especially those with MTHFR, MTR, or MTRR mutations.

The Normal Folate Cycle 

Folate, a B-vitamin, plays a central role in:

• DNA synthesis 
• Methylation 
• Neurotransmitter production (via SAMe) 

Here is how it works, if you like details:  

• 5,10-methylene-THF helps make thymidine (for DNA).
• Some of this is converted to 5-MTHF by MTHFR.
• 5-MTHF donates a methyl group to homocysteine, converting it to methionine, in a process catalyzed by methionine synthase, which requires vitamin B12.
• This regenerates THF, which goes back into the cycle.

 

The Methyl Folate Trap

 

If there is a vitamin B12 deficiency, or methionine synthase (MTR) dysfunction, the conversion of 5-MTHF → THF is blocked. This causes:

·         5-MTHF to accumulate (it’s “trapped”)

·         THF and 5,10-methylene-THF to fall

·         DNA synthesis to halt

·         Elevated homocysteine, and low SAMe

The result:

·         Anemia

·         Neurological symptoms

·         Behavioral worsening in autism

This is known as the methyl folate trap — and it explains why giving high-dose folate without enough B12 can backfire.

In summary, the methyl folate trap occurs when B12 deficiency or methionine synthase dysfunction prevents 5-MTHF from recycling to THF, stalling DNA synthesis and methylation, even if folate levels are high.

  

Could the Folate Trap Cause Aggressive or Behavioral Regression?

Yes. In autism, worsening behaviors (irritability, aggression etc) after high-dose folinic acid may reflect a relative B12 deficiency or impaired methionine synthase, leading to:

·    Folate trapping

·   Disrupted neurotransmitter synthesis (especially dopamine/serotonin)

·    Low SAMe

In these cases, adding B12 (methylcobalamin or hydroxycobalamin) often improves tolerance to folate therapy and reduces side effects.

 

Other reasons for a possible negative reaction to calcium folinate

Folate metabolism is tightly connected to glutamate and GABA balance.

High folate dosing in some sensitive individuals may cause excess glutamate activity (excitatory), triggering aggression or anxiety-like behaviors.

Children with fragile neurochemical balance may not tolerate sudden shifts in methylation or neurotransmitter levels. A rapid increase in serotonin, dopamine, or norepinephrine can destabilize mood or cause agitation/aggression. This is why you start low and gradually increase your folate supplement.

In such children 5-MTHF may work better, but you still B12.

Apparently, some doctors prescribe antipsychotics to treat agitation caused by calcium folinate; I am not sure that is a good idea.

 

 Choosing the Right Folate: Folinic Acid vs 5-MTHF

	Calcium Folinate / Leucovorin	5-MTHF
Form	Precursor to 5-MTHF	Final active form
Requires MTHFR?	Yes	No
Can enter CSF?	Indirectly	Directly
Behavioral reactions?	More common in some	Usually better tolerated

For whom is 5-MTHF better?

1.      Those with MTHFR mutations (esp. C677T)

2.      Those who react negatively to folinic acid

3.      Those needing direct CNS access

Folinic acid /Leucovorin is converted to 5-MTHF (active folate) through a series of enzymatic steps. First, it is converted into 5,10-methylenetetrahydrofolate, and then the enzyme MTHFR  converts it to 5-MTHF.

In people with MTHFR mutations, this final step may be slower or impaired, meaning folinic acid may not fully convert to active folate. Direct supplementation with 5-MTHF is often preferred in those with these genetic variants.

 

  

The Problem with Synthetic Folic Acid

 Status of mandatory folic acid fortification in 2019

 

In countries like the US folic acid is added to many foods such as flour, bread, pasta and rice in addition to products like breakfast cereals. This is to reduce the incidence of neural tube defects like spina bifida that occur when a fetus lacks sufficient folate in the first 28 days of life.

In Europe there is much less mandatory supplementation of folic acid due to the negative effects. In older people folic acid supplementation can mask vitamin B12 deficiency. High intake of synthetic folic acid can correct the anemia caused by B12 deficiency without correcting the neurological damage. This can lead to delayed diagnosis of B12 deficiency, increasing the risk of irreversible nerve damage, cognitive decline, and dementia in the elderly.

Folic acid is synthetic and must be converted by DHFR (slow, limited in humans).

It competes with both folinic acid and 5-MTHF for cellular entry.

High levels of unmetabolized folic acid can block folate receptors and worsen autism symptoms in some.

Some people with autism should avoid folic acid supplements and fortified foods.

 

The Dilemma: One Size Does not Fit All

While folic acid fortification benefits the general population, especially women of childbearing age, it may pose risks for other groups:

·    Elderly: Risk of masking B12 deficiency

·    Children with autism or FRAA: Risk of blocked folate receptors and behavioral regression

·    Those with MTHFR variants. They have reduced ability to activate folic acid because their ability to convert folic acid into the active form, 5-MTHF, is reduced. This can lead to unmetabolized folic acid (UMFA) in the blood, which may interfere with normal folate metabolism. It can lead to blocking the transport of natural folates into the brain.

 

Here is a study showing that folic acid impairs the transport of active folate (5-MTHF) across the blood brain barrier.

 

Folic acid inhibits 5-methyltetrahydrofolate transport across the blood–cerebrospinal fluid barrier:Clinical biochemical data from two cases

Results: Both patients had low CSF 5MTHF before treatment and high-dose FA therapy did not normalize CSF 5MTHF. There was a dissociation between serum total folate and 5MTHF concentrations during FA therapy, which was considered to be due to the appearance of unmetabolized FA. The addition of folinic acid did not improve low CSF 5MTHF in the KSS patient and the cessation of FA resulted in the normalization of CSF 5MTHF. In the patient homozygous for MTHFR C677T, minimization of the FA dosage resulted in the normalization of CSF 5MTHF and an increased CSF-to-serum 5MTHF ratio.

Conclusions: Our data suggest that excess supplementation of FA impaired 5MTHF transport across the blood-CSF barrier. In the treatment of CFD, supplementation of folinic acid or 5MTHF (in cases of impaired 5MTHF synthesis) is preferred over the use of FA. The reference values of CSF 5MTHF concentration based on 600 pediatric cases were also provided.

  

B12 - Forms and why it matters

To prevent the folate trap, adequate B12 is critical.

                          

Methylcobalamin        Active, supports methylation directly

Hydroxycobalamin      Longer-lasting, converted to methyl- or adeno-B12

Adenosylcobalamin     Active in mitochondria

Cyanocobalamin         Synthetic, less ideal, may not work in autism

 

Methylcobalamin or hydroxycobalamin are best for autism and CFD.

 

Can it be oral?

Yes, but high doses needed (1–5 mg daily)

Subcutaneous injections may be better absorbed in some

 

What About Betaine / TMG?

Betaine (trimethylglycine) provides methyl groups to convert homocysteine to methionine via the BHMT pathway (mostly in the liver, not brain).

Useful if:

·         Homocysteine is high

·         B12 metabolism is impaired

·         Need extra methylation support

 But, it does not bypass the folate trap in the brain — you still need functional methionine synthase and B12.

 

When Do You Need More SAMe?

SAMe (S-adenosylmethionine) is the body’s master methyl donor, essential for: 

·         Neurotransmitter synthesis

·         Myelination

·         Detox pathways

 

You may need extra SAMe if:

·         You have low methionine/SAMe

·         There is fatigue, depression, or tics

·         Homocysteine is high despite folate + B12

Oral SAMe is poorly absorbed unless enteric-coated.

Do not assume “more folate = better” without addressing B12

 

Conclusion

Whether a person with autism stands to benefit from tuning up their folate metabolism will depend on their unique situation. Many people need no intervention at all.

For others it is highly beneficial to customise an intervention plan. It would include some, or all, of the following. 

·   Reduce expose to synthetic folic acid used to fortify flour, pasta, bread, rice, breakfast cereals etc.

·   Supplement with 5-MTHF or calcium folinate / Leucovorin

·   Supplement vitamin B12, in the form of methylcobalamin or hydroxycobalamin

·    Supplement Betaine/TMG

·    Supplement SAM

     ·  Consider supplementing PQQ if positive for FRAA 

 

The only substance that is prescription-only is calcium folinate / Leucovorin. It looks like 5-MTHF is actually the better choice for most people and it is much more accessible.

We have seen that the potency of generic calcium folinate / Leucovorin is highly variable, possibly due to different excipients that are added. How reliable the OTC 5-MTHF supplements are is an open question.

If you find this subject confusing, use ChatGPT to help you. You can even upload a screenshot of your MTHFR/MTR/MTRR mutations and then get tailored advice. It is free !!  (for now)

 

If you are someone who likes lab tests, the options include: 

• Folate receptor antibodies (FRAA) – to check for blocking autoantibodies www.fratnow.com
• Serum and CSF 5-MTHF – to detect cerebral folate deficiency
• Homocysteine – elevated if methylation is impaired
• MMA (methylmalonic acid) – elevated in B12 deficiency
• Vitamin B12 – ideally with active B12
• Genetic testing – particularly MTHFR, MTR, and MTRR variants to assess methylation capacity

High MMA = likely B12 deficiency, even if serum B12 is "normal".

This is especially important in people with neurological symptoms or MTHFR-related metabolism issues.

 

Measuring serum (blood) 5-MTHF provides insight into how much active folate is circulating in the body. This helps detect:

• Folate trap from B12 deficiency (high folate, low methylation)
• Impaired folate metabolism in MTHFR or MTR/MTRR variants
• Folate absorption or transport problems, especially if CSF 5-MTHF is also tested
  It’s particularly useful when deciding whether folinic acid, 5-MTHF, or B12 supplementation is effective or needed.

CSF 5-MTHF (cerebrospinal fluid via lumbar puncture) gives a direct measure of active folate availability inside the brain. This is important because:

• Some children with autism or FRAA (folate receptor autoantibodies) have low CSF 5-MTHF even with normal blood folate. Some have FRAA and normal CSF 5-MTHF
• High serum folic acid can block transport of 5-MTHF into the brain, lowering CSF levels.
• It can help diagnose Cerebral Folate Deficiency (CFD), especially if symptoms improve with folinic acid.

Low CSF 5-MTHF with normal serum levels suggests a transport problem, not a folate intake issue.

PQQ as a Folate Transport Enhancer

A supplement called Pyrroloquinoline quinone (PQQ) may help bypass folate receptor autoantibody (FRAA) blockage by upregulating alternative folate transporters (RFC and PCFT) in the brain. This could improve delivery of both calcium folinate (leucovorin) and 5-MTHF into the brain when folate receptor alpha (FRα) is blocked.

Human data is lacking; all evidence from animal/cell studies. Some people report adverse effects (e.g. fatigue, overactivation)

For individuals with FRAA, PQQ might enhance the effectiveness of folinic acid or 5-MTHF by improving alternative transport into the brain.

Autism & Schizophrenia - Histamine degradation via HMT (requiring SAMe) and via DAO

Today’s post is a little complicated because it links together various issues ranging from food allergies to severe headaches, brain inflammation to arthritis.

The common link here is histamine, which has been covered at length on this blog.  You may recall that the H1 histamine receptor is the one associated with hay fever, H2 is expressed in the intestines and is involved in regulating acidity levels, H3 is mainly found in the central nervous system (CNS).

The Histamine H4 receptor has been shown to be involved in mediating eosinophil shape change and mast cell chemotaxis.

Here is the full paper, for those interested in mast cells:-

Histamine H4 Receptor Mediates Chemotaxis and Calcium Mobilization of Mast Cells 

In addition to all these receptors, histamine causes an increase in the pro-inflammatory cytokine IL-6.  IL-6 is elevated in autism and many other inflammatory conditions ranging from arthritis to traumatic brain injury (TBI). 

One of interesting interventions in this post is SAMe (S-Adenosyl methionine )and its precursor L-methionine.  We will see why a deficit of SAMe causes a problem when the body tries to degrade/deactivate histamine.

We will also see in a later post that the level of SAMe in the body modulates the release anti-inflammatory cytokines like IL-10 and IL-35.  Here is one link, for now.

IL-35 Is a Novel Responsive Anti-inflammatory Cytokine — A New System of Categorizing Anti-inflammatory Cytokines

5. Higher expression of IL-35 could be induced by higher hypomethylation status in tissues

Previous reports showed that epigenetic mechanisms, including methylation and demethylation, control T helper cell differentiation and cytokine generation [41]. As we discussed in our recent review [42], the ratio of cellular methylation donor S-adenosylmethionine (SAM) levels over S-adenosylhomocysteine (SAH) levels is an important metabolic indicator of cellular methylation status [43], [44]. A higher SAM/SAH ratio suggests a higher methylation status than normal (hypermethylation) whereas a lower SAM/SAH ratio indicates a lower methylation status than normal (hypomethylation).  A previous report showed that feeding rats with SAM, a methyl donor, inhibits the expression of TGF-βR1 and TGF-βR2 [45], suggesting that intracellular global methylation status regulates anti-inflammatory cytokine signaling.  … Cont/

Interestingly, I found that for decades SAMe  has been a mainstream drug therapy used in Italy to treat arthritis.

    

Histamine degradation

In mammals, histamine is metabolized by two major pathways: N(tau)-methylation via histamine N-methyltransferase (HMT) and oxidative deamination via diamine oxidase (DAO).

HMT and uses S-adenosyl-L-methionine (SAMe) as the methyl donor.  If SAMe is lacking HMT cannot degrade histamine.

In the brain, the neurotransmitter activity of histamine is controlled by N(tau)-methylation.  It is disputed whether diamine oxidase is found in the central nervous system.  Some sources say it is not, but other studies specifically measure DAO levels in the brain, finding them elevated in schizophrenia.

A common genetic polymorphism affects the activity levels of HMT in red blood cells.  This can be tested for.

People with low levels of DAO will not be able to degrade histamine in their body nor, it appears to me, in the brain.

People with low levels of SAMe will not be able to degrade histamine as they should, that has crossed the BBB (blood brain barrier).  Those same low levels of SAMe will have raised the inflammatory cytokines and reduced the anti-inflammatory cytokines.

Methionine metabolism

I am always very wary when I see charts like the one below.  Often they are used to justify all kinds of strange ideas.  So the following methionine description is just a cut and paste from Wikipedia.

If anything goes wrong in this metabolism, you might indeed expect strange things to happen.  The ratio of SAMe/SAH is measurable  and tends to be markedly low in people with ASD.  This why DAN doctors use vitamin B12 injections, other B vitamins and other exotic sounding “supplements”.

Metabolic biomarkers of increased oxidative stress and impairedmethylation capacity in children with autism

Methionine is an essential amino acid that must be provided by dietary intake of proteins or methyl donors (choline and betaine found in beef, eggs and some vegetables). Assimilated methionine is transformed in S-adenosyl methionine (SAM) which is a key metabolite for polyamine synthesis, e.g. spermidine, and cysteine formation (see the figure on the right). Methionine breakdown products are also recycled back into methionine by homocysteine remethylation and methylthioadenosine (MTA) conversion (see the figure on the right). Vitamins B₆, B₁₂, folic acid and choline are essential cofactors for these reactions. SAM is the substrate for methylation reactions catalyzed by DNA, RNA and protein methyltransferases.

The products of these reactions are methylated DNA, RNA or proteins and S-adenosylhomocysteine (SAH). SAH has a negative feedback on its own production as an inhibitor of methyltransferase enzymes. Therefore SAM:SAH ratio directly regulates cellular methylation, whereas levels of vitamins B₆, B₁₂, folic acid and choline regulates indirectly the methylation state via the methionine metabolism cycle.^[44][45] A near ubiquitous feature of cancer is a maladaption of the methionine metabolic pathway in response to genetic or environmental conditions resulting in depletion of SAM and/or SAM-dependent methylation. Whether it is deficiency in enzymes such as methylthioadenosine phosphorylase, methionine-dependency of cancer cells, high levels of polyamine synthesis in cancer, or induction of cancer through a diet deprived of extrinsic methyl donors or enhanced in methylation inhibitors, tumor formation is strongly correlated with a decrease in levels of SAM in mice, rats and humans.^[46][47]

Low levels of SAMe do seem to cause problems in some people and it is straightforward to increase it.  You can either give extra SAMe, which is expensive, or L-methionine, which is cheap.

Interestingly, L-methionine is used at Johns Hopkins to treat autism and apparently is particularly effective at increasing speech.

If L-methionine was effective it could be for reasons including:-

·        cellular methylation was dysfunction

·        histamine in the brain had been elevated

·        the level of pro/anti-inflammatory cytokines had been out of balance 

Here are some examples of the use of SAMe (methionine)

S-Adenosyl-l-methionine(SAMe): from the bench to the bedside—molecular basis of a pleiotrophic molecule

In its native form, SAMe is labile and degrades rapidly. However, several patents for stable salts of SAMe have been granted. Among them, toluenedisulfonate and 1,4-butanedisulfonate forms have been chosen for pharmaceutical development, and as a result, preclinical and clinical studies have been performed. Numerous studies over the past 2 decades have shown that SAMe is effective in the treatment of depression (4–6), osteoarthritis (7–8), and liver disease (9–11). Moreover, SAMe has a very favorable side-effect profile, comparable with that of placebos. Thus, SAMe offers considerable advantages as an alternative to standard medications.

Depression

Clinical studies performed as early as 1973 indicated that SAMe had antidepressant effects (38). Over the next 2 decades, the efficacy of SAMe in treating depressive disorders was confirmed in > 40 clinical trials. Several review articles that summarize these studies were published in 1988 (4), 1989 (5), 1994 (6), and 2000 (12). In a meta-analysis, Bressa (6) reviewed 25 controlled trials including a total of 791 patients. The outcome of this analysis showed that SAMe had a significantly greater response rate than did placebo and was comparable to tricyclic antidepressants. Brown et al (12) summarized the literature on the use of SAMe in depressive disorders up to the time of publication in 2000; they reported that SAMe had been studied in 16 open, uncontrolled trials (660 patients); 13 randomized, double-blind, placebo-controlled trials (537 patients); and 19 controlled trials comparing SAMe with other antidepressants (1134 patients). Significant antidepressant effects were observed in all 16 open trials. In 18 controlled trials, SAMe was as effective as was impramine, chlorimipramine, nomifensine, and minaprine. An important observation from these studies is that SAMe had far fewer side effects than did standard medications.

Neurologic disorders

Several studies indicate that a CNS methyl group deficiency may play a role in the etiology of Alzheimer disease (AD). Reduced SAMe concentrations were found in CSF (34) and in several different brain regions (51) of patients with AD. In addition, reduced phosphatidylcholine concentrations were found in postmortem brain tissue from AD patients (52), and significant changes in brain phospholipids that are dependent on SAMe metabolism were detected in vivo with 31p magnetic resonance spectroscopy in the early stages of AD (53). Deficiencies of folate and vitamin B-12 are common in the elderly (39, 40) and can lead to decreased CNS SAMe concentrations. Several studies indicate that elevated blood homocysteine concentrations, considered to be a marker for folate deficiency, vitamin B-12 deficiency, and impaired methylation, may be a risk factor for AD (54–56). It is therefore important to note that preliminary studies using either SAMe (57) or alternative methyl group donors [such as betaine (58) or folate and vitamin B-12 (59, 60)] can improve measures of cognitive function. These treatments may be able to restore methyl group metabolism and normalize blood homocysteine concentrations. Reduced SAMe concentrations in CSF were also reported in patients with subacute combined degeneration of the spinal cord resulting from folate or vitamin B-12 deficiency (39) and in children with inborn errors of the methyl-transfer pathway who had demyelination (61). In these cases, treatment with methyl-group donors such as SAMe, methyltetrahydrofolate, betaine, and methionine was associated with remyelination and a clinical response (61).

Lancet. 1991 Dec 21-28;338(8782-8783):1550-4.

Association of demyelination with deficiency of cerebrospinal-fluid S-adenosylmethionine in inborn errors of methyl-transfer pathway.

We have shown that demyelination is associated with cerebrospinal-fluid S-adenosylmethionine deficiency and that restoration of S-adenosylmethionine is associated with remyelination.

Remyelination is also interesting.  Damage to the critical myelin layer has been suggested to occur with mitochondrial disease.  Most young people with autism show signs of mitochondrial disease (based on post mortem samples) but not old people with autism.

Demyelination is the loss of the myelin sheath insulating the nerves, and is the hallmark of some neurodegenerative autoimmune diseases, including multiple sclerosis.

Liver disease

The potential benefit of SAMe in treating liver disease stems from several important aspects of SAMe metabolism. In mammals, as much as 80% of the methionine in the liver is converted into SAMe (23). Hepatic glutathione, which is dependent on methionine and SAMe metabolism, is one of the principal antioxidants involved in hepatic detoxification. Studies have shown that abnormal SAMe synthesis is associated with chronic liver disease, regardless of its etiology. Early studies indicated that patients with liver disease are unable to metabolize methionine, resulting in elevated blood concentrations (67). Subsequent studies in patients with liver disease showed that the defect resulted from decreased activity of a liver-specific isoenzyme, MAT I/III; this defect effectively blocks the conversion of methionine to SAMe (68). Several well-designed experimental studies indicated that MAT I/III is regulated by cellular concentrations of both nitric oxide and glutathione. Thus, increased nitric oxide concentrations and decreased glutathione concentrations were shown to inhibit MAT I/III via mechanisms involving increased S-nitrosylation and free radical damage to the enzyme protein (69, 70). Experimental studies and clinical trials showed that parenteral and oral SAMe administration can increase glutathione concentrations in red blood cells (71) and in hepatic tissue (72, 73) and can effectively replenish depleted glutathione pools in patients with liver disease. The literature on the clinical potential of SAMe in the treatment of liver disease (including cholestasis, hepatitis, and cirrhosis) has been the subject of several review articles (9–11, 74, 75).

  

Osteoarthritis

The potential benefit of SAMe in treating osteoarthritis was discovered when patients enrolled in clinical trials of SAMe for depression reported marked improvement in their osteoarthritis symptoms (76). Nine clinical trials in Europe (77) and 1 in the United States (7) with a total of > 22 000 participants have confirmed the therapeutic activity of SAMe against osteoarthritis. SAMe has effects similar to those of the nonsteroidal anti-inflammatory drugs, but its tolerability is higher.

  

Back to DAO

I think we have established the one mechanism for histamine degradation has useful pointers for those interested in autism; now it is time to look at the other one.

D-amino acid oxidase (DAAO; also DAO, OXDA, DAMOX) is an enzyme. Its function is to oxidize D-amino acids to the corresponding imino acids, producing ammonia and hydrogen peroxide.

Recently, mammalian D-amino acid oxidase has been connected to the brain D-serine metabolism and to the regulation of the glutamatergic neurotransmission. In a postmortem study, the activity of DAAO was found to be two-fold higher in schizophrenia.
DAAO is a candidate susceptibility gene and may play a role in the glutamatergic mechanisms of schizophrenia.  Risperidone and sodium benzoate are inhibitors of DAAO.

Reviewing the role of the genes G72 and DAAO in glutamate neurotransmission in schizophrenia.

Abstract

We review the role of two susceptibility genes; G72 and DAAO in glutamate neurotransmission and the aetiology of schizophrenia. The gene product of G72 is an activator of DAAO (D-amino acid oxidase), which is the only enzyme oxidising D-serine. D-serine is an important co-agonist for the NMDA glutamate receptor and plays a role in neuronal migration and cell death. Studies of D-serine revealed lower serum levels in schizophrenia patients as compared to healthy controls. Furthermore, administration of D-serine as add-on medication reduced the symptoms of schizophrenia. The underlying mechanism of the involvement of G72 and DAAO in schizophrenia is probably based on decreased levels of D-serine and decreased NMDA receptor functioning in patients. The involvement of this gene is therefore indirect support for the glutamate dysfunction hypothesis in schizophrenia.

Increased brain D-amino acid oxidase (DAAO) activity in schizophrenia.

Abstract

D-serine has been shown to be a major endogenous coagonist of the N-methyl D-aspartate (NMDA) type of glutamate receptors. Accumulating evidence suggests that NMDA receptor hypofunction contributes to the symptomatic features of schizophrenia. d-serine degradation can be mediated by the enzyme d-amino acid oxidase (DAAO). An involvement of d-serine in the etiology of schizophrenia is suggested by the association of the disease with single nucleotide polymorphisms in the DAAO and its regulator (G72). The present study aims to further elucidate whether the DAAO activity is altered in schizophrenia. Specific DAAO activity was measured in postmortem cortex samples of bipolar disorder, major depression and schizophrenia patients, and normal controls (n=15 per group). The mean DAAO activity was two-fold higher in the schizophrenia patients group compared with the control group. There was no correlation between DAAO activity and age, age of onset, duration of disease, pH of the tissue and tissue storage time and no effect of gender, cause of death and history of alcohol and substance abuse. The group of neuroleptics users (including bipolar disorder patients) showed significantly higher D-amino acid oxidase activity. However, there was no correlation between the cumulative life-time antipsychotic usage and D-amino acid oxidase levels. In mice, either chronic exposure to antipsychotics or acute administration of the NMDA receptor blocker MK-801, did not change d-amino acid oxidase activity. These findings provide indications that D-serine availability in the nervous system may be altered in schizophrenia because of increased D-amino acid degradation by DAAO.

Association of the DAO and DAOA gene polymorphisms with autism spectrum disorders in boys in Korea: a preliminary study.

Abstract

We examined the association of autism spectrum disorders (ASD) with polymorphisms in the DAO and DAOA genes. The sample comprised 57 children with ASD, 47 complete trios, and 83 healthy controls in Korea. Although the transmission disequilibrium test showed no association, a population-based case-control study showed significant associations between the rs3918346 and rs3825251 SNPs of the DAO gene and boys with ASD.

The neurobiology of D-amino acid oxidase (DAO) and its involvement inschizophrenia

DAO as a target for the treatment of schizophrenia

As noted above, both D-serine and D-alanine show some effectiveness as add-on treatment in schizophrenia, in particular for the amelioration of negative and possibly cognitive symptoms. There are also comparable approaches and data regarding glycine augmentation. Since enzymes represent viable drug targets, DAO is receiving attention as a potential alternative therapeutic means to enhance NMDAR function in schizophrenia. The fact that DAO activity appears to be increased in schizophrenia provides another reason to propose that its inhibition might be beneficial. It is also intriguing that the original antipsychotic, chlorpromazine, was shown to be a DAO inhibitor in vitro over fifty years ago,² confirmed recently and also found to apply to risperidone; whether these observations are relevant clinically are unknown, but they do provide a precedent for the potential therapeutic benefits of selective DAO inhibitors.

To date there have been no clinical trials of DAO inhibitors in schizophrenia, but several preclinical studies which, although findings remain preliminary, show that inactivation of DAO, either in ddY/DAO- mice or after pharmacological DAO inhibition in rats and mice, produces behavioural, electrophysiological and neurochemical effects suggestive of a pro-cognitive profile (Table 4). The Table includes the three DAO inhibitors for which functional data have been published thus far: AS057278,¹⁰ CBIO,^201,203 and Compound 8.²⁰² Several other small molecule DAO inhibitors have been patented but their behavioural effects have yet to be reported.^62,204

Conclusions and future directions

DAO, as the enzyme which degrades the NMDAR co-agonist D-serine, has the potential to modulate NMDAR function and to contribute to NMDAR hypofunction in schizophrenia. Both genetic and biochemical data support an involvement of DAO in the disorder, however the processes involved are difficult to interpret. This is due to the many questions left unanswered concerning the neurobiology of DAO and its physiological roles. Notably there is still much that is unclear as to its localization and activity within the brain, and its spatial and functional relationships with its substrates. In addition, D-serine and thus DAO may have roles other than NMDAR modulation, whilst other DAO substrates, especially D-alanine, may also be relevant to any involvement of DAO in schizophrenia. Similarly, although recent preclinical data hint at potential therapeutic benefits of DAO inhibitors, extensive further study is required to establish their efficacy, tolerability, and mechanism.

Many drugs act as DAO inhibitors to a limited degree, even though this is not their intended mode of action.

We have heard about Sodium benzoate and Risperidone, but there are many others.

Evaluation of theinhibitory effect of various drugs / active ingredients on the activity ofhuman diamine oxidase in vitro

           

Results

Chloroquine and clavulanic acid showed greatest inhibition potential on diamine oxidase (> 90%). Cimetidine and verapamil showed inhibition of about 50%.

Moderate influence on DAO was caused by isoniazid and metamizole, acetyl cysteine and amitriptyline

(>20%). Diclofenac, metoclopramide, suxamethonium and thiamine have very low inhibition potential (<20%).  Interestingly cyclophosphamide and ibuprofen displayed no effect on DAO.

Conclusion

Since even levels of about 30% inhibition may be critical, most of the observed substances, can be designated as DAO inhibitors. Other drug components than active ingredients did not affect DAO activity or its interaction with a specific drug.

Note that cimetidine (Tagamet), a histamine H2-receptor antagonist drug used in promoting the healing of active stomach and duodenal ulcers.  Verapamil is in my “Polypill” and is a potent mast cell stabilizer.   Is this link back to histamine a coincidence?  I think not.

Antihistamine May Decrease Schizophrenia Symptoms

Histamine H₂ Receptor Antagonists in Schizophrenia

Histamine and schizophrenia

Conclusion

The experts are yet to conclude much, but it does seem that SAMe levels are low in autism and brain DAO levels are high schizophrenia (adult onset autism).  In Korea, DAO was shown to be dysfunction in autism.

It seems that, by coincidence, Risperidone happens to be an inhibitor of DAO and this indeed accounts for some its side effects.  Risperidone has actions at several 5-HT (serotonin) receptor subtypes, Dopamine receptors, Alpha α1/2 adrenergic receptors and even H1 histamine receptors.  Risperidone seems to be drug of last resort.

There are no selective DAO inhibitors currently in use.

We did see that two old drugs Tagamet and Verapamil are potent DAO inhibitors in vitro.

This suggest to me that while sodium benzoate has been trialed “successfully” in schizophrenia, perhaps it would be worth comparing the effect of Tagamet and Verapamil.

When it comes to autism/schizophrenia, it would seem that in some people one or more of the following might be helpful:-

·        Sodium benzoate, or cinnamon a precursor
·        Tagamet the H2 antihistamine, already used by some people with mastocytosis

 ·        Verapamil, the calcium channel blocker that actually does much more

·        SAMe, or L-methionine a precursor.