"Mitochondrial Modifying Nutrients" and chronic fatigue syndrome: a pilot study

"Recent evidence suggests that mitochondrial dysfunction may play a role in the pathophysiology of chronic fatigue syndrome (CFS)" was the starting point for the study results reported by Ranjit Menon and colleagues [1].

Detailing findings -  "open-label trial" findings - following use of a 'nutraceutical combination' in a small number of participants with CFS, researchers produced evidence that further investigations might be needed. The trial protocol for their investigation can be viewed here. The 'combination' under inspection included "primary nutrients: Coenzyme Q10, Alpha lipoic acid, Acetyl-l-carnitine, N-acetyl cysteine, B Vitamins"; many of which have been shown to act on various "mitochondrial targets" in the context that mitochondria might play a role in at least some cases of CFS (see here for example), but not necessarily all (see here). Indeed, I'll draw your attention when other groups have talked about nutraceutical 'intervention' (see here) in the context of mitochondria and CFS previously (see here and see here).

Over the 16 weeks of the trial period, researchers quite regularly assessed various parameters relating to the core feature of fatigue (based on use of the Chalder Fatigue Scale) and various mood, sleep and general health variables. They observed that alongside "a significant improvement in fatigue symptoms across [the] treatment period on the Chalder Fatigue Scale" there were also some potentially important differences noted in other measures too. Not least with "clinician-reported symptom-improvement" in mind.

Obviously the emphasis on the Menon results being an open trial (i.e. not blinded/masked, not randomised, with no control group), and very much, a small open trial, mean that these are preliminary findings and shouldn't yet be informing any research or clinical opinions. The additional fact that no objective 'actigraphic' measure of physical functioning was included for study is something else to bear in mind. Such results *should* support further research; indeed, one would hope that in this new era of interest and 'changing perspectives' with CFS in mind (see here), many more investigations in this thread would be forthcoming.

And whilst on the topic of clinical trials for CFS, the news out of Norway when it comes to the use of Rituximab is not looking too good despite a previously promising start [2]. No-one said it was going to be easy...

To close, I've nabbed a screenshot of a picture from the film Unrest that I think is starting to take on an almost iconic status...

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[1] Menon R. et al. Mitochondrial Modifying Nutrients in Treating Chronic Fatigue Syndrome: A 16-week Open-Label Pilot Study. Advances in Integrative Medicine. 2017. Nov 15.

[2] Fluge Ø. et al. Benefit from B-lymphocyte depletion using the anti-CD20 antibody rituximab in chronic fatigue syndrome. A double-blind and placebo-controlled study. PLoS One. 2011;6(10):e26358.

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NAC for 'social impairment' in youth with autism... probably not

"The results of this trial indicate that NAC [N-acetylcysteine]  treatment was well tolerated, had the expected effect of boosting GSH [glutathione] production, but had no significant impact on social impairment in youth with ASD [autism spectrum disorder]."

So said the results reported by Logan Wink and colleagues [1] (open-access) who, continuing an autism research theme, looked at whether this important L-cysteine prodrug might have more to give when it comes to at least some facets of some autism. Their trial registration entry can be found here. Reporting results from "a 12-week randomized, double-blind, placebo-controlled trial of oral NAC in youth with ASD" researchers followed some 30 children (aged 4-12 years) diagnosed with autism based on their use of NAC or a placebo. Alongside various biological measures including blood levels of "reduced and oxidized glutathione (GSH and GSSG)" and the big 'H' (homocysteine), the primary outcome was the effect on "the CGI-I scale anchored to study physician assessment of core social impairment considering the individuals’ overall level of cognitive, adaptive, and social functioning." I might add that other secondary behavioural outcomes were also included for study.

Bearing in mind the loss (dropping out) of some participants during the study period including details that "three withdrew due to irritability (NAC), diarrhea and encopresis (placebo), and defiant and self-injurious behavior (placebo), respectively" the authors report data on 25 study completers. Titrated doses of NAC depending on tolerance and body weight of participants did seem to do what they were supposed to in terms of an effect on levels of glutathione: "had the expected effect of boosting GSH production in peripheral blood" at 12 weeks.

But... on every other measure - biological and behavioural - there were no significant differences between the NAC and placebo groups leading the authors to conclude that their results "do not support the use of NAC for treatment of core social impairment of ASD." The research door does however remain open as they also comment that: "the health impact of the resultant increase on GSH remains unclear."

These are interesting results. NAC has seemingly found something of a research place in quite a few areas of psychiatry including 'some' autism (see here) and 'some' schizophrenia (see here). The focus has tended to be more on the 'irritability' side of things (see here) which makes it all the more surprising that one of the participants in the Wink trial receiving NAC actually withdrew 'due to irritability'. That being said, the very controlled nature of the Wink study cannot be readily ignored assuming no influence from the placebo [2].

I would like to see a little more on the whole NAC -- cysteine -- glutathione connection given previous discussions with autism in mind (see here). This includes the idea that blood levels of the various compounds involved might not be the same as 'brain levels' and taking into 'level of functioning' into account (see here). But in the context of the Wink data, one has to perhaps realise that NAC is not likely to be a panacea when it comes to autism...

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[1] Wink LK. et al. A randomized placebo-controlled pilot study of N-acetylcysteine in youth with autism spectrum disorder. Molecular Autism. 2016; 7:26.

[2] Masi A. et al. Predictors of placebo response in pharmacological and dietary supplement treatment trials in pediatric autism spectrum disorder: a meta-analysis. Transl Psychiatry. 2015 Sep 22;5:e640.

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Wink, L., Adams, R., Wang, Z., Klaunig, J., Plawecki, M., Posey, D., McDougle, C., & Erickson, C. (2016). A randomized placebo-controlled pilot study of N-acetylcysteine in youth with autism spectrum disorder Molecular Autism, 7 (1) DOI: 10.1186/s13229-016-0088-6

The genetics of self-injurious behaviour accompanying autism? Not quite...

I'd like to start by making one thing abundantly clear about today's post: I am not insinuating that self-injurious behaviour (SIB) accompanying autism is solely under genetic (or epigenetic) control.

As I've discussed before on this blog, there are potentially many, many reasons why SIB under the umbrella of the so-called 'challenging behaviours' occurs (see here). As and when it does happen, the onus is on those significant others to turn detective before anyone immediately reaches for something like the anti-challenging behaviour meds (see here) or indeed makes any sweeping generalisations about it 'just being part of their autism'. I say this mindful that sometimes it can seemingly be the smallest things that can trigger such episodes...

The findings reported by Matthew Shirley and colleagues [1] (open-access) do however require some attention with the idea that certain genetic issues *might* "contribute to the etiology of SIB." The specific genetic issues under the research spotlight were copy number variants (CNVs) and authors were looking at quite a precise cohort of children/young adults diagnosed with "autism and intellectual disability with self-injurious behavior (SIB) resulting in tissue damage" (N=14). I might add that CNVs with autism and learning disability in mind have some history (see here).

Based on quite a thorough work-up (including a functional behavioural assessment), researchers zoomed in on 4 children (29%) where they identified "a CNV likely to have a causal role" in SIB. I'm afraid my very limited knowledge of genetics precludes any critical discussion about the nature or role of any individual genetic issues reported but I might backtrack slightly based on something the authors write regarding 'causality': "the present findings are not able to indicate definitively that any of these variants is causal." Apparently we need to wait for more data from additional patients with the same/similar clinical phenotype before much more can be said on this issue. Indeed: "it is likely that exome or genome sequencing will greatly increase the diagnostic yield of the cohort we are studying."

Perhaps just as important as the question of whether genetics plays a role in a complex behaviour pattern like SIB are the authors' observations of what might have triggered SIB in their participants. The authors talk about the results of the very important functional behaviour assessments as revealing some common themes: "SIB was multiply maintained by escape from demands and access to preferred toys... SIB was multiply maintained by access to preferred foods and access to attention... Head-banging was found to be maintained by access to preferred foods... Head-hitting, self-biting, and head-banging against hard surfaces were observed to be maintained by automatic reinforcement." What these excerpts tell me is that SIB could potentially be a communicative act, bearing in mind details of language and communication 'level' of participants are fairly scant in the Shirley paper. As I've talked about previously (see here), issues such as fatigue and setting event are also potentially important parameters when getting to the bottom of SIB and other challenging behaviours.

The final question, and perhaps an important one when one realises just how extreme an effect SIB can exert (see here), is 'what can be done about reducing levels of SIB' when they present.  Well, working out the hows and whys of such behaviour should be the first strategy, and can sometimes yield impressive results. Although I suggested at the beginning of this post that the 'anti-challenging behaviour meds' should be a further-down-the-list resort, there is evidence that they can be helpful for some people in some situations assuming appropriate medicines management and monitoring for potential side-effects (see here). With no medical or clinical advice given or intended, I'd also be minded to direct readers to some research looking at adjuvant therapies such as the use of N-acetylcysteine (NAC) where issues like irritability might show some connection to SIB (see here and see here) or even something of particular interest to me, the use of naltrexone (see here). More research is indicated and indeed, quite a lot more with much greater participant numbers before anyone starts on about having identified the genetics of SIB in autism...

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[1] Shirley MD. et al. Copy Number Variants Associated with 14 Cases of Self-Injurious Behavior. PLoS ONE. 2016; 11: e0149646.

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Shirley, M., Frelin, L., López, J., Jedlicka, A., Dziedzic, A., Frank-Crawford, M., Silverman, W., Hagopian, L., & Pevsner, J. (2016). Copy Number Variants Associated with 14 Cases of Self-Injurious Behavior PLOS ONE, 11 (3) DOI: 10.1371/journal.pone.0149646

Acetylcysteine and autism: another case report

I don't want to spend too long on the findings reported by Danielle Stutzman & Julie Dopheide [1] talking about how: "Treatment with acetylcysteine improved ASD [autism spectrum disorder] symptoms, including irritability and aggression, in a teenage patient" but it is a blog-worthy paper.

Describing the experiences of a "7-year-old Hispanic male with ASD and intellectual disability" who was hospitalised due to some rather 'challenging behaviours', the authors noted how the addition of acetylcysteine (often called N-acetlycysteine or NAC for short) seemed to have some pretty interesting positive effects on this young boy's behaviour. Not least also that the use of NAC "was well tolerated, with no observed or reported adverse effects." The authors go on to speculate that within the context of other reports on the use of NAC either alone or as an adjunct medicine, there may be quite a bit more to see with autism in mind, as well as providing some important information about relevant biological pathways in relation to specific 'types' of autism.

I've talked about NAC and autism before on this blog, both within the context of group studies (see here) and under more individual 'N=1' conditions (see here) including with the word 'adjunct' in mind (see here). Within the context of issues that seem to come under the heading of 'challenging behaviours' (bearing in mind the variety of factors that such a description covers) there does appear to be some promising stories coming out of the use of NAC which might have all the be more importance given the lack of good therapeutic interventions for such behaviours.

I'm not at this point going to speculate too much about exactly how and why NAC seems to 'help' when it comes to some challenging behaviours for some people on the autism spectrum. I will suggest that set within the context of studies on glutathione and some autism (see here) there may be some further research to do. That, and not being afraid to look at NAC in relation to something like schizophrenia (see here), and I dare say that there could be surprises for NAC in relation to some autism in future times...

Music to close, and in amongst some recent discussions about 'Where are all the climate change songs?' a gem from The Pixies about a monkey...

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[1] Stutzman D. & Dopheide J. Acetylcysteine for treatment of autism spectrum disorder symptoms. Am J Health Syst Pharm. 2015 Nov 15;72(22):1956-9.

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Stutzman D, & Dopheide J (2015). Acetylcysteine for treatment of autism spectrum disorder symptoms. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 72 (22), 1956-9 PMID: 26541950

KPAX002 for Chronic Fatigue Syndrome?

My attention was grabbed recently by the paper published by Jon Kaiser [1] (open-access available here) detailing the results of a 'proof-of-concept investigation' examining the use of something called KPAX002 on a small number of participants diagnosed with Chronic Fatigue Syndrome (CFS).

Looking at how KPAX002 - "a combination of low-dose methylphenidate hydrochloride and mitochondrial support nutrients currently under development by K-PAX Pharmaceuticals" - impacted on fatigue symptoms and "concentration disturbance" symptoms, Kaiser reports that there may be more to see from this preparation.

Indeed, after 12 weeks of use: "Treatment with KPAX002 was well tolerated and significantly improved fatigue and concentration disturbance symptoms in greater than 50% of patients with CFS." Further information about the current (and future) trial results can be found here including details on the Synergy trial (see here and see here) representing the next step in the research process. I  might also draw your attention to an interview with Dr Kasier here (thanks to Russell for the link).

Before progressing further, I should perhaps comment on a few methodological issues to bear in mind. This was very much an observational 'pilot' study over and above a thorough clinical trial. Participants knew that they were taking KPAX002 and when it came to scoring behaviours over the trial period, this was done using subjective instruments without any objective representation. That no control group was employed (either asymptomatic nor CFS taking a placebo) should be noted. Also slightly unusually, in the section titled 'Disclosure of conflict of interest' on the paper, the words 'none' appears although in the discussion section, Dr Kasier elaborates that: "as a current employee of K-PAX Pharmaceuticals, the author may be viewed as biased toward the success of this treatment."

Such issues aside, I'm interested in this formulation and findings reported. I was not aware that methylphenidate, more typically indicated as a management option for attention-deficit hyperactivity disorder (ADHD), was something 'suggested' for CFS. Kaiser does make reference to the findings reported by Blockmans and colleagues [2] who reported that under placebo-controlled conditions: "Methylphenidate at a dose of 2 x 10 mg/day is significantly better than placebo in relieving fatigue and concentration disturbances in a minority of chronic fatigue syndrome patients." Various other studies looking at the issue of 'fatigue' attached to various other diagnoses have utilised methylphenidate with varying degrees of clinical success.

The 'mitochondrial support nutrients' included in the KPAX002 preparation are a little more familiar to me. Covering 30+ additional vitamins, minerals and other nutrients including acetyl L-carnitine and N-acetylcysteine, I was interested in the possibilities here. Mitochondria and CFS is a topic that has cropped up on this blog before (see here) in light of the findings from Sarah Myhill and colleagues [2]. As a point of note, Dr Myhill's book 'Mitochondria, Not Hypochondria' received something of an accolade at the recent British Medical Association (BMA) book awards suggesting that views might be changing in this area of the CFS landscape. Although quite a bit more research is required on the topic, mitochondrial issues in relation to CFS is something of a research growth area [3].

Reiterating that the current Kasier results should be viewed with methodological caution, it will be interesting to see what becomes of KPAX002 in relation to [some] CFS. As a point of note, Kaiser also has another entry on the US ClinicalTrials.gov database for KPAX002 in relation to an equally mystifying condition: Gulf War Syndrome (GWS) on the basis of a "high degree of symptom overlap" between CFS and GWS. No doubt KPAX002 will be gracing this blog again in future...

Music: Semisonic - Secret Smile.

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[1] Kaiser JD. A prospective, proof-of-concept investigation of KPAX002 in chronic fatigue syndrome. Int J Clin Exp Med. 2015 Jul 15;8(7):11064-11074.

[2] Blockmans D. et al. Does methylphenidate reduce the symptoms of chronic fatigue syndrome? Am J Med. 2006 Feb;119(2):167.e23-30.

[3] Morris G. & Maes M. Mitochondrial dysfunctions in myalgic encephalomyelitis/chronic fatigue syndrome explained by activated immuno-inflammatory, oxidative and nitrosative stress pathways. Metab Brain Dis. 2014 Mar;29(1):19-36.

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Kaiser JD (2015). A prospective, proof-of-concept investigation of KPAX002 in chronic fatigue syndrome. International journal of clinical and experimental medicine, 8 (7), 11064-74 PMID: 26379906

Mercury, autism and mitochondrial dysfunction?

Appreciating that to mention the words 'mercury and autism' in the same sentence can lead to furrowed brows and invoke eye-rolling in some quarters, I don't want to shy away from the results reported by Shannon Rose and colleagues [1] (open-access here) and their suggestion that: "the epidemiological link between environmental mercury exposure and an increased risk of developing autism may be mediated through mitochondrial dysfunction". Further that their result: "support the notion that a subset of individuals with autism may be vulnerable to environmental influences with detrimental effects on development through mitochondrial dysfunction."

Having previously talked about research from this group (see here) based on their examinations of lymphoblastoid cell lines (LCLs) from people with autism, their latest paper seems to be something of an extension of this project. Based on investigations on LCLs from 16 autism/control pairings, mitochondrial respiration was examined as and when said cells were exposed to ethylmercury. A subgroup of LCLs from the autism group "exhibited a greater reduction in ATP-linked respiration, maximal respiratory capacity, and reserve capacity when exposed to ethylmercury, compared to control LCLs." Interestingly, the pre-administration of NAC (N-acetlycysteine) "reduced (normalized) baseline respiratory parameters and blunted the exaggerated ethylmercury-induced reserve capacity depletion." That being said: "LCLs derived from children with autism exhibit significant abnormalities in mitochondrial respiration at baseline with these abnormalities worsening following exposure to ethylmercury" so one has to be a little guarded about making too many universal judgements.

OK. Wearing the cold, dispassionate and [hopefully] objective blinkers of science, there may be a few important implications from this work. First is the idea that for some on the autism spectrum, the puzzle that is mitochondria and mitochondrial dysfunction may require quite a bit more investigation (see here). In these days of plural autisms (see here) the focus perhaps needs to be on subgroups too. Second, as per their previous efforts in this area [2] is the idea that various factors might have the ability to impact on mitochondrial function for some people on the autism spectrum. Third, although still very much a source of deep division within the autism and wider community, the suggestion that ethylmercury (a metabolite of the preservative thiomersal / thimerosal) might have the ability to impact on mitochondrial function for at least some on the autism spectrum perhaps requires further scrutiny. I say this based on the small participant numbers included in the Rose study and their specific focus on LCLs. The doses of ethylmercury used might also require further investigation in terms of translating results from lab to real world.

Finally, the idea that pre-treatment of LCLs with NAC might carry a protective role is rather interesting. Aside from the 'oxidative stress' implications of their findings, I wonder if such an observation might also carry some link to the suggestion that post-vaccination administration of paracetamol (acetaminophen) might be 'implicated' in cases of autism [3]. I say this from a rather non-expert stance in this area but with the knowledge that paracetamol has an effect on glutathione stores under certain circumstances. Glutathione by the way, is one part cysteine and has cropped up in other autism research (see here) as well as subsequently [4]. Separately, given also that glucuronidation is a primary pathway for metabolising paracetamol and with the work from Stein and colleagues [5] in mind (see here), I wonder if there may indeed be more to see here (although accepting that there may be other effects from such antipyretic use).

This is not the first time that mitochondrial dysfunction and "impaired oxidative–reduction" have been studied from the point of view of downstream metabolites of thiomersal as per the paper by Geier and colleagues [6]. Again, the focus on that occasion was cell lines and so one has again to be a little cautious about extrapolating results beyond that. That also other research, in studies of mouse models for example [7], have not tended to support a connection between thiomersal exposure and 'neurodevelopmental disorders' is an important point to make, bearing in mind that mice are mice and not people. Similar sentiments apply to the important recent results from Curtis and colleagues [8] too.

But... the Rose findings cannot be readily dismissed particularly with their focus being potentially relevant to a subgroup of those on the autism spectrum. Adding the paper from Mady Hornig (a very well-respected researcher) into the mix (again based on mice) [9]: "Host differences in maturation, metabolism, nutrition, sex, and autoimmunity influence outcomes" when it comes to the potential of "thimerosal-related neurotoxicity" and quite a bit more research is perhaps indicated.

Music then. Bobby Womack - Across 110th Street.

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[1] Rose S. et al. Increased susceptibility to ethylmercury-induced mitochondrial dysfunction in a subset of autism lymphoblastoid cell lines. J Toxicol. 2015;2015:573701.

[2] Rose S. et al. Oxidative stress induces mitochondrial dysfunction in a subset of autistic lymphoblastoid cell lines. Transl Psychiatry. 2014 Apr 1;4:e377.

[3] Schultz ST. et al. Acetaminophen (paracetamol) use, measles-mumps-rubella vaccination, and autistic disorder: the results of a parent survey. Autism. 2008 May;12(3):293-307.

[4] Abdel-Salam OME. et al. Nuclear Factor-Kappa B and Other Oxidative Stress Biomarkers in Serum of Autistic Children. OJMIP. 2015; 5: 1.

[5] Stein TP. et al. Bisphenol A Exposure in Children With Autism Spectrum Disorders. Autism Research. 2015. Jan 13.

[6] Geier DA. et al. Mitochondrial dysfunction, impaired oxidative-reduction activity, degeneration, and death in human neuronal and fetal cells induced by low-level exposure to thimerosal and other metal compounds. Toxicol Environ Chem. 2009 Jun;91(3-4):735-749.

[7] Berman RF. et al. Low-level neonatal thimerosal exposure: further evaluation of altered neurotoxic potential in SJL mice. Toxicol Sci. 2008 Feb;101(2):294-309.

[8] Curtis B. et al. Examination of the Safety of Pediatric Vaccine Schedules in a Non-Human Primate Model: Assessments of Neurodevelopment, Learning, and Social Behavior. Environ Health Perspect. 2015. Feb 18.

[9] Hornig M. et al. Neurotoxic effects of postnatal thimerosal are mouse strain dependent. Mol Psychiatry. 2004 Sep;9(9):833-45.

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Rose, S., Wynne, R., Frye, R., Melnyk, S., & James, S. (2015). Increased Susceptibility to Ethylmercury-Induced Mitochondrial Dysfunction in a Subset of Autism Lymphoblastoid Cell Lines Journal of Toxicology, 2015, 1-13 DOI: 10.1155/2015/573701

NAC + risperidone = decreased irritability in autism?

It's been a while since I talked about NAC - N-acetylcysteine - on this blog with either autism or schizophrenia in mind (see here and see here respectively). Today I'm going to remedy that situation by bringing the paper by Nikoo and colleagues [1] to your attention, and their observation: "N-acetylcysteine can be considered as an adjuvant therapy for ADs [autistic disorders] with beneficial therapeutic outcomes." Adjuvant therapy by the way, refers to a sort of add-on therapy.

We have to call him, Havok. That's his name now.

Just in case you don't know, NAC among other things is the treatment of choice when it comes to paracetamol (acetaminophen) overdose through it's very important role in the formation of the glutathione (the big 'G' as I should start to call it). Glutathione already has something of a research interest when it comes to autism (see here); more recently increased following papers such as the one by Rahbar and colleagues [2] taking about some of the genetics of the glutathione system with [some] autism in mind, touched upon in a recent post.

Nikoo et al reported results based on a gold-standard randomised, double-blind trial whereby one group of children/adolescents with autism received the antipsychotic risperidone plus NAC and another group received risperidone plus placebo over the course of 10 weeks. Risperidone, as I just mentioned is an antipsychotic medicine which has some interesting history when it comes to [some] autism (see here). Irritability was the focus of the study, and what happened to scores on the "Aberrant Behavior Checklist-Community (ABC-C) Irritability subscale" at baseline (start), 5 weeks and 10 weeks. 

The results suggested that NAC may well have some value as an add-on treatment when it came to scores of irritability in cases of autism as per the authors findings: "By week 10, the NAC group showed significantly more reduction in irritability (P = 0.02) and hyperactivity/noncompliance (P = 0.01) subscales scores."

This is not the first time that NAC + risperidone has been mentioned in the peer-reviewed autism research literature. The paper by Ghanizadeh & Moghimi-Sarani [3] (open-access) also reported significant positive effects albeit alongside a few adverse events such as: "constipation (16.1%), increased appetite (16.1%), fatigue (12.9%), nervousness (12.9%), and daytime drowsiness (12.9%)." This follows other research out of Iran looking at NAC + risperidone in relation to some of the negative symptoms of schizophrenia [4]. On all these research occasions, the experimental period of observation was relatively short (8-10 weeks).

Like many others, I'm always a tad reserved when it comes to the use of antipsychotics for cases/behaviours of/associated with autism. As per my recent discussions on weight gain and such pharmaceutics (see here), one always needs to be a little cautious about the use of such medicines and the application of good medicines management including continual health monitoring as a priority when used. The guidance from NICE here in Blighty advising that such medicines should not be used to manage the core symptoms of autism (see here) is testament to the research base on their effectiveness and their limited place in any management plan. That being said, such pharmaceutics do have a role for some people on the autism spectrum [5] even only if as a 'last resort' in the short-term.

I end by harking back to the paper by Hardan and colleagues [6] talked about in a previous post, which suggested that NAC on it's own might have something to add when it comes to irritability in relation to some autism.  I don't necessarily endorse NAC as being a cure-all for irritability in relation to autism - irritability as part of the so-called challenging behaviours is a very multi-faceted thing with lots of potential precursors [7] - but one might give some consideration to NAC as an intervention for some on the autism spectrum. The next question needs to be: how precisely does it work, and does it have any link back to 'the big G' findings with autism in mind?

Music then. Marvin Gaye and Heard it Through The Grapevine (and something funky is going down apparently).

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[1] Nikoo M. et al. N-Acetylcysteine as an Adjunctive Therapy to Risperidone for Treatment of Irritability in Autism: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial of Efficacy and Safety. Clin Neuropharmacol. 2015 Jan 9.

[2] Rahbar MH. et al. Interaction between GSTT1 and GSTP1 allele variants as a risk modulating-factor for autism spectrum disorders. Research in Autism Spectrum Disorders. 2015; 12: 1-9.

[3] Ghanizadeh A. & Moghimi-Sarani E. A randomized double blind placebo controlled clinical trial of N-Acetylcysteine added to risperidone for treating autistic disorders. BMC Psychiatry. 2013 Jul 25;13:196.

[4] Farokhnia M. et al. N-acetylcysteine as an adjunct to risperidone for treatment of negative symptoms in patients with chronic schizophrenia: a randomized, double-blind, placebo-controlled study. Clin Neuropharmacol. 2013 Nov-Dec;36(6):185-92.

[5] Dinnissen M. et al. Clinical and pharmacokinetic evaluation of risperidone for the management of autism spectrum disorder. Expert Opin Drug Metab Toxicol. 2015 Jan;11(1):111-24.

[6] Hardan AY. et al. A randomized controlled pilot trial of oral N-acetylcysteine in children with autism. Biol Psychiatry. 2012 Jun 1;71(11):956-61.

[7] Guinchat V. et al. Acute behavioral crises in psychiatric inpatients with autism spectrum disorder (ASD): Recognition of concomitant medical or non-ASD psychiatric conditions predicts enhanced improvement. Research in Developmental Disabilities. 2015; 38: 242–255.

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Nikoo M, Radnia H, Farokhnia M, Mohammadi MR, & Akhondzadeh S (2015). N-Acetylcysteine as an Adjunctive Therapy to Risperidone for Treatment of Irritability in Autism: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial of Efficacy and Safety. Clinical neuropharmacology PMID: 25580916

Oxidative stress inducing mitochondrial dysfunction in autism?

Consider this post a sort of accompaniment to my recent chatter about the paper by Suzanne Goh and colleagues on brain lactate levels and mitochondrial dysfunction as a neurobiological subtype of autism (see here). Read on...

I've probably mentioned it before but outside of some light reading around the topic, mitochondria (plural) and mitochondrial dysfunction still remains a source of bafflement to me. Yes, I think I know the basics as per my learner post (see here) but it's the kinda of topic where I need to keep reading and re-reading sentences before any sense comes of it.

Bord de mer II @ Wikipedia 

It is therefore with a degree of trepidation that I approach the paper by Shannon Rose and colleagues [1] (open-access here) and their conclusion: "a significant subgroup of AD [autistic disorder] children may have alterations in mitochondrial function, which could render them more vulnerable to a pro-oxidant microenvironment as well as intrinsic and extrinsic sources of ROS [reactive oxygen species] such as immune activation and pro-oxidant environmental toxins". I might add that reports of mitochondrial dysfunction in cases of autism are seemingly increasing in the peer-reviewed literature [2].

OK, in very small steps, a few things to talk about here outside of my previous links to describing mitochondria shown above. ROS - reactive oxygen species - describes as the name suggests, molecules which contain oxygen (the important stuff that most creatures including us humans rely on for living). ROS are both a by-product of living (endogenous production) and can produced via other external sources (exogenous ROS). Endogenous production of ROS involves mitochondria, the so-called power plants in cells. Oxygen and various simple sugars are used to create ATP (adenosine triphosphate) as part of the process of oxidative phosphorylation. ROS are a by-product of this reaction which under certain circumstances can result in cell damage.

I'll also draw your attention to the concept of oxidative stress and it's relevance to this story. Basically, the body has ways to ensure that ROS production doesn't get out of hand via various cellular antioxidants. Regular readers of this blog might have already comes across some discussions on one of those antioxidants - glutathione - and the various findings in relation to autism (see here). As long as a happy balance is struck between appropriate levels of ROS and the scavenging availability of antioxidants, everything should tick along just fine. If however, ROS start to get the upper hand as described by the term oxidative stress, all sorts of effects can occur such as lipid peroxidation and oxidative damage to DNA. Ergo, balance is an important concept.

Back to the Rose paper then, which relied on something called lymphoblastoid cell lines (LCLs) as a means of measuring something called reserve capacity: "a measure of the ability of the mitochondria to respond to physiological stress" in cases of autism. LCLs came from the AGRE or the NIMH and researchers looked at mitochondrial reserve capacity "before and after exposure to reactive oxygen species (ROS)". Actually that wasn't the only research done on these LCLs, as the effect of N-acetylcysteine (NAC), "a glutathione precursor", pretreatment was also reported in the paper. The agent of choice for representing ROS in the study was something called DMNQ by the way.

Results, bearing in that I'm not going to go into the details of all the results because it's all there in open-access form for your interpretation:

• First and foremost: "LCLs derived from children with AD exhibit significant abnormalities in mitochondrial respiration after exposure to increasing levels of ROS". I temper those words with the authors suggestion that getting on for about half of the LCLs looked at (44%) seemed to drive the results obtained for the autism group. This might imply that in amongst all the talk about plural autisms, a sizeable subgroup of people on the autism spectrum may demonstrate such issues.
• "NAC rescues the atypical mitochondrial respiratory response". So, that pretreatment of the LCLs with NAC, specifically those 44% (10/22) who showed an abnormal adaptive response to ROS, seemed to improve mitochondrial respiration. This effect was not significantly present in the remaining LCLs from participants with autism.
• Glutathione (GSH) levels were also checked in cells (intracellular free GSH and also reduced glutathione - GSSG). As probably would be expected based on the other research literature in this area [3] lower glutathione levels were reported in the LCLs from participants with autism and a higher GSSG compared with controls. Perhaps not unexpectedly: "Pretreatment with NAC increased intracellular GSH and the GSH/GSSG ratio and reduced GSSG" in the LCLs from participants with autism.
• There are various other findings reported but the authors summarise by saying: "we demonstrate a new type of mitochondrial disorder that may affect a significant subgroup of AD children and provide insight into the interactions between systems that have been independently demonstrated to be abnormal in ASD [autism spectrum disorder]".

I know that I have gone on a little bit in this post because of the often quite technical jargon which is included in a study like this, so for that I apologise. My amateur status when it comes to talking about mitochondria and autism has probably not helped matters but I hope you can seem some glimmers of what the important results were derived from this relatively small-scale study. And yes, replication - independent replication - is an absolute must for this area of research bearing in mind facets of these results overlap with previous research by some of the same authors [4] and also here [5]. I might also add that other groups have started to talk about similar processes being involved in some autism too [6].

That all being said, I think you can see how important this work might eventually turn out to be when it comes to the area of mitochondrial dysfunction and autism, and indeed the possibility of links with other important areas of work such as the glutathione and NAC stories. Once again, I'm waiting attentively to see other published results in this area... including further replication of even more results from Napoli and colleagues [7] further discussed here.

And just in case my explanation of this area of work still leaves you baffled, I'll hand over to the experts and their recent review paper [8] ...

[Update: 16 March 2015: a clarification has been published over the paper from Rose and colleagues. Overlapping results had been mentioned...]

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[1] Rose S. et al. Oxidative stress induces mitochondrial dysfunction in a subset of autistic lymphoblastoid cell lines. Transl Psychiatry. 2014 Apr 1;4:e377.

[2] Giulivi C. et al. Mitochondrial Dysfunction in Autism. JAMA. 2010; 304(21): 2389–2396.

[3] Main PAE. et al. The potential role of the antioxidant and detoxification properties of glutathione in autism spectrum disorders: a systematic review and meta-analysis. Nutr Metab (Lond). 2012; 9: 35.

[4] James SJ. et al. Cellular and mitochondrial glutathione redox imbalance in lymphoblastoid cells derived from children with autism. FASEB J. 2009 Aug;23(8):2374-83.

[5] Rose S. et al. Oxidative stress induces mitochondrial dysfunction in a subset of autism lymphoblastoid cell lines in a well-matched case control cohort. PLoS One. 2014 Jan 8;9(1):e85436.

[6] Napoli E. et al. Evidence of reactive oxygen species-mediated damage to mitochondrial DNA in children with typical autism. Mol Autism. 2013 Jan 25;4(1):2.

[7] Napoli E. et al. Deficits in Bioenergetics and Impaired Immune Response in Granulocytes From Children With Autism. Pediatrics. 2014. April 21.

[8] Rossignol DA. & Frye RE. Evidence linking oxidative stress, mitochondrial dysfunction, and inflammation in the brain of individuals with autism. Front. Physiol. 2014. April 22.

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Rose, S., Frye, R., Slattery, J., Wynne, R., Tippett, M., Melnyk, S., & James, S. (2014). Oxidative stress induces mitochondrial dysfunction in a subset of autistic lymphoblastoid cell lines Translational Psychiatry, 4 (4) DOI: 10.1038/tp.2014.15

Methylcobalamin and folinic acid for autism? Hold it right there...

The title of this post should also have included the word 'glutathione' too based on the results reported by Richard Frye and colleagues* (open-access) describing behavioural and biochemical data from a 3-month open trial of methylcobalamin, a vitamin B12 'vitamer', and folinic acid with a group of children diagnosed with an autism spectrum disorder (ASD).

Dr Frye and his various research are no stranger to this blog; ranging from mitochondrial dysfunction linked to cases of autism (see here), through to tetrahydrobiopterin (BH4) and autism (see here), and folate receptor autoantibodies and autism (see here). Indeed that last link on folate receptor autoantibodies brings into view a potential reason why folinic acid was included in their recent study. That and the inclusion of Jill James on the authorship list and her previous studies looking at combined methylcobalamin and folinic acid supplementation for autism** (open-access) discussed as part of a previous post (see here).

The crux of this study was the suggestion that in the great and complex pathway which links the recycling of homocysteine (the big 'H') and the folate cycle, there is potentially enough going on in cases of autism to interfere with (a) the process of methylation (see here) and (b) that most useful of compounds, glutathione (see here), well reduced glutathione anyway. I'm also inclined to point readers the way of the very thorough analysis of glutathione and autism produced by Main and colleagues*** (open-access) a while back (see here) just in case you think I'm talking biochemical mumbo-jumbo.

Readers might already have seen mention of the words 'open trial' at the top of this post. This indicating that the latest study from Frye and colleagues was a case of following 37 children who fitted the entrance criteria - including "abnormal methylation capacity (SAM/SAH < 3.0) and glutathione redox metabolism (GSH/GSSG < 6.0)" - and seeing how they went over the course of a "sterile subcutaneous injection of methylcobalamin in the fatty tissue of the buttocks" every 3 days combined with oral delivery of folinic acid twice daily mixed with food. For those wincing or furrowing their brows about those injections of methylcobalamin with children with autism, I'll just say that the issue of drug delivery has been talked about in a previous post and this study was passed through an ethics committee "at the University of Arkansas for Medical Sciences".

The results are interesting. Quite a few behavioural changes were documented according to use of the VABS. This bearing in mind that (a) there was no control or placebo group and (b) VABS is a parent-report schedule which in this case merely looked at unblinded pre- and post-intervention scores. Nonetheless, the intervention resulted in "significant increases in VABS scores for all domains, including daily living, social, and communication skills, with an average effect size of 0.59, which is in the medium-to-large range." The authors even went as far to say that the VABS changes indicated something like an average 7.7 month gain over the 3 month period of study.

All well and good with that open-trial caveat well and truly in place. It is however the details regarding the biochemical measure of glutathione measurement that I was more interested in. Indeed, if I had to suggest one improvement to this paper, it would have been to include a simple table showing glutathione measures - GSH/GSSG - at baseline compared with at 3 months. Instead, the glutathione results are all bundled up with the VABS results as per the example of figure 3 showing: "the change in the glutathione redox status (reduced-to-oxidized glutathione ratio) and change in subscales of the Vineland Adaptive Behavior Scale (VABS) subscales".

What I did manage to glean is that: "the overall glutathione redox status was not related to VABS subscales, indicating that overall development did not appear to be related to overall glutathione redox status". Fair enough, a possible selection issue based on the group eventually included for study. It was the change in glutathione redox status after intervention which seemed to tie into the VABS results reported. Still, I would have liked to have the biochemical data presented as a stand-alone table.

I'm trying not to be overly-critical of this paper and results contained within. As with many other researchers, I'm guilty of the odd open-trial forming part of my CV (see here). Whilst useful as a starting point for looking at a particular intervention or trying to get others to do a more methodologically-sound study, one has to be quite cautious of such work and the myriad of biases that they contain.

I do get the impression that outside of just a more methodologically-sound trial, a lot more questions need to be asked about this intervention regime before it can be considered as something more mainstream. Outside of the 2 children who dropped out of the study because "parents were uncomfortable giving the methylcobalamin injections", there's also a question of what such an intervention is actually doing. I note the authors when discussing the previous James trial**, are quoted as saying: "The fact that the treatment [methylcobalamin and folinic acid] improved but did not normalize methionine, SAM and glutathione concentrations may reflect ongoing metabolic compensation for incompletely resolved oxidative stress". This may very well be true, but could also indicate that intervention was also working on other biological systems too.

That also mention is made of the Hardan trial of N-acetlycysteine (NAC) for autism (see here) and NAC being a direct glutathione precursor, suggests to me that when it comes to glutathione production, the shortest point might be A to B bearing in mind what results have been obtained from direct glutathione supplementation**** (open-access).

To close, the Clash have a question for you.... (it's the indecisions which bug me).

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* Frye RE. et al. Effectiveness of Methylcobalamin and Folinic Acid Treatment on Adaptive Behavior in Children with Autistic Disorder Is Related to Glutathione Redox Status. Autism Res Treat. 2013: 609705.

** James SJ. et al. Efficacy of methylcobalamin and folinic acid treatment on glutathione redox status in children with autism. Am J Clin Nutr. 2009 January; 89(1): 425–430.

*** Main PA. et al. The potential role of the antioxidant and detoxification properties of glutathione in autism spectrum disorders: a systematic review and meta-analysis. Nutr Metab (Lond). 2012 Apr 24;9:35.

**** Kern JK. et al. A clinical trial of glutathione supplementation in autism spectrum disorders. Med Sci Monit. 2011 Dec;17(12):CR677-82.

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Richard Frye, Stepan Melnyk, George Fuchs, Tyra Reid, Stefanie Jernigan, Oleksandra Pavliv, Amanda Hubanks, David W. Gaylor, Laura Walters, S. Jill James (2013). Effectiveness of Methylcobalamin and Folinic Acid Treatment on Adaptive Behavior in Children with Autistic Disorder Is Related to Glutathione Redox Status Autism Research and Treatment DOI: 10.1155/2013/609705

NAC for autism: a case study

NAC or N-acetlycysteine has appeared a couple of times on this blog in relation to both autism (see here) and schizophrenia (see here). Not bad for a compound which more readily finds a home in modern medicine following paracetamol (acetaminophen) overdose or as a consequence of its mucolytic properties.

As one might imagine, the autism link is of particular interest to this blog, focused specifically on the findings of Hardan and colleagues* when it came to putting NAC to the [albeit preliminary] experimental test. The results by the way were encouraging for at least some parts of the presentation of childhood autism with the promise of more to come.

As a sort of follow-up to the Hardan paper, I'm talking today about a case report offered by Ghanizadeh & Derakhshan** (open-access) highlighting a little more individual detail following the use of NAC with an 8-year old boy diagnosed with autism. I know the word 'case report' sends a shudder down many a scientific shoulder, but as I've said quite a few times before, we ignore the N=1 in autism at our peril given the wide, wide heterogeneity present and all that associated comorbidity to contend with. Real personalised medicine you might say.

If I have managed to persuade you to listen to the rest of my ramblings on this paper and topic, there are a few important points to make about/from the Ghanizadeh paper:

• From the description provided, the child in question seemed quite floridly autistic with the important add-ons of hyperactivity and inattention present from an early age. Although we aren't told what exactly it means, the authors note: "His laboratory examination was unremarkable".
• Oral NAC (800mg per day) was begun as part of another trial by the authors to counteract nail-biting***. As unusual as it might sound, mail-biting has been a focus of some NAC research coincident to the presence of anxiety.
• Indeed, the boy's nail-biting behaviours did seem to subside alongside the installation of NAC but perhaps of greater interest were the reports that "there was a marked reduction in his autism symptoms 30 days after the onset of NAC administration". OK so this report did come from the boy's parents, and without causing any offence, the issue of objectivity might come into play.
• The types of 'changes' reported however were in core areas such as his verbal skills, social interaction and a quite unusual preoccupation with having his hair cut (I say unusual because a visit to the barber or hairdresser described by many parents about their child with autism, is often characterised by entirely the opposite reaction).
• Aside from "a mild abdominal pain" the authors importantly say that "nothing worsened after the administration of NAC" which I take to indicate that side effects were minimal over the course of the intervention.

I should have perhaps mentioned at the beginning that there is some sound logic why NAC might have some effect on cases of autism. The amino acid cysteine as well as containing sulfur, so potentially tied into to that most forgotten areas of autism research sulfur chemistry (see here), is also the precursor to another important compound, glutathione. I know my regular readers are probably getting a little bored of me going on about this 'elephant in the room' and in particular that glutathione overview paper by Main and colleagues (see here) but a possible link is a possible link.

I was also interested to read the authors' discussions on how NAC might also have the ability to decrease "high glutamate levels". As any good biochemist will tell you, glutathione, which is dependent on cysteine, is a tripeptide which also incorporates the amino acids glycine and glutamate into its triadic manufacture. From that point of view, circumstances where any of the three amino acids were low or not optimally biologically available might affect the production of glutathione. If that happens to mean you have low cysteine levels, glutathione would be low but also this might mean levels of glutamate or glycine could be higher as a result of not being used up to make glutathione. Glutamate is another compound finding some significant interest with regards to autism and conditions presenting with autistic symptoms.

Reiterating that the Ghanizadeh paper is a case report, I do find there to be some interesting observations reported. With my speculating hat on, I do wonder whether that link with nail-biting and onwards anxiety suggested for NAC might also be part and parcel of the effect observed in this case given the quite considerable link suggested between autism and anxiety (see here)?

And by the looks of things NAC is in the research ascendancy perhaps even with a prophylactic effect****...

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* Hardan AY. et al. A randomized controlled pilot trial of oral N-acetylcysteine in children with autism. Biol Psychiatry. 2012 Jun 1;71(11):956-61. doi: 10.1016/j.biopsych.2012.01.014.

** Ghanizadeh A & Derakhshan N. N-acetylcysteine for treatment of autism, a case report. J Res Med Sci. 2012 Oct;17(10):985-7.

*** Ghanizadeh A. et al. N-acetylcysteine Versus Placebo for Treating Nail Biting, A Double Blind Randomized Placebo Controlled Clinical Trial. Antiinflamm Antiallergy Agents Med Chem. 2013 May 6. [Epub ahead of print]

**** Beloosesky R. et al. Prophylactic maternal N-acetylcysteine in rats prevents maternal inflammation-induced offspring cerebral injury shown on magnetic resonance imaging. Am J Obstet Gynecol. 2013 Mar;208(3):213.e1-6. doi: 10.1016/j.ajog.2013.01.023.

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Ghanizadeh A, & Derakhshan N (2012). N-acetylcysteine for treatment of autism, a case report. Journal of research in medical sciences : the official journal of Isfahan University of Medical Sciences, 17 (10), 985-7 PMID: 23826003

The focus is on autism

This is one of my more 'advertorial' posts I'm afraid, as I bring to your attention two important special supplements on autism published in two high-profile journals.

The first is yet another open-access special edition published in Nature (see link here), which complements their previous special edition from this time last year (2011). I'm impressed it has to be said, that Nature would choose to return to autism two years running, which really does tell you how much scientific and lay interest there is about the condition.

As to content, lots of interesting views and opinions but a few highlights to mention:

• Well it's nice to see that epigenetics (there's so much more to the genome) gets a mention as per this article by Sarah Williams*. The possible usefulness of systems biology is also discussed, albeit with more of slant on proteomics over my favourite, metabolomics. 
• Michael Eisenstein** talks pharmacotherapy which includes quite a bit about Fragile X syndrome chatter and all those glutamate-targeting advances (see here) which potentially offer so much. My attention however was more focused on the preliminary results from administration of N-acetlycysteine (NAC) in cases of autism and even some suggestion that the immune-inflammatory link to some cases of autism might be a target for therapy, and quite unconventional - helminthic - therapy at that. 
• Of course one cannot talk about autism nowadays with making some reference to DSM-V as per the article by Emily Singer*** which complements/is complemented by a recent piece by Jon Brock elsewhere.

The second special edition / supplement graces the journal Pediatrics, and a whole slew of articles on autism (see link here). Regular readers of this blog (hello, anyone there...) will have already been given a heads-up for one of the articles published as part of the Pediatrics supplement by a cracking group of researchers, all discussing gastrointestinal (GI) factors and autism (see here).

Some more interesting tidbits for your, pardon the pun, digestion:

• Perrin and colleagues**** discuss the use of complementary and alternative medicine (CAM) in autism. As someone who does not necessarily see dietary intervention as being anything like CAM - remember Hippocrates 'Let food be thy medicine' - it's nevertheless interesting to read about how CAM use seems to be more widespread among those children whose autism is present alongside other comorbidites such as GI problems and seizure disorders. I hate to use the term ' the bleeding obvious' but it does kinda stand to reason that GI issues might persuade someone to look at diet for example, as being a potential player to those issues. Or maybe it's just me? I note also that Dr Susan Hyman is among the authorship group to this paper, which got me wondering about the status of that gluten- and casein-free diet study that she was undertaking which still appears on the ClinicalTrials.gov website, albeit 'status unknown'. 
• Sikora and colleagues***** report some really interesting results based on what happens when ADHD and autism are comorbid. Again, probably not something completely unexpected in that quality of life is not great, or at least not as great as when ADHD symptoms are not present. If ever there was another example that comorbidity can be (a) present and (b) a real challenge for people with autism, here it is.
• Beth Malow and colleagues****** describe a potentially very informative tool, an insomnia practice pathway to help identify such issues in cases of autism. So, screening taking into account other medical factors, discussing various therapies which does not necessarily just mean introduce melatonin, and an important one here, follow-up and "evaluate effectiveness and tolerance of the therapy". It all sounds great in principle, but again I'm just going back to the 2010 Pediatrics guidance on GI conditions and autism******* and wonder how successful such best-laid plans turn out to be in practice.
• Final one, Ann Reynolds and colleagues******** talk iron and autism (as I have previously done on this blog) and report that issues with the availability of iron might not actually be all that widespread in autism after all. By saying this, I'm not taking away anything from the cases where iron availability is an issue. 

There is plenty of bedtime reading there for everyone and importantly, an ideal vehicle for keeping autism and autism research in the public consciousness. To close, a song that I think everyone would welcome, young and old, either first thing in the morning or last thing at night...

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* Williams SCP. Genetics: searching for answers. Nature. 2012; 491: S4-S6.

** Eisenstein M. Treatments: in the waiting room. Nature. 2012; 491: S14-S16.

*** Singer E. Diagnosis: redefining autism. Nature. 2012; 491: S12-S13.

**** Perrin JM. et al. Complementary and alternative medicine use in a large pediatric autism sample. Pediatrics. 2012; 130: S77-S82.

***** Sikora DM. et al. Attention-Deficit/Hyperactivity Disorder Symptoms, adaptive functioning, and quality of life in children with autism spectrum disorder. Pediatrics. 2012; 130: S91-S97.

****** Malow BA. et al. A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents With autism spectrum disorders. Pediatrics. 2012; 130: S106-S124.

******* Buie T. et al. Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: a consensus report. Pediatrics. 2010;125 Suppl 1:S1-18.

******** Reynolds A. et al. Iron Status in Children With Autism Spectrum Disorder. Pediatrics. 2012; 130: S154-S159.

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