Autism and Non-Antibiotic Properties of Common Beta-lactam Antibiotics

If you are looking for personalized medicine, you or your doctor need to be a good detective. Not to mention you need some clues.

If you are treating a condition like autism and certain things cause a marked change in the severity of the condition, these are pretty good places to start.

In the case of our reader in Delhi, it is Beta-lactam antibiotics (penicillin, amoxicillin etc), that consistently seem to improve her son’s autism. Improvement during treatment with antibiotics is reported quite often in autism, but with all kinds of different antibiotic.  Nothing is simple.

For non-medical readers, there are several categories of antibiotics; common types including:-

·        Beta-lactams (e.g. Penicillins)

·        Macrolides (e.g. Erythromycin, Azithromycin)

·        Fluoroquinolones (e.g. Ciprofloxacin) 

·        Tetracyclines (e.g. Minocycline) 

Macrolides have already had a dedicated post about their immunomodulatory effects, which did also cover some history about Poland from Monty's homework.

Macrolide Antibiotics for Some Autism? Or better still, Azithromycin analogue CSY0073, or just Nystatin?

Beta Lactam Antibiotics

In earlier posts we came across something called glutamate transporter GLT1 (also known as EAAT2).

Glutamate is the major excitatory neurotransmitter, and is inactivated by uptake via GLT-1 (EAAT2) and GLAST (EAAT1) transporters.

Many people given the observational diagnosis of autism appear to have an underlying imbalance between excitatory and inhibitory neurotransmitters (E/I imbalance). By correcting the specific type of E/I imbalance, even profound symptoms of autism including MR/ID and epilepsy can be moderated. If you have autism and/or epilepsy tuning your E/I imbalance is likely the most important step you can take.

Some drugs increase the expression of GLT-1 and so reduce the amount of glutamate. Macrolide antibiotics are one of these drugs.

So if a person has too much glutamate and this causes/contributes to their E/I imbalance then improved behaviour while taking penicillin antibiotics, who have a simple explanation.

Since you would not want to take penicillin forever you would then look for a non antibiotic drug that also increases the uptake of Glutamate. Once such drug, Riluzole, does exist and has already been trialed on children with OCD. 

But beta-lactams have other effects, so it is not certain that GLT-1 accounts for the beneficial effect sometimes found in autism. Fortunately some researchers have assembled most previous research into a single review paper. This paper does not mention autism and does miss some things out.

Review of Antibiotic and Non-Antibiotic Properties of Beta-lactam Molecules.

There are seven categories:-

·        Antibiotic

·        Epileptogenic

·        Neuroprotective

·        Analgesic

·        Immunomodulatory

·        Anxiolytic

·        Antineoplastic

Antibiotic Effect

We all know something about bacteria. If you have a bacterial infection like an ear infection your doctor might prescribe you an antibiotic.

As well as inflaming your ear, the bacteria may well affect gene expression. We saw in a previous post that bacteria and viruses change the expression of many genes, but the study of this is in its infancy. In autism we know that many genes are miss-expressed, but this varies from person to person. So a bacteria or virus has the potential to make autism worse (e.g. PANS and PANDAS), but also better. Bacteria are not always bad.

A person whose autism responds to an antibiotic might have bacteria that are worsening his autism. This is simplest of explanation of all.

The question then is where is the bacteria? If it is an intestinal bacterium this could be proven by using an antibiotic that only works there, like Vancomycin.

Epileptogenic effects

In this review they concluded the effects relate to GABA and here we are talking about negative effects. 

penicillin is a potent epileptogenic agent = it is capable of causing an epileptic attack

“This could mean that penicillin is a competitive GABA specific antagonist, which would further explain its epileptogenic properties.”

The paper omits to point out that in some people beta-lactams protect from epileptic seizures. The effect on Glutamate is likely at least sometimes what stops seizures.

Beta-Lactam Antibiotics as A Possible Novel Therapy for Managing Epilepsy and Autism, A Case Report and Review of Literature

The really clever thing in the above case report is that appears that the effect on glutamate may be by an epigenetic mechanism (via GLT1), since the effect is long lasting. Read later in this post about the epigenetic effects of beta-lactams.

Neuroprotective properties

“These results suggest that the neuroprotective effect induced by beta-lactam antibiotics is due to their capacity to stimulate GLT1 expression and thus regulate the concentration of glutamate in the synaptic cleft. GLT1 is a glutamate transporter inducing its reuptake by astrocytes preventing excessive glutamate concentration in the synaptic cleft

It was subsequently shown that the neuroprotective effect of BLMs was due not only to glutamate down regulation, but also to a diminished glutamate-induced intracellular Ca2+ concentration and an increased uptake of glutamate

Another probable mechanism of neuroprotection induced by BLMs is down-regulation of oxidative stress and modulation of apoptotic pathways shown in rat spinal cord when CFX was administered for 7 days prior to induction of constrictive neuropathy. This effect was apparently mediated by both a reduction in proapoptotic proteins Bax, and an increment in the antiapoptotic protein Bcl2.

CFX (Ceftiaxone) may induce neuroprotection by other mechanisms besides GLT1 overexpression. Yamada and Jinno [51] reported that the antibiotic reversed axotomy-induced up regulation of GFAP, a neuronal damage marker, and increased neuronal survival; apparently not only through glutamatergic regulation, but also by direct reduction of glial hypereactivity. Supplementary to this is the finding of an attenuation of microglial activation induced IL-1 expression in an ischemic injury model when CFX was administered as a pre-treatment [52]. This result may indicate a direct action on glial cells since partial reduction of astrocytes and microglia was observed.”

Analgesic (pain killing) Properties

“Interestingly, despite the widespread clinical use of BLMs (beta-lactams), some of their known non-antibiotic effects have been either disregarded or misinterpreted as resulting from bacterial microbiome regulation. For example, Caperton, Heim-Duthoy [54] hypothesized that chronic inflammatory arthritis could have a bacterial component and that therefore the clinical course of a patient could be affected by administration of CFX (Ceftriaxone).

Both the anti-inflammatory and neuromodulating effects exerted by BLMs either peripherally or centrally may be related to their analgesic properties in some pathologies that are difficult to treat such as the complex regional pain syndrome [65] or to the analgesic effect of a single preoperative dose of CFX in a clinical protocol [66].

Immunomodulatory Properties 

Not many people seem to have read this paper. They did not flesh out immunomodulation, so I draw on a different paper. People who write about immunomodulation usually say that beta-lactams do not have this effect, but that appears to be incorrect. 

Beta-lactam antibiotics modulate T-cell functions and gene expression via covalent binding to cellular albumin

Recent work has suggested that beta-lactam antibiotics might directly affect eukaryotic cellular functions. Here, we studied the effects of commonly used beta-lactam antibiotics on rodent and human T cells in vitro and in vivo on T-cell–mediated experimental autoimmune diseases. We now report that experimental autoimmune encephalomyelitis and adjuvant arthritis were significantly more severe in rats treated with cefuroxime and other beta-lactams. T cells appeared to mediate the effect: an anti-myelin basic protein T-cell line treated with cefuroxime or penicillin was more encephalitogenic in adoptive transfer experiments. The beta-lactam ampicillin, in contrast to cefuroxime and penicillin, did not enhance encephalomyelitis, but did inhibit the autoimmune diabetes developing spontaneously in non-obese diabetic mice. Gene expression analysis of human peripheral blood T cells showed that numerous genes associated with T helper 2 (Th2) and T regulatory (Treg) differentiation were down-regulated in T cells stimulated in the presence of cefuroxime; these genes were up-regulated in the presence of ampicillin. The T-cell protein that covalently bound beta-lactam antibiotics was found to be albumin. Human and rodent T cells expressed albumin mRNA and protein, and penicillin-modified albumin was taken up by rat T cells, leading to enhanced encephalitogenicity. Thus, beta-lactam antibiotics in wide clinical use have marked effects on T-cell behavior; beta-lactam antibiotics can function as immunomodulators, apparently through covalent binding to albumin.

 Anxiolytic effects (reduce anxiety)

“CA (Clavulanic acid) has proven effective as an anxiolytic drug, since it was reported that this drug diminished anxiety-like conduct in both rodent and primate models”

Antineoplastic effects (preventing tumors)

“CFX (Ceftriaxone) elicit antitumor activity both in vitro and in vivo models”

Addiction

Addiction did not appear in the chart above, but it gets a mention in the text 

“When tested in an opiate dependence model, both CFX [72] and CA [73] inhibited both physical dependence and withdrawal symptoms. This could mean that the effect shown by CFX is not due to its particular molecular structure, but can be reproduced by other BLMs (several BLMs effects shown on Fig. 3)

Other effects

“CA (Clavulanic acid) has been shown to increase dopamine release”

Epigenetic Effects

These were not mentioned in the paper, but I do think epigenetics is a fundamental part of many diseases, including much autism.

The paper really explains why short term use of beta-lactams can stop a person with epilepsy having seizures for a long time.

Off-Target drug effects resulting in altered gene expression events with epigenetic and"Quasi-Epigenetic" origins.

This review synthesizes examples of pharmacological agents who have off-target effects of an epigenetic nature. We expand upon the paradigm of epigenetics to include "quasi-epigenetic" mechanisms. Quasi-epigenetics includes mechanisms of drugs acting upstream of epigenetic machinery or may themselves impact transcription factor regulation on a more global scale. We explore these avenues with four examples of conventional pharmaceuticals and their unintended, but not necessarily adverse, biological effects. The quasi-epigenetic drugs identified in this review include the use of beta-lactam antibiotics to alter glutamate receptor activity and the action of cyclosporine on multiple transcription factors. In addition, we report on more canonical epigenome changes associated with pharmacological agents such as lithium impacting autophagy of aberrant proteins, and opioid drugs whose chronic use increases the expression of genes associated with addictive phenotypes. By expanding our appreciation of transcriptomic regulation and the effects these drugs have on the epigenome, it is possible to enhance therapeutic applications by exploiting off-target effects and even repurposing established pharmaceuticals. That is, exploration of "pharmacoepigenetic" mechanisms can expand the breadth of the useful activity of a drug beyond the traditional drug targets such as receptors and enzymes.

DAO inhibition

As our reader Agnieszka pointed out in the comments section, one commonly prescribed beta-lactam antibiotic called Augmentin contains a second antibiotic, Clavulanic acid, to boost its effectiveness; by chance is also a very potent DAO inhibitor. Diamine oxidase (DAO), also known as histaminase, is an enzyme in your body that is used to inactivate histamine. Histamine is found in food that you eat as well as being produced in your body and released by your mast cells during an allergic reaction.

DAO neutralizes the histamine in food so it does not enter your bloodstream.

So this particular antibiotic should be avoided by those people who are histamine intolerant and so do not produce enough DAO. This is about 1% of the general population, but might be more common in those with autism although there is no data on this subject.

Some people believe that ADHD is associated with a reduced level of DAO.

Indeed there is a patent to treat ADHD with a combination of DAO and caffeine.

Diamine oxidase for use in the treatment or prevention of attention deficit hyperactivity disorder (ADHD)

[0087] DAO can also be mixed with caffeine, strengthening the role of prevention and treatment of attention deficit hyperactivity disorder. Thus, also disclosed herein compositions comprising DAO and caffeine. 

[0088] Caffeine, a xanthine alkaloid group having stimulating properties for the treatment of attention deficit hyperactivity disorder. 

[0089] DAO content of the present invention per unit dose 0 · l-50mg, preferably 2-20mg. 

[0090] The present invention is caffeine content per unit dose 1-lOOmg, preferably 5-50mg. 

[0091] for the prevention and treatment of attention deficit hyperactivity disorder DAO or compositions comprising DAO may be before a meal or postprandial meal administration.

[0092] The use of DAO of the invention or compositions comprising DAO directly affect blood histamine levels, thus affecting the symptoms of attention deficit cumulative histamine levels induced hyperactivity disorder.

You can actually buy DAO supplements and of course caffeine.

Perhaps people consuming DAO inhibitors long term, such as NAC and Verapamil, and have chronic allergies or mast cell disorders might benefit from extra DAO. 

Evaluation of the inhibitory effect of various drugs / active ingredients on the activity of human diamine oxidase in vitro

Most DAO is actually in your digestive tract, where the dietary histamine is.

You can measure DAO levels in your blood.

Serum diamine oxidase (DAO) activity as a diagnostic test for histamine intolerance  

We can conclude that determination of DAO activity in serum is a useful diagnostic tool, together with detailed history to differentiate between food allergy and histamine intolerance.

We found that DAO activity was significantly lower in patients than in healthy control subjects.

Conclusion

I think there is plenty of food for thought here for parents of children whose autism and/or epilepsy improves when taking a beta-lactam antibiotic.  Hopefully some people will figure out which effect is the beneficial one and find something else to replicate it.

There is a lot previously written in this blog about upregulating GLT1, other than by a beta-lactam. My favoured option was Riluzole, but Bromocriptine will also do this, among its other actions. Riluzole is a drug for ALS, that has been trialed in children with OCD, without side effects.    

People technically without histamine intolerance (normal levels of DAO) who incidentally take large amounts of DAO inhibitors, may end up exacerbating an existing mast cell related problem. One potential solution for that small group might be taking an OTC DAO supplement.

Winter Olympics

Today’s post is about the non-academic benefits of treating classic autism, which mainly seem to come from raising cognition (IQ).

Our reader Liz from Australia, whose five year old daughter has been using Bumetanide for two years, was telling us recently in her comments how her daughter can now go surfing with her four brothers.

While we do all want success at school and mastering practical skills like doing up shoe laces, the importance of being able to actively participate with siblings should not be underestimated.

Some siblings may be angels, but quite often there is resentment about having a sibling with special needs. One way to compensate is to have cool talents like surfing, skiing, fencing - something you can do well.

When I started this blog I was contacted by an Australian doctor who has a son with autism, she went to the same university as me. Her son was diagnosed early with severe autism with MR/ID, but progressed remarkably well and attended a mainstream school. His chosen sport at school was fencing (sword fighting). At that time Monty’s big brother was also having fencing classes and had all the equipment. I recall at the time thinking there is no way Monty could ever do that. Five years later though, Monty and his big brother are fighting together with homemade swords.

Fencing can look very impressive and certainly seems to count as a cool activity by modern day teenagers.

The main sport of Monty, now aged 14 with autism, is swimming - particularly underwater. While people with classic autism are at a greatly elevated risk of drowning, that is no longer something we have to worry about. Monty is more likely to be the rescuer than the one in trouble. If we lived in Australia, he too would be going to the beach to surf.

We did have swimming lessons, but only post-Polypill did Monty get competent. Now he swims really well and can swim a very long way underwater.

I do think that things that improve exercise endurance may be helpful to those with a neurological condition like autism. Just look what Nordic skiers, cyclists and tennis stars get into trouble for taking - much relates to getting more output from your mitochondria.  High altitude training is not an option for us, but swimming underwater may have a similar effect. There actually is research about what changes biologically in endurance divers (holding their breath) and people who train at high altitude. I suspect that moderate diving may improve brain perfusion, extreme diving is different because they are functioning when a typical person would have lost consciousness due to lack of oxygen. Moderate diving, like high altitude training, should increase how much oxygen your blood can carry.

Native Andean and Himalayan populations have better oxygenation at birth, enlarged lung volumes throughout life, and a higher capacity for exercise. Tibetans demonstrate a sustained increase in cerebral blood flow, but a typical hemoglobin concentration, whereas in the Andes they have significantly elevated levels of hemoglobin. Hemoglobin/haemoglobin is the protein in your blood that transports the oxygen around your body.  How do the Tibetans manage without extra hemoglobin?

“The Tibetan hemoglobin distribution closely resembled that from a comparable, sea-level sample from the United States whereas the Aymara (Andes) distribution was shifted toward 3-4 gm/dl higher values.”

https://www.researchgate.net/publication/13589414_Hemoglobin_concentration_of_high-altitude_Tibetans_and_Bolivian_Aymara

The performance-enhancing effect of altitude training appears not to be due to increased red blood cell count or increased hemoglobin, as thought until recently, but rather something called Red Blood Cell (RBC) Hypoxic Metabolic Reprograming.

In essence, the hemoglobin becomes better at holding on to oxygen. Perhaps this is what Tibetans do.

Lay people suggest that:

More hemoglobin = More oxygen delivery.

It appears that you do not need more hemoglobin, you just need to make your existing hemoglobin work better.  And for that you need to give it a challenge; perhaps regularly swimming a long way on a single breath counts?

Two weeks in the mountains can change your blood for months

When scientists examined the oxygen-carrying proteins, known as hemoglobin, in volunteers’ red blood cells, they found multiple changes affecting how tightly it hung onto its oxygen load. Roach says a simplistic analogy is comparing this to what happens when baseball players loosen their grip on a mitt. “If I relax my hand, it will let go of the ball,” he says. Such changes had been observed before in the lab, but never in humans, and never at high altitude, the team reports this month in the Journal of Proteome Research. The scientists also found that the metabolic processes producing these changes were considerably more complex than suspected. And because red blood cells live for about 120 days, the changes last as long as the cells do.

Red Blood Cell (RBC) Hypoxic Metabolic Reprograming

Skiing

Skiing is popular where we live and most children from our school go once a year, either with school or with their family. 

Unless you live in the mountains, skiing is not a sport people do very often and so you could question whether it is worth all the expense. 

Monty started skiing when he was five with a couple of instructors who had recently started a ski school in Zell am See in Austria, just for children with disabilities like autism.

In the beginning just putting on all the equipment and riding up the mountain in the cable car was a big challenge.  It certainly was a case of stepping out of his comfort zone.  Having started we did persevere, in part so that big brother also had his chance to learn to ski.

2018 was the first week of skiing without any lessons.

This year big brother was concerned that he would have no one to ski with and was planning to make new friends on the slopes.

He did agree that he would ski with little brother, but much to his surprise spent the whole week skiing with him. It was not at all what he had expected. They could ski all over the resort using multiple types of ski lift. Who lost his ski while on a chair lift and had it fall into the trees? Not Monty, who had to ski by himself to the bottom of the slope while big brother retrieved his ski.

Being left alone at the top of the mountain, might have been a cue for one of those old-time “meltdowns”, but much to big brother’s surprise, Monty just skied alone down the mountain and waited for him, once he had found his missing ski. No awkward explaining to parents what had happened to Monty was required.

So then big brother decided to teach Monty how to do ski jumps, just like any regular teenager.

Both have been skiing for 8 years. Monty skis on red slopes (medium difficulty), whereas his brother would also go on the black slopes (the hardest).

Regarding myelination from a recent post, many people (like me) who learn skiing in adulthood often never myelinate their “skiing neuronal pathways” and so each year you come back as a near beginner. This is clearly not the case with Monty, he now retains his skiing skills, even though he has not used them for a year. 

Other Sports

Trampolining is something remarkably popular among people with severe autism. I suppose this is all about seeking sensory stimulation. Monty loves water slides and we used to know twins with autism/Asperger’s who were obsessed with roller coasters.

There is a common view that if you have a mental disability you must have a physical disability. Monty’s new teachers at high school were surprised when they learnt he skis just like a regular boy. Of course he showed the ski jump video to his classmates.

Conclusion

While you can ski with an IQ less than 70, as in Down Syndrome and most Classic Autism, it goes even better when you boost IQ.

I imagine the same applies to surfing and other water sports like sailing.

Clearly raising IQ means parents have far less safety issues to worry about.

Music of course is another great potential area for people with autism and Asperger’s. I wrote a post a long time ago about talents and savants, suggesting that people with autism really should be encouraged to use their abundant free time to develop such skills. Many people already do. Most of the Asperger’s people I have come across are now very talented musicians, practising hours every day. One is also an excellent skier on black slopes.

Verapamil or Rezular (R-verapamil) for Irritable Bowel Syndrome (IBS)?

A nasty condition that is equally nasty to spell - diarrhoea/diarrhea

Today’s post may help to explain why some people’s GI problems seem to vanish when they take Verapamil for their autism.

Verapamil is usually prescribed as an L-type calcium channel blocker, to lower blood pressure. This type of ion channel is widely expressed in the brain, the heart and the pancreas. The pancreas is where your body makes those digestive enzymes. Mast cells that release histamine also contain L-type calcium channels.

Verapamil blocks the L-type calcium channel Cav1.2, which in posts a few years ago I showed could be relevant for some types of autism. An extreme dysfunction of this ion channel leads to Timothy Syndrome, which is a single gene variant of autism with severe heart defects.  There is now some more recently published research which I have highlighted below.

L-type calcium channels as drug targets in CNS disorders

L-type calcium channels are present in most electrically excitable cells and are needed for proper brain, muscle, endocrine and sensory function. There is accumulating evidence for their involvement in brain diseases such as Parkinson disease, febrile seizures and neuropsychiatric disorders. Pharmacological inhibition of brain L-type channel isoforms, Cav1.2 and Cav1.3, may therefore be of therapeutic value. Organic calcium channels blockers are clinically used since decades for the treatment of hypertension, cardiac ischemia, and arrhythmias with a well-known and excellent safety profile. This pharmacological benefit is mainly mediated by the inhibition of Cav1.2 channels in the cardiovascular system. Despite their different biophysical properties and physiological functions, both brain channel isoforms are similarly inhibited by existing calcium channel blockers. In this review we will discuss evidence for altered L-type channel activity in human brain pathologies, new therapeutic implications of existing blockers and the rationale and current efforts to develop Cav1.3-selective compounds.

From Gene to Behavior: L-Type Calcium Channel Mechanisms Underlying Neuropsychiatric Symptoms.

The L-type calcium channels (LTCCs) Ca_v1.2 and Ca_v1.3, encoded by the CACNA1C and CACNA1D genes, respectively, are important regulators of calcium influx into cells and are critical for normal brain development and plasticity. In humans, CACNA1C has emerged as one of the most widely reproduced and prominent candidate risk genes for a range of neuropsychiatric disorders, including bipolar disorder (BD), schizophrenia (SCZ), major depressive disorder, autism spectrum disorder, and attention deficit hyperactivity disorder. Separately, CACNA1D has been found to be associated with BD and autism spectrum disorder, as well as cocaine dependence, a comorbid feature associated with psychiatric disorders. Despite growing evidence of a significant link between CACNA1C and CACNA1D and psychiatric disorders, our understanding of the biological mechanisms by which these LTCCs mediate neuropsychiatric-associated endophenotypes, many of which are shared across the different disorders, remains rudimentary. Clinical studies with LTCC blockers testing their efficacy to alleviate symptoms associated with BD, SCZ, and drug dependence have provided mixed results, underscoring the importance of further exploring the neurobiological consequences of dysregulated Ca_v1.2 and Ca_v1.3. Here, we provide a review of clinical studies that have evaluated LTCC blockers for BD, SCZ, and drug dependence-associated symptoms, as well as rodent studies that have identified Ca_v1.2- and Ca_v1.3-specific molecular and cellular cascades that underlie mood (anxiety, depression), social behavior, cognition, and addiction.

I have crossed these ion channels off my “to do” list because I have found an effective therapy that works for my son and for the children of some other readers.  It does not work for everyone, but that should not come as a surprise. I think those with mast cell disorders and/or major GI problems are most likely to be responders. 

As well as halting the cascade of anxiety towards self-injury, reducing allergy, it was reported that Verapamil made long term GI symptoms vanish.

In your pancreas β-cells make insulin. These β-cells have Cav1.2 calcium channels. In people with type-1 diabetes their β-cells have died so their pancreas produces no insulin. In people with the increasingly common type-2 diabetes, they start out with enough insulin but their body has a reduced sensitivity to it; often as they age their β-cells begin to die, at which point they start having to inject insulin like a type-1 diabetic. We saw that by blocking Cav1.2 you can stop these β-cells from dying. This means that a person with type-2 diabetes should take Verapamil to maintain their pancreas producing insulin.

Without wanting to go further into how the pancreas functions, I assumed that perhaps there were other Cav1.2 calcium channels involved in producing enzymes in the pancreas that might result in digestive problems in some people, that in turn produce symptoms of IBS.

I already highlighted in a post that Verapamil also affects an interesting potassium channel called Kv1.3. This channel is involved in the inflammatory response and this is the channel that TSO parasites use to trick their host into not attacking and expelling them.

It appears that Kv1.3 is over expressed in auto-immune diseases including MS. So inhibitors of this ion channel are potential treatments for MS. Add TSO parasites to that list of novel MS therapies!

Some venoms are Kv1.3 inhibitors and may form the basis of new drugs.

Toxins Targeting the KV1.3Channel: Potential Immunomodulators for Autoimmune Diseases

Since autism is in-part an auto-immune disease a Kv1.3 inhibitor could be therapeutic.
Verapamil does inhibit Kv1.3, but I do not know if it is to a therapeutic extent.  Most drugs have numerous effects but only one dominant one.


Melatonin MT1 and Serotonin 5-HT2b receptors

Today we learn that two further receptors are affected by Verapamil, one Melatonin and one Serotonin.

Melatonin, at high doses, we saw in an old post has potent beneficial effects on some GI conditions and trials showed it to be as effective as prescription drugs for those conditions. Melatonin is very cheap, but cannot be patented, so will not be researched seriously.

The two isomers of Verapamil

When you think of a chemical you may think of its formula, but it can be more complex, as you might have learnt in high school chemistry.

The two compounds below are both thalidomide. R-thalidomide is effective against  insomnia and morning sickness, but the mirror image called L-thalidomide can cause birth defects.

This was discovered too late, for many people.

Many drugs are a mixture of Right and Left, confusingly they like to also call Left “S”. In Latin sinister is the adjective left and dexter is the adjective for right.

Recall Arbaclofen (R-Baclofen) ? I am sure Roche does, a $40 million bet that did not pay off.

Now we have R-Verapamil.

Pharmacology of R-Verapamil: A Novel Therapy in IBS

John Devane, Mary Martin, John Kelly

Racemic verapamil, primarily a cardiovascular agent, has been widely used off-label in patients with irritable bowel syndrome (IBS). Initial observations of its usefulness followed recognition of a high incidence of constipation with use in cardiovascular conditions. The enantiomers of verapamil are known to differ in cardiovascular potency, the S-isomer being much more potent than the R-isomer. In addition we found the S-isomer to be equiactive in relaxing vascular and colonic smooth muscle but the R-isomer to be 5-times more potent in relaxing colonic than vascular muscle. This selectivity led us to develop R-verapamil (Rezular) as a gut selective treatment in IBS and we have shown doses from 60mg/day to 240mg/day to greatly improve symptoms in non-constipation IBS patients. To better understand the mechanism by which R- verapamil improved the symptoms of IBS, we undertook an in-vitro screen of binding of R-verapamil to 147 receptors/receptor sub-types. Specific ligand binding was initially assessed using 10x-5 M verapamil and if there was greater than 50% inhibition of control specific binding, then binding at 8 different concentrations was tested andIC50 values (concentrationfor half-maximalinhibition of controlspecific binding (x10 -7M)) calculated. The therapeutic plasma concentration range of free R-verapamil was conservatively set at 0.1-3x10-7 M. Within this range R-verapamil showed affinity for 3 receptors: melatonin (MT1)(IC50 0.6), 5-HT2b (IC50 1.1) and L-type calcium channel (IC50 2.4). In addition compared with S-verapamil, R-verapamil showed stereoselectivity x40)for MT1 binding, whereas S-verapamil showed stereo selectivity (x3) for L-type calcium channel binding. R-Verapamil was selective for 5-HT2b relative to other 5-HT receptor sub types and affinity was low for 5-HT3(IC 50 3,400) or 5-HT4(>100) receptors.It was also highly selective for MT1(IC50 0.6) versus MT2 (IC50 >100) receptors. We conclude that R verapamil most likely exerts its therapeutic effects in IBS via a previously unrecognized mechanism involving combined effects at melatonin receptors, serotonin receptors and L type calcium channels

  

https://www.drugdevelopment-technology.com/projects/rezular/

"In May 2009, Rezular (arverapamil) failed in Phase III development, where it underwent extensive evaluation in the ARDIS clinical trial programme in patients with IBS-D.

Phase III trials were taken up with patients already receiving treatment in the ARDIS-1 trial. In this randomised, double-blind, placebo-controlled, parallel group the efficacy and safety of Rezular (arverapamil) was assessed in about 1,200 patients.

Three doses of Rezular (arverapamil) were compared with placebo over a 12-week treatment period.

In September 2009, AGI announced that it plans to consider alternative uses of Rezular. The company believes that Rezular can prove effective in treating diarrhoea and non-diarrhoea related problems.

IBS is a common, but until recently poorly understood, disorder of the gastrointestinal (GI) tract. It is described as a functional disorder of the GI tract, in which there is no obvious underlying pathology.

IBS has proved notoriously difficult to diagnose and treat effectively. Until recently no drugs were specifically indicated for the treatment of IBS. Instead, patients would often seek over-the-counter (OTC) remedies to treat constipation, diarrhoea, abdominal pain and bloating associated with IBS.

AGI Therapeutics, Rezular (arverapamil) is a single enantiomer moiety of racemic verapamil, a cardiovascular drug that has been in clinical use for 35 years.

However, in contrast to currently available commercial forms of racemic verapamil (a mixture of two enantiomers), arverapamil shows preferential activity in treating the symptoms of IBS-D without the traditional cardiovascular actions of the racemic drug. It combines affinity at L-type calcium channels with 5-HT_2b and melatonin (MT1) receptor binding.

Gut function is controlled by both the enteric (intestinal) nervous system (ENS) and CNS, in which the neurotransmitter serotonin (5-HT) plays a fundamental role. Serotonin is present in large amounts in the ENS where it is involved in sensory, motor and secretory processes within the gut. It modulates gut motility and the perception of pain and also mediates intestinal secretion. Minor disturbances in serotonergic function can lead to symptoms of IBS described above."

Irritable bowel syndrome (IBS) is a common comorbidity of autism.

According to the Mayo Clinic:-

https://www.mayoclinic.org/diseases-conditions/irritable-bowe

l-syndrome/symptoms-causes/syc-20360016

IBS is a chronic condition that you'll need to manage long term.

Only a small number of people with IBS have severe signs and symptoms. Some people can control their symptoms by managing diet, lifestyle and stress. More-severe symptoms can be treated with medication”

The precise cause of IBS isn't known. Factors that appear to play a role include:

·       Muscle contractions in the intestine. The walls of the intestines are lined with layers of muscle that contract as they move food through your digestive tract. Contractions that are stronger and last longer than normal can cause gas, bloating and diarrhea. Weak intestinal contractions can slow food passage and lead to hard, dry stools.

• Nervous system. Abnormalities in the nerves in your digestive system may cause you to experience greater than normal discomfort when your abdomen stretches from gas or stool. Poorly coordinated signals between the brain and the intestines can cause your body to overreact to changes that normally occur in the digestive process, resulting in pain, diarrhea or constipation.
• Inflammation in the intestines. Some people with IBS have an increased number of immune-system cells in their intestines. This immune-system response is associated with pain and diarrhea.
• Severe infection. IBS can develop after a severe bout of diarrhea (gastroenteritis) caused by bacteria or a virus. IBS might also be associated with a surplus of bacteria in the intestines (bacterial overgrowth).
• Changes in bacteria in the gut (microflora). Microflora are the "good" bacteria that reside in the intestines and play a key role in health. Research indicates that microflora in people with IBS might differ from microflora in healthy people.

Triggers

Symptoms of IBS can be triggered by:

• Food. The role of food allergy or intolerance in IBS isn't fully understood. A true food allergy rarely causes IBS. But many people have worse IBS symptoms when they eat or drink certain foods or beverages, including wheat, dairy products, citrus fruits, beans, cabbage, milk and carbonated drinks.
• Stress. Most people with IBS experience worse or more frequent signs and symptoms during periods of increased stress. But while stress may aggravate symptoms, it doesn't cause them.
• Hormones. Women are twice as likely to have IBS, which might indicate that hormonal changes play a role. Many women find that signs and symptoms are worse during or around their menstrual periods.

Research shows that some people with IBS report improvement in diarrhea symptoms if they stop eating gluten (wheat, barley and rye) even if they don't have celiac disease.

Rezular – Patent for Oral Treatment for IBS

http://www.google.com.na/patents/WO2009090453A2?cl=ko

  

Conclusion

I guess we may never know why some people’s IBS responds to Verapamil. It is likely because of one of the following:-

The experts suggested:-

     ·      Cav1.2
·      Melatonin MT1
·      Serotonin 5-HT2b

I earlier proposed (in addition to Cav1.2)

•   ·      Kv1.3

R-Verapamil failed in its trial for IBS-D (IBS that causes increased diarrhoea is often called IBS-D).

But Verapamil clearly does help some types of IBS, you would just have to try it. I did try it on myself and it worked for me.

This post again shows the limitations of clinical trials, because we actually do know Verapamil does resolves the GI problems of some people.

Perhaps they got it all wrong and should have trialed S-Verapamil, or indeed just the regular mixture of Verapamil. They did not do the latter because how do you patent/make money out of an existing ultra-cheap generic drug? One pack costs $1.

It looks strange to me that people with Type-2 diabetes are not prescribed Verapamil, it might save a lot of insulin injections later in their lives. 

Online Autism Communities

I am often surprised what counts as academic research these days, but I stumbled upon one such paper that I thought might be of general interest.

It is a study from 2017 of the 550,000 comments left on two popular forums, autismweb.com and autism-pdd.net. Both of these forums have since closed down.

Cataloguing Treatments Discussed and Used in Online Autism Communities

A large number of patients discuss treatments in online health communities (OHCs). One research question of interest to health researchers is whether treatments being discussed in OHCs are eventually used by community members in their real lives. In this paper, we rely on machine learning methods to automatically identify attributions of mentions of treatments from an online autism community. The context of our work is online autism communities, where parents exchange support for the care of their children with autism spectrum disorder. Our methods are able to distinguish discussions of treatments that are associated with patients, caregivers, and others, as well as identify whether a treatment is actually taken. We investigate treatments that are not just discussed but also used by patients according to two types of content analysis, cross-sectional and longitudinal. The treatments identified through our content analysis help create a catalogue of real-world treatments. This study results lay the foundation for future research to compare real-world drug usage with established clinical guidelines.

Top 10 treatment by number of users, identified in the ASD data set:-

Term	Number of users
Probiotics	819
speech therapy	565
Chelation	520
early intervention	475
special education	395
Melatonin	391
Antibiotics	381
Enzymes	352
Zinc	332
Vitamins	283

The most important building block of future work following this study is to compare the list of treatments discovered in OHCs automatically by the computational tool with established clinical guidelines. For example, while effectiveness of chelation is still under investigation by researchers, it already becomes a rather popular choice among autism community members. It is therefore critical to further quantify how broad the gap is between established guideline and patients’ actual practice. The future work will contribute to understanding how information support and consumption in OHC affect members’ decision makings regarding disease management, and hence how OHC participation makes physical and psychological impact.

I think what is happening is these kind of discussions have moved to other channels like Facebook and also that discussions are going on in closed groups, rather than in public.

Online communities for very rare, but well defined, disorders seem like a great idea and allow people to connect with others facing the same challenges.

This blog is public and so all kinds of people read it, some of whom would never join a closed group. Most readers are parents who come via Google or Facebook, some are regular readers, some are doctors, but there are researchers and even drug producers. Readership is very much skewed to North America. Australia and Eastern Europe are over-represented while the United Kingdom is slightly under-represented. There are almost no readers from Germany and Austria (the original home of autism and Asperger’s), but a fair number from France and not only Bumetanide researchers

The experimental approach put forward here is unorthodox and I know that some researcher readers do not entirely approve, but it is the end result that matters. 

I think the fact that some researchers are aware that lay people are reading about their research, and some are even applying it, is a good thing.

The online communities tend to be discussing supplements and the protocols of alternative doctors. This blog is looking at science and, based on that, seeing what drugs might be therapeutic; this narrows the potential audience somewhat because things do get rather complicated. 

I do not know if anyone has analysed all the comments in this blog, if they did they would see that a small but growing number of people have impressive long term results from repurposing some safe old generic drugs.  Because most people want to be anonymous, these comments do not carry the weight of case reports published in journals, but I think they can still be very useful.

I think only a small proportion of readers actually get access to the novel therapies indicated by the research, it all depends on where you live. Living in a Latin country, or being a doctor clearly helps.