A controlled trial with ORG 2766, an ACTH-(4-9) analog, in 50 relatively able children with autism

Targeted Biomedical Treatment for Autism Spectrum Disorders

BACKGROUND

A diagnosis of autism spectrum disorders (ASD) represents presentations with impairment in communication and behaviour that vary considerably in their clinical manifestations and etiology as well as in their likely pathophysiology. A growing body of data indicates that the deleterious effect of oxidative stress, mitochondrial dysfunction, immune dysregulation and neuroinflammation, as well as their interconnections are important aspects of the pathophysiology of ASD. Glutathione deficiency decreases the mitochondrial protection against oxidants and tumor necrosis factor (TNF)-α; immune dysregulation and inflammation inhibit mitochondrial function through TNF-α; autoantibodies against the folate receptors underpin cerebral folate deficiency, resulting in disturbed methylation, and mitochondrial dysfunction. Such pathophysiological processes can arise from environmental and epigenetic factors as well as their combined interactions, such as environmental toxicant exposures in individuals with (epi)genetically impaired detoxification. The emerging evidence on biochemical alterations in ASD is forming the basis for treatments aimed to target its biological underpinnings, which is of some importance, given the uncertain and slow effects of the various educational interventions most commonly used.

METHODS

Literature-based review of the biomedical treatment options for ASD that are derived from established pathophysiological processes.

RESULTS

Most proposed biomedical treatments show significant clinical utility only in ASD subgroups, with specified pre-treatment biomarkers that are ameliorated by the specified treatment. For example, folinic acid supplementation has positive effects in ASD patients with identified folate receptor autoantibodies, whilst the clinical utility of methylcobalamine is apparent in ASD patients with impaired methylation capacity. Mitochondrial modulating cofactors should be considered when mitochondrial dysfunction is evident, although further research is required to identify the most appropriate single or combined treatment. Multivitamins/multiminerals formulas, as well as biotin, seem appropriate following the identification of metabolic abnormalities, with doses tapered to individual requirements. A promising area, requiring further investigations, is the utilization of antipurinergic therapies, such as low dose suramin.

CONCLUSION

The assessment and identification of relevant physiological alterations and targeted intervention are more likely to produce positive treatment outcomes. As such, current evidence indicates the utility of an approach based on personalized and evidence-based medicine, rather than treatment targeted to all that may not always be beneficial (primum non nocere).

Practical Paediatric Psychopharmacological Prescribing in Autism

Claims of ‘miracle cures’ for autism in the press and on the Internet bring new pressures to bear on parents of children with autism, and the professionals who care for them. Between a third and a half of people with autism in America are receiving some psychotropic medication. Despite recent advances in paediatric psychopharmacology, there is no proof that any medication can target the primary social impairments that characterize autism. The article discusses the evidence behind two approaches to psychopharmacological management in children with autism. The first approach selects certain target symptoms such as resistance to change, ritualistic/compulsive behaviours, hyperactivity, aggressive behaviours and sleep problems. The evidence for the effectiveness of agents including stimulants, anti- depressants, and melatonin when used to treat these symptoms is appraised. The second approach attempts to treat or cure the primary social impairment underlying autism. The evidence for the effectiveness of agents including naltrexone, fenfluramine and secretin is appraised. Early reports in this field have generated false hope, and the need for well-designed larger multicentre trials is emphasized.

Baseline factors predicting placebo response to treatment in children and adolescents with autism spectrum disorders: a multisite randomized clinical trial

IMPORTANCE

The finding of factors that differentially predict the likelihood of response to placebo over that of an active drug could have a significant impact on study design in this population.

OBJECTIVE

To identify possible nonspecific, baseline predictors of response to intervention in a large randomized clinical trial of children and adolescents with autism spectrum disorders.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial of citalopram hydrobromide for children and adolescents with autism spectrum disorders and prominent repetitive behavior. Baseline data at study entry were examined with respect to final outcome to determine if response predictors could be identified. A total of 149 children and adolescents 5 to 17 years of age (mean [SD] age, 9.4 [3.1] years) from 6 academic centers were randomly assigned to citalopram (n = 73) or placebo (n = 76). Participants had autistic disorder, Asperger syndrome, or pervasive developmental disorder, not otherwise specified; had illness severity ratings that were moderate or more than moderate on the Clinical Global Impression-Severity scale; and scored moderate or more than moderate on compulsive behaviors measured with the modified Children's Yale-Brown Obsessive-Compulsive Scale.

INTERVENTIONS

Twelve weeks of treatment with citalopram (10 mg/5 mL) or placebo. The mean (SD) maximum dose of citalopram was 16.5 (6.5) mg by mouth daily (maximum dose, 20 mg/d).

MAIN OUTCOMES AND MEASURES

A positive response was defined as having a score of at least much improved on the Clinical Global Impression-Improvement scale at week 12. Baseline measures included demographic (sex, age, weight, and pubertal status), clinical, and family measures. Clinical variables included baseline illness severity ratings (the Aberrant Behavior Checklist, the Child and Adolescent Symptom Inventory, the Vineland Adaptive Behavior Scales, the Repetitive Behavior Scale-Revised, and the Children's Yale-Brown Obsessive-Compulsive Scale). Family measures included the Caregiver Strain Questionnaire.

RESULTS

Several baseline predictors of response were identified, and a principal component analysis yielded 3 composite measures (disruptive behavior, autism/mood, and caregiver strain) that significantly predicted response at week 12. Specifically, participants in the placebo group were significantly less likely than participants in the citalopram group to respond at week 12 if they entered the study more symptomatic on each of the 3 composite measures, and they were at least 2 times less likely to be responders.

CONCLUSIONS AND RELEVANCE

This analysis suggests strategies that may be useful in anticipating and potentially mitigating the nonspecific response in randomized clinical trials of children and adolescents with autism spectrum disorders.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00086645.

Management of symptoms in children with autism spectrum disorders: a comprehensive review of pharmacologic and complementary-alternative medicine treatments

In the care of children with autism spectrum disorders (ASD), medical treatment is typically considered an adjunct to educational and behavioral interventions. Nonetheless, large proportions of children with ASD are managed medically and receive both pharmacologic and complementary-alternative medicine (CAM) treatments. Although many medical treatments have been studied in children with ASD, studies vary widely in terms of the sample, sample size, research design, purposes of treatment, and measurements of change. Surprisingly, comprehensive reviews of the options for medical management in ASD are lacking, particularly reviews that address both pharmacologic and CAM treatments. Furthermore, reviews to date tend to emphasize general effects of medication; this perspective contradicts medical practice, which targets particular symptoms during treatment selection and monitoring. This review of 115 studies adds to the ASD treatment literature by (1) including studies of individuals 0 to 22 years of age; (2) aggregating studies of pharmacologic treatments and CAM treatments; and importantly, (3) organizing treatment response by ASD symptoms, differentiating core and associated symptoms.

AEDs and psychotropic drugs in children with autism and epilepsy

The efficacy of antiepileptic drugs (AEDs) and psychotropic medications in children with autism is limited to the treatment of seizures or to specific behaviors such as irritability, impulsivity, hyperactivity, repetitive behaviors, or aggression. The reliability and value of the available data--to determine the efficacy of these medications in autism--are limited by lack of controlled clinical trials, the small number of subjects, the heterogeneity of the population studied, and the brief duration of most drug trials. Indeed, few controlled clinical trials using AEDs in autism, with or without seizures, have been conducted. Because some AEDs also have a positive effect on mood, the benefits that children with autism sometimes obtain from these medications may not be due to the treatment of the abnormal electrical activity or the seizures per se but to an effect on common neuronal systems responsible for both behavior and epilepsy. The relationship between epilepsy and autism, and specifically the effects that abnormal electrical activity may have on the developing brain, may provide some valuable insights into the type of studies that are needed to help us understand the pathophysiology of autism.

Impact of recent findings on study design of future autism clinical trials

There are specific challenges to studying the design of pharmacologic trials in child/adolescent and adult autism, such as subject stratification and parallel versus crossover designs. This article describes how optimal study design is influenced by subject selection and outcome measures chosen. Lessons learned in study design from the Research Units on Pediatric Psychopharmacology Autism Network trial with risperidone, Seaver Center trials with fluoxetine and valproate, Dartmouth trials with amantadine, and National Institutes of Health secretin trials are highlighted. The Internet System for Assessing Autistic Children system for managing multicenter clinical trials in autism and statistical issues in autism research are also described.

Melanocortins applied intravitreally delay retinal dystrophy in Royal College of Surgeons rats

BACKGROUND

Alpha-melanocyte-stimulating hormone (MSH) is a neurotrophic agent. In Royal College of Surgeons (RCS) rats, the effects of an MSH analog (MA) were investigated on: (1) the preservation of photoreceptors in vivo following MA intravitreal injection; (2) whether MA is a mitogenic factor.

METHODS

The study comprised five RCS rat groups, two injected with different doses of MA, one injected with PBS, and two non-injected groups. A single injection of MA or PBS was applied intravitreally to RCS rats on postnatal day 20 (20p). Photoreceptor preservation on 40p was studied using light microscopy. Considering the mitogenic effect of MA, it was studied whether cell proliferation was induced by MA in cultured retinal pigment epithelium (RPE) using the thymidine uptake technique.

RESULTS

In degenerating untreated RCS retinae the number of photoreceptor rows on 40p was 60-70% lower than on 20p. Retinae treated with higher doses of MA revealed on 40p a localized significant photoreceptor rescue in the retinal hemisphere which had been injected. However, only a small area of photoreceptor preservation was noted in the injected hemisphere in retinae treated with the lower MA dose. MA showed no mitogenic effect in endothelial or RPE cell culture in vitro.

CONCLUSIONS

This study is the first to demonstrate that: (1) intravitreally injected MA promotes a dose-related localized rescue of photoreceptors in RCS retinae which may be related to the hormone's neurotrophic activity; (2) MA has no mitogenic or angiogenic properties; (3) MA, as a neuroprotective agent, might be considered for future treatment of retinal dystrophy.

The autistic spectrum: subgroups, boundaries, and treatment

There is consensus about the disorders that comprise the autistic spectrum, with autistic disorder, Asperger's disorder, and PDD-NOS as the most typical examples and Rett's disorder and disintegrative disorder as the other components. Important controversies regarding the precise definitions of autistic spectrum disorders and the boundaries between the milder manifestations of those disorders, particularly PDD-NOS, and non-autistic conditions have not been and cannot be resolved fully as long as there is no known biologic cause or consistent biologic or psychological marker. This includes issues as basic as whether the autistic spectrum is a predominantly unitary entity or a collection of more or less similar phenotypes with multiple, varying etiologies. This is why the highest long-term priority in the area of definite diagnosis is the search for biologic marker(s) for autism and related autism spectrum disorders [91]. In the absence of a medical test to unequivocally diagnose autism, definitions of autism and related conditions are based only on manifestations in overt behavior, with all the unreliability this entails. In the future, the discovery of biologic correlates, causes, and pathogenetic pathways will undoubtedly change the way in which autism is diagnosed and lead to a new nosology [95]. Until that time the definitions in the current versions of the classification systems should be considered in a state of evolution. The key problem of the current classification systems is the fact that the boundaries between the various disorders are fuzzy. Instead of a categorical approach, a more useful description might be that of "autistic spectrum disorder," which reflects the range of severity of symptoms. Such a dimensional understanding of PDD is useful to clinicians, who may otherwise use nonspecific terms to avoid the categorical diagnosis of autism [31]. Rutter and Schopler [96] argued for separate clinical and research schemes because clinical and research needs are different. For research purposes it is desirable to have as much direct comparability across studies as possible. The focus is on a high degree of homogeneity within diagnostic groupings. A price must be paid for this detailed specification, and the main cost lies in the proportion of cases left undiagnosed. For example, there may be good scientific reasons for a narrowly defined categorical diagnosis that includes only individuals who definitely and clearly have a specifically defined condition and excludes individuals who may have the condition. For clinicians and educators, classification helps guide the selection of treatments for an individual. From this point of view, broader diagnostic concepts may be most appropriate [95].

Improved antisaccade performance with risperidone in schizophrenia

OBJECTIVE

Antisaccade errors are consistently increased in schizophrenia. As they have been demonstrated only in cross sectional studies, it is unclear how they vary longitudinally or with different medications. In a previous cross sectional study, we reported a trend towards a reduction in error rates in a patient group treated with risperidone, compared with clozapine and sulpiride treated groups.

METHODS

Gap random and antisaccade paradigms were performed on two occasions in the same sample of DSM-IV schizophrenic patients (n=12) in transition between conventional antipsychotic drugs and risperidone. A cross over design was used with six patients switching from risperidone to conventional (group I) and six in the opposite direction (group II). A control sample (n=12) was also tested on two occasions and their performance compared. The effects of practice between first and second testing and of switching between conventional antipsychotic drugs and risperidone and vice versa was also evaluated.

RESULTS

A significant reduction in error rate was demonstrated during risperidone treatment (n=12), compared with conventional APD treatment. Switching from conventional to risperidone produced a reduction in errors, and vice versa.

CONCLUSIONS

Treatment with risperidone was associated with improvement in antisaccade errors.

Psychopharmacotherapy in children and adults with intellectual disability

The prevalence of psychiatric disorders is increased in children and adults with intellectual disability. Brain damage or dysfunction interact with social and family factors to increase susceptibility to mental illness. Psychiatric disorders in the context of genetic syndromes are commonly overlooked, and there is substantial underdiagnosis of mental disorders because of the atypical and non-specific clinical presentations, and the frequent assumption that psychiatric symptoms are an inherent part of the underlying intellectual disability. There is a strong need for evidence-based practice in the prescribing and monitoring of drugs in this population, especially since many of the drugs are unlicensed for use in children. There is an urgent need to understand and establish the pharmacokinetics, pharmacodynamics, and side-effect profiles of psychotropic medication in this population. Positive trends in pharmacotherapy include the use of atypical antipsychotics instead of the classic antipsychotics, serotonin-specific reuptake inhibitors (SSRIs) rather than tricyclic antidepressants, and newer antiepileptic drugs. Another welcome trend is the use of SSRIs instead of antipsychotics in the long-term management of challenging behaviour in this population.