Latest Research in FXS , Carriers and FXTAS

FRAXSOCAL Conference 10-1-17

Randi Hagerman MD

Distinguished Professor of Pediatrics

Endowed Chair in Fragile X Research

MIND Institute UC Davis Medical Center

Conflicts/Funding from NICHD, Roche/ Genentech, Fulcrum

NFXF, Novartis, Zynerba, Neuren, Marinus, Alcobra, HRSA, DoD

Two different mutations in the same FMR1 gene

Fragile X syndrome (FXS)

Primary Ovarian Insufficiency (FXPOI)

Fragile X-associated

Tremor Ataxia Syndrome (FXTAS)

Depression and anxiety

ADHD, OCD, seizures and ASD

mRNA

FMRP

Clinical

Typical Premutation Full mutation (CGG) < 45 55 - 200 (CGG) > 200 (CGG)

normal

1/130-250 females

1/250-810 males 1/3600-5000

WES has identified point mutations and

CNVs in FMR1 causing FXS (Quartier et al

2017)

3 carrier daughters more

severely affected than

expected but treated with

phenobarbital for seizures

and exposure to pesticides

Ricaurte, Colombia

Benefits of the Premutation

• A subgroup have an exceptionally high IQ

probably related to high FMRP levels

• Great verbal abilities combined with high

drive for achievement and obsessive

thinking can lead to high education levels,

many MD, PhDs, lawyers, clergy, very

successful business people, pilots etc with

the premutation

Reaction time in women with the

premutation was better than controls on a magnitude estimation task (p=0.05)

Goodrich-Hunsaker et al 2011 Brain and Cognition

fragile X

syndrome

FXPOI, anxiety

neuropathy

muscle pain, lupus

FXTAS, nl cognition,

FXPOI

FXTAS

cognitive decline, dementia,

neuropathy

+ autism (mild)

89 yr

61 yr

38 yr

proband

The Fragile X Mutation

A family affair

Four generations

A different course in women with FXTAS

nucleolus

inclusion

Intranuclear inclusions Loss of brain volume

CGG repeats

< 45 (normal)

55-200

excess, toxic mRNA

Women with FXTAS were not

described until 2004

(Hagerman et al 2004 AJHG)

and only 13% have the MCP

Findings on MRI studies

(Adams et al 2007), less

dementia

Inclusions reported in 2002

(Greco et al 2002,Berman et al

2015)

amygdala

New MRI Findings in FXTAS

• White matter disease

in the pons

• Thinning of the

corpus callosum and

wmd in splenium

• Involvement of the

insula

Adams et al 2012 NFXF conf and Apartis et al 2012

65 Women with FXTAS (Schneider et al

2017 )

Diagnostic Criteria for FXTAS updated

Executive function deficits minor

Short term memory deficits minor

Parkinsonism minor

Gait ataxia major

Intention tremor major Clinical exam

Moderate to severe generalized atrophy minor

Cerebral white matter hyperintensity minor

Middle cerebellar peduncle (MCP) lesions major MRI

Inclusion criterion: 55 – 200 CGG repeats

1 clinical major

AND

1 MRI minor

2 clinical major

OR

1 MRI major AND

1 clinical minor

1 clinical major

AND

1 MRI major

Possible Probable Definite

Diagnostic categories

Inclusions (post mortem)

Neuropathy minor

minor WMH in Splenium

Brainstem Volume Change: NC Vs. PNF (Wang et al 2017)

Age

Bra

inste

m

Volu

me (

ml)

Quadratic relationship

PNF: ‒0.19± 0.67 ml, t = ‒0.29, p = 0.77

Age x group: ‒0.048 ± 0.017 ml, t = ‒2.82, p =

0.005

Annual rate of change

NC: ‒0.001 × age2 + 0.091 × age

PNF: ‒0.001 × age2 ‒ 0.044 × age

Age of divergence in volume: 4.1 years

Age

Linear relationship

NC: 4.13 ± 1.10 ml, t = 3.74, p = 0.0003

Age x NC: 0.16 ± 0.06 ml, t = 2.4, p =

0.016

Age x PNF: 0.31 ± 0.08 ml, t = 3.8, p =

0.0002

Annual rate of change

NC: ‒0.07 ± 0.06 ml; PNF: 0.08 ± 0.08 ml

PWF: ‒0.23 ± 0.05 ml

PWF vs. PNF: difference in volume

occurs after age 50

Cerebellar Volume Change Begins in Childhood (Wang et al 2017)

Age

Cere

bella

r V

olu

me (

ml)

Linear relationship

PNF: ‒0.24 ± 2.53 ml, t = ‒0.10, p = 0.92

Age x group: ‒0.14 ± 0.06 ml, t = ‒2.24, p =

0.026

Annual rate of change

NC: ‒0.36 ± 0.04 ml

PNF: ‒0.50 ± 0.06 ml

Age of divergence in volume: 6.4 years

Age Linear relationship

NC: 22.4 ± 1.86 ml, t = 12.1, p <

0.0001

PNF: 13.0 ± 2.17 ml, t = 5.99, p <

0.0001

Annual rate of change

‒0.54 ± 0.11 ml

PWF vs. PNF: difference in volume

occurs before age 50

Spectrum of Premutation Involvement

FMR1 CGG-repeat

toxic RNA “trigger”

Calcium

dysregulation

Upregulation of

heatshock proteins

RAN translation,

FMRpolyG

Kinase activation

Sequestration of

DROSHA,DGCR8

Sam68

Mitochondrial

dysfunction

Inclusion

formation,WMD

Background

gene effects Environmental

effects

Including

Alcoholism

Opioids

Chemotherapy

Toxins

Smoking

Stroke

CTE

Neurodevelopmental problems

Social anxiety ASD

ADHD

Cognitive deficits

Psychiatric involvement

Anxiety

Stress

Depression

Endocrine dysfunction

FXPOI

Immune dysregulation

Hypothyroidism

Fibromyalgia

Lupus- MS features

Neurological problems

Neuropathy-chronic pain

Migraine, sleep apnea, RLS

Memory problems, foggy thinking

Hypertension , erectile dysfunction

FXTAS

tremor, ataxia, Parkinsonism

autonomic dysfunction, EF deficits,

memory and cognitive decline

Cellular

dysregulation

Presymptomatic FXTAS Case 1: 50 yo man with 102 repeats

• Healthy, athletic man who played football

in high school and college and history of

multiple head trama/concussions

• insomnia and hypertension but denied

tremor and ataxia.

• Cognitive testing : VIQ of 122, PIQ of 114

and F/S IQ of 120.

• His neurological exam was normal except

for a positive snout reflex.

Case 1: MCP, Splenium sign and subtle

pons involvement

Case 3: 60 yo man with 74 repeats

• Healthy male who denied neurological

symptoms

• Smoker since age 14 and 2 drinks per day;

gradual hearing loss for 15 years

• VIQ 116, PIQ 113, F/S IQ116

• Exam: BP 152/86; no tremor or ataxia,

positive palmomental and snout reflex.

• RTC after 4 years with head tremor,

intention tremor, gait ataxia so diagnosed

with FXTAS

Case 3 at age 60yo with MCP

and splenium sign in CC

Cultured

hippocampal

neurons (HN) from

preCGG or

Wt mice

Ca2+-selective

microelectrode

Resting Ca2+ concentration is elevated in

premutation neurons (mouse) Gaelle Robin et al. (2017)

PreCGG HN Ca2+ levels are chronically > Wt

Pessah Lab

cytoplasm

nucleus

Lamin A/C

p25

Cdk5

p35

Cdk5

Cdk5

p35 p25

Calpain

activation

Ca2+

Cdk5

inclusion

H2AX

ATM

DNA-

PKcs/Ku86/Ku70

Mre11

NBS1

RAD50

MRN

MDC1

53BP1

Ctp1

ATM

p53 p53

ATM

p25

Cdk5

The DNA Damage Repair (DDR) model

Paul Hagerman 2017

Mitochondrial dysfunction in FXTAS • Reactive oxygen species (ROS) are generated in mitochondria during the

course of mitochondrial respiration.

• Superoxide is (normally) decomposed by superoxide dismutase 1 (SOD1) in

the intermembrane space and by SOD2 (MnSOD) in the matrix to form

hydrogen peroxide, thence to water.

• Under mitochondrial stress, excess superoxide (normally eliminated by

superoxide dismutases (SOD1 and 2) is converted to the reactive hydroxyl

radical (OH•), or to the potent oxidant and nitrating agent peroxynitrite

(ONOO−).

Cecilia Guilivi lab

Treatments for premutation carriers

Polussa et al 2014

Brain Disorders

and Therapy

Treatment of premutation

problems including FXTAS

• Seritan et al 2014 J Cl Psychiatry;

Controlled trial of memantine was not

helpful for tremor, ataxia or executive

function deficits in patients with FXTAS

• Subgroup of FXTAS patients underwent

event related potential (ERP) studies

(n=41) and treatment benefits in cued recall

memory and N400 repetition effects were

seen compared to placebo (Jin-Chen Yang et al 2016, 2017)

Allopregnanolone from Mike Rogawski MD PhD

• Endogenous neurosteroid

• Produced by cortical and hippocampal pyramidal neurons

• Positive allosteric modulator

• GABA(A) Receptor

• Enhance inhibitory effect of GABA

• Neuroprotection (prevention of apoptosis)

• Neurogenesis

Allopregnanolone: a natural neurosteroid

GABAA agonist

• AlloP is being studied in tramatic brain injury

and in Alzheimer’s Disease (Brinton et al 2013)

• AlloP reduced spike frequency and duration in

premutation neurons (Cao et al 2012 HMG)

• Stimulates neurogenesis,

and neuroregenerative

Open label trial (12 weeks)

in FXTAS approved by FDA

Studies in AD mouse: Wang et al 2010 PNAS;

Chen et al 2011 Plos One

Once weekly IV infusion is optimal timing for

neurogenesis and pathology reduction in AD

mouse (Brinton lab) so open label study in

FXTAS

Allopregnanolone infusion once a

week 3 to 6 mg/infusion for 3 mo (Jun Yi Wang et al 2017 Neurotherapeutics)

Cognitive improvements with Allopregnanolone

treatment

-5.00

0.00

5.00

10.00

15.00

MMSE total score changes post infusion

Point change

Percent change

0

5

10

15

20

25

sco

re(u

nit

s)

pe

rce

nta

ge (

%)

BDS-2 score change post infusion

Change

Percentage change

• BDS-2 measures executive

function, working memory

• Improvement in scores in all

patients

• Frontal cortex involved

• Majority show improvements in

scores post infusion

• No change in JN’s scores; SG slight

decrease

• Compare against a control for

natural progression of disease

Functional Outcomes

• Before infusion

– Impaired executive function,

learning, and memory

– Comprised verbal fluency

• After infusion

– Significantly improved executive

function and associative learning

– Improved memory scores and

reduced psychological

symptoms in 75-80% patients

BDS-2 Total

Score

CANTAB

PAL Total Error

BDS = Behavioral Dyscontrol Scale

CANTAB = Cambridge Neuropsychological Test Automated Battery

PAL = Paired Associates Learning

p = 0.009 p = 0.042

Before After Before After

MRI Findings

• Before infusion

– Volume atrophy

– Accelerated hyperintensity

expansion

– Corpus callosal integrity loss

Age

Hip

po

ca

mpus (

cm

3)

Hyp

erin

ten

sitie

s (

cm

3)

CC

FA

CC

MD

(µ

m2/m

s)

Age

Patients Controls CC = corpus callosum, FA = fractional anisotropy,

MD = mean diffusivity P from < 0.001 to 0.045

MRI Findings

• Before infusion

– Volume atrophy

– Accelerated hyperintensity

expansion

– Corpus callosal integrity loss

• After infusion

– Changes occur in both

directions in individual patients

– Not significant as a group

Hippocampus (cm3) Hyperintensities (cm3)

CC FA CC MD (µm2/ms)

Before After Before After

Before After Before After

CC = corpus callosum, FA = fractional anisotropy,

MD = mean diffusivity

ERPs N400 amplitude improvements in

verbal memory task ( Jin chen Yang in

Olichney lab)

Anavex 2-73 a Sigma-1 Receptor Agonist

Anavex 2-73 Sigma-1 receptor agonist

• Clinical validation to enhance cognition in

Alzheimer Disease in phase 2a and moving

to phase 2/3 trials

• Preclinical validation in mouse models for

depression, anxiety, epilepsy, infantile

spasms, FXS, Rett syndrome, multiple

sclerosis and Parkinson disease

• Planning 3 month controlled trial in FXTAS

and preFXTAS with wmd or neurological

symptoms followed by 1 year open label

• Submitting IND and will begin in 3 to 4 mo

Enhanced electrodermal responses to sensory

stimuli, which correlates inversely with FMRP

levels

Enhanced sympathetic activity related to lower

inhibition (GABA deficits)

(Miller et al. 1999)

Normals FXS

Sensory modulation or processing

problems in FXS

Handbiting 60% Handflapping 80% Poor eye

Contact 90%

Tactile 80%

defensiveness

Unusual

sensory

responses to

stimuli

Perseverative speech

or behavior in

almost all-routines

hyperactivity

60% of boys with FXS have ASD

FMRP mRNA targets associated with ASD, schizophrenia and

mood disorders (Fernandez, Rajan, Bagni 2014 Frontiers NS)

FMRP deficits appears to be a unifying feature

among neuropsychiatric disorders, ASD

• ASD, depression, bipolar with brain FMRP deficit (Fatemi et al 2010,2011,2012)

• Schizophrenia: FMRP deficits correlate with age

of onset and IQ (Kovacs et al 2013; Keleman et al 2013)

• Hypoxia at birth lowers FMRP levels

• Seizures can worsen autism symptoms in ASD,

Neurofibromatosis, Tuberous Sclerosis, FXS and

premutation involvement (Chonchiaya et al 2011; Berry-Kravis

et al 2012; Van Eeghen et al 2012 DMCN )

• Early life seizures disrupt FMRP (Bernard et al 2013)

Early life seizures displaces FMRP from

dendritic puncta to perinuclear location

A: control with FMRP (green color and white arrows) in puncta of dendrites in rat hippocampus at 60d

B: After early life seizures FMRP shifts to perinuclear location (yellow arrow) and enhanced LTP With focal deficits of FMRP

Bernard, Costanos, Benke 2012 SFN

Bernard et al 2013

Dramatic Up-regulation of Proteins in the CNS without FMRP

Bassell and Gross 2008

mGluR theory of FXS

Bear et al 2004

Arbaclofen

Lovastatin

mGluR5 Antagonist Trials • AFQ056 (Novartis)

– Adult (2212) and adolescent (2214) trials finished

failed to meet primary endpoint of improved behavior

on the ABC during 3 month placebo-controlled trial

– Extensions (2278 and 2279) ended (August 2014)

and development plan for trial with reading

intervention and trial with young kids stopped

• RO4927523 (Roche)

– Large phase 2/3 adult study – age 14 and up

– Small phase 2 child study – age 5-13

– Both studies completed – primary endpoints not met

Open label AFQ056 improvements

AFQ056+ PILI in 3-6yo FXS through NeuroNEXT

FX-LEARN Trial

• Effects of AFQ056 on Language Learning in Young Children with

FXS to take place at 14 NeuroNEXT centers in US

• Change paradigm/create model for development of mechanism

targeted pharmacotherapy in NDDs – effects of drug on plasticity

• Address many Quandries: incorporate young age (3-6y), longer trial,

objective measures, learning intervention, biomarkers for target

engagement

• Randomize to AFQ056 or placebo - lead-in period when adjust to

best dose (MTD), then add PILI and then open label

• Extension for 8 months on AFQ056 for all participants

Study Team PI: Elizabeth B-Kravis; Co-PIs: Randi

Hagerman, Len Abbeduto; Co-Is: Walter Kaufmann, Craig

Erickson, David Hessl, Flora Tassone

Follow

Up

Open-label Treatment

v1 v2 v3 v4 v5 v14 v15 v10 v11

Blinded Treatment Period Language Intervention

v13 v12 v8 v7 v9 v6

1 month 8 months 6 months

20 month Total Dosing Period

Initiate Language Intervention

Language Intervention Baseline Screening,

Begin Dosing End Dosing

Effects of AFQ056 on Language Learning in Young Children with Fragile X Syndrome (FXS) – Protocol Design

End Placebo-Controlled Period

Begin Open Label Extension

6 months

Hagerman et al 2014 JCP

SEROTONIN SYNTHESIS CAPACITY:

Autistic vs. Non-autistic Children

Chugani et al., 1999

Syndromic and non syndromic forms of ASD

have reduced tryptophan metabolism

• Boccoto et al 2013 Mol Aut: Studied 137

lymphoblastoid cell lines of patients with

neurodevelopmental disorders with (80) and

without ASD and 78 controls (2.5 to 35yo)

• Metabolic profiling demonstrated deficits in

tryptophan metabolism in ASD with

reduced NADH, not seen in ID or

schizophrenia

• Found abnormal gene expression of

enzymes in tryptophan metabolism pathway

Tryptophan metabolic pathway

Boccoto et al 2013

Sertraline is an optimal SSRI for

FXS and ASD

• SSRIs stimulate neurogenesis in the mouse and in humans (Malberg et al 2004; Warner-Schmidt et al 2006)

• SSRIs stimulate BDNF levels (Bianchi et al 2010;Taler et al 2013)

• Sertraline in FXS has a calming effect to the anxiety and may directly stimulate speech or improve language as a secondary effect from less anxiety

• Sertraline is the only SSRI to stimulate dopamine levels in the striatum and nucleus accumbens (Kitaichi

et al 2010)

Sertraline Treatment in Early Childhood in FXS A retrospective study of 45 children followed 12 to 50 months and 11 treated

with sertraline: significant differences in expressive and receptive language in TX

vs non treated (p=0.0001 and p=0.0071 respectively)

Winarni et al 2012 Autism Treatment and Research

Expressive language

Receptive language

Randomized, double blind, controlled trial of sertraline in 2 to

6yo with FXS lasting 6 months

Laura Greiss Hess PhD, OTR

Kerrie Lemons Chitwood PhD, CCC

initiated study

Sarah Fitzpatrick

NFXF summer student fellow

finalized the study and data

Baseline and 6 month Follow-up:

1* CGI-I, MSEL Expressive Language

2* MSEL: Receptive, fine motor, visual reception,

Composite T score, Sensory Processing Measure-

(SPM) Preschool version, Visual Analogue Scale

Controlled Trial of low dose Sertraline in FXS

Mullen Scales of Early Learning (MSEL)

(Hess et al 2016 JDBP)

P=0.007

P=0.047 P=0.031

P=0.005

p=0.008

P=0.038

BDNF val/val genotype with most

improvement on sertraline in FXS

AlObaly et al 2017 Tassone lab

Conclusions • MSEL visual perception and fine motor subtests, the

composite T score, and the combined mean of all the

subtests scores were improved on sertraline vs placebo so

cognitive and motor benefits and improvement in social

participation on SPM-P. It was safe without signif AEs

• Primary outcome measure choice is difficult and N/S here

• A significantly beneficial treatment by age 2 yo reinforces

the need for early diagnosis and even newborn screening

• From a clinical perspective families liked the effects of

sertraline and all wanted to continue clinically on sertraline

after the trial

• Now a sertraline trial in young children with ASD 2-6 so

refer patient to me: rjhagerman@ucdavis.edu

GABAA receptor expression is

down-regulated in FXS • GABAA expression is down- regulated in

the KO mouse (D’Hulst et al 2007; Kooy et

al 2005)

• GABAA agonists: Ganaxolone

– Investigational medication with efficacy in infantile

spasms and other types of epilepsy: A controlled double

blind cross-over trial (each arm 7 weeks) in children

with FXS (6 -18y) funded by DOD is finished.

– Paper in press to JNDD Andrew Ligsay et al 2017

– Targeting improvement in anxiety and behavior

– Frank Kooy has studied 11 patients in Belgium and we

studied 48 patients at the MIND

Results: CGI-I

p = 0.448

0

5

10

15

20

25

30

Very Muchimproved

Much Improved MinimallyImproved

No Change Minimally Worse Much Worse Very Much Worse

Nu

mb

er

of

Sub

ject

s

CGI_I Rating Scale

Ganaxalone

Placebo

Ligsay et al 2017 JNDD in press

Post-hoc: High Anxiety (PARS>13)

VAS – Anxiety ADAMS – General Anxiety

p=0.023 p=0.035

0

1

2

3

4

5

6

7

Baseline End

Me

asu

red

Sco

re (

cm)

GNX Placebo

0

2

4

6

8

10

12

Baseline End

Sub

scal

e T

ota

l Sco

re

GNX Placebo

VAS-Anxiety ADAMS-General Anxiety

Controlled trial of lovastatin in 10 to18yo

combined with Parent Implemented Language

Intervention (PILI) • Lovastatin is an inhibitor of the rate-limiting enzyme in

cholesterol biosynthesis and an FDA-approved treatment for

hyperlipidemia (Acosta et al 2011).

• Lovastatin down-regulates the RAS-ERK1/2 pathway and

lowers the excessive protein synthesis in FXS

• In FX KO mice lovastatin rescues seizures and lowers

excess protein production in KO mouse (Osterweil et al

2013)

• Lovastatin was beneficial in open label trial in FXS

• Lovastatin has anti-inflammatory effects

Every one gets PILI intervention

• PILI is twice a week with S and L therapist

and with behavior interventionist on skype

in your home

• Controlled trial of lovastatin increasing

from 10 mg gradually up to 40 mg if

tolerated

• Total trial lasting 18 weeks ages 10 to 18yo

• Contact Erika Bickel

(esbickel@ucdavis.edu) at the MIND

institute or rjhagerman@ucdavis.edu

Maternal Use of Intervention Strategies

were significantly improved with PILI

Data from McDuffie

et al 2016

Metformin

• Originally introduced for treatment of type

2 diabetes, then expanded to treatment of

obesity and now considered to be the

“Aspirin of the 21st century with a role in

gestational diabetes, prevention of

preeclampsia and cancer, and the promotion

of longevity” (2017 Romero et al AJOG)

Metformin Targets Multiple

Pathways and improves longevity

Barzilai et al 2016 Cell Metabol

Anticancer Effects of Metformin

Irie et al 2016 Oncology Letters

Metformin a type 2 diabetes med • Known to help overeating and obesity

• Can prevent cognitive deficits in diabetics

• Helpful in several patients with Prader-Willi

Phenotype of FXS (obesity and hyperphagia),

present in less than 10% of FXS

• Drosophila FX model: elevated insulin signaling

via PI3K/Akt/mTOR pathway and metformin

improved circadian rhythm defect and memory

problems (Monyak et al 2016)

• Rescues phenotype in KO mouse (Gantois et al

2017 Nature Med)

Metformin rescues many phenotypes in

KO mouse (Gantois et al 2017 Nat Med)

Bardoni & Mandel, 2002

The Prader-Willi Phenotype (PWP) of Fragile X Syndrome

Those with the PWP have a higher rate

of autism (70%) than those with FXS

alone and lower CYFIP levels (Nowicki et al 2007 )

GH is a treatment for PWS and maybe for PWP

Old and young patients with FXS treated with metformin

mothers requested this after NFXF conference

Open label clinical use of

metformin in FXS • First in those with obesity or the Prader-

Willi Phenotype of FXS

• A rare patient with type 2 diabetes and FXS

with elevated fasting glucose and HgbA1c

• Clinical Genetics (Dy et al 2017) our

experience with 7 patients ages 4 to 60y.

All had improvements in weight gain,

appetite control, behavior on the ABC

especially with irritability rating but most

remarkably better speech and language

abilities

Controlled trial of metformin in FXS

• Ages 6 to 40yo with FXS private foundation

funding

• Randomized, double blind controlled trial

lasting 4 months so baseline, 2 month and 4

month visits to the MIND and then open label

with clinical follow-up with PCP

• Baseline and outcome measures with language

sampling, NIH toolbox for cognition, behavior

measures, ERP, eye tracking with Tobii,

biomarkers (NFXF funded biobank)

• Contact rjhagerman@ucdavis.edu if interested

A flood of referrals of young children

with FXS wanting metformin

Case No./Initials

Age in Years (Starting on Metformin)

Treatment Length

(Months) Dose Labs ASD

Diagnosis Concomittant Medications

1 - TB 2.2 4 50mg75mg

BID Non-ASD Sertraline, Folic Acid, NAC,

Probiotic, Melatonin

2 - JD 4.2 3 50mg BID -->

100mg BID ASD Sertraline, Clonidine,

Melatonin

3- GF 6 3 50mg QD -->

BID HbA1C: 5.3 Non-ASD Sertraline, Quillivant XR,

Minocycline

4 - JR 4.2 3 50 mg BID ASD Sertraline, Guanfacine,

Methyl Folate

5 - FS 4.5 4 50mg BID -->

150mg BID Non-ASD Guanfacine, Minocycline

6 - OS 4.5 4 50mg BID -->

150mg BID Non-ASD Guanfacine, Minocycline

Side effects of metformin • Mainly loose stools, although if you increase the

dose slowly then you are less likely to see diarrhea.

So in young children begin with 50 mg at dinner

then go to 50 mg bid (solution 500 mg/5ml made

by Riomet)

• Hypoglycemia is not thought to be a problem with

metformin ( check fasting blood glucose in F/up)

• One patient had a seizure a week after starting

metformin (glucose was normal in ER; MRI had

heterotopias) uncertain if related to metformin

New treatments for FXS andASD • Cannabidiol: CBD (not THC) will likely be helpful for

ASD, FXS and premutation involvement especially for

anxiety, sleep disturbances and pain (GABAA agonist).

Study with Zynerba CBD cream not funded by DOD

• Suramin: purigenic antagonist (Naviaux et al 2015)

– Many effects including decreasing PI3K,AKT,APP and

TDP43 in ASD and FXS mouse

• Bumetanide: diuretic (Tyzio et al 2014)

– bumetanide to mother rescues the GABA developmental

sequence and autistic phenotype in rodents with FXS or

ASD. Now in patient trials for ASD.

• Fulcrum: Wants to up regulate FMRP

• Press Release: 9-30-17

• Zynerba Pharmaceuticals today announced positive top

line results from an open label exploratory Phase 2 FAB-C

(Treatment of Fragile X Syndrome Anxiety and Behavioral

Challenges with CBD) clinical trial evaluating ZYN002

cannabidiol (CBD) gel in pediatric and adolescent patients

with Fragile X syndrome (FXS). The study successfully

met its primary endpoint, achieving a 46% improvement

(p<0.0001) in the total score of Anxiety, Depression, and

Mood Scale (ADAMS) at week twelve compared to

baseline. ZYN002 also achieved clinically meaningful

improvements in all measures of the Aberrant Behavior

Checklist for Fragile X (ABC-FXS), which address the key

symptoms of FXS including social avoidance, temper

tantrums, repetitive movements, and hyperactivity.

Zynerba Data

CBD oils: here 25:1 CBD :THC

anecdotal reports are positive

Yoga and Mindfulness Meditation

improves GABA inhibition

NNZ-2566 (Neuren) Trofinetide

ERK and AKT biomarkers

Growth hormone IGF-1/GPE (glypromate) analog

Works on overactive ERK/AKT pathway in FXS mouse

ERK/ARK in signaling pathway for mGluRs/other receptors

Normalizes hyperactivity, social behavior, cognition, dendritic spines,

ERK/AKT, even testis size in FXS mouse

Neuren Phase 2 placebo controlled trial

with IGF1 analogue Trofinetide • Safe in males14-40 yo with FXS over 42

days of treatment carried out at 5 US

centers. Highest dose was most effective

Vitamins and antioxidants in Fragile X mouse and

man

• Vit E (Alpha tocopherol) and N acetyl L cysteine (NAC) improved

behavior and cognition in KO mouse (de Diego et al 2009)

• Controlled trial of Vit E and C in 6 to 18yo with FXS 10 mg/kg/day

for 24 weeks (de Diego-Otero et al 2014)

• Omega 3 diet increased sociability in KO mouse and BDNF in DG of

hippocampus (Pietropaolo et al 2014 Psychoneuroimmunology)

n-3 PUFAs = omega 3 Polyunsaturated fatty acids

New treatments for ASD and FXS

• Cannabidiol: CBD (not THC) will likely be helpful for

ASD, FXS and premutation involvement especially for

anxiety, sleep disturbances and pain (GABAA agonist).

Study with Zynerba CBD cream not funded by DOD

• Suramin: purigenic antagonist (Naviaux et al 2015)

– Many effects including decreasing PI3K,AKT,APP and

TDP43 in ASD and FXS mouse

• Bumetanide: diuretic (Tyzio et al 2014)

– bumetanide to mother rescues the GABA developmental

sequence and autistic phenotype in rodents with FXS or

ASD. Now in patient trials for ASD.

Targeted Treatments must be combined with

innovative educational programs • If synaptic connections are improved with

targeted treatment we must enhance these

connections with educational interventions

• Combine treatment trials with educational

interventions (PILI), digital programs such as

CogMed, Headsprout for reading, AT devices,

iPAD apps

FX tracking game CHAT Alt CHAT 40

Co-Writer and write out loud iPAD apps

MIND Institute

Kyoungmi Kim

Len Abbeduto

Kathy Angkustsiri

David Hessl

Susan Rivera

Andrea Schneider

Mary Jae Leigh

JunYi Wang

Norman Brule

Laura Potter

Patrick Adams

Jasdeep

Erika Bickel

Susan Harris

Lisa Makhoul

Jen Cogswell

Maria Diez

Dept. Radiology

James Brunberg

NTRI Researchers

Isaac Pessah

Rob Williamson

Rob Berman

Dept. Neurology

Lin Zhang

John Olichney

Ricardo Maselli

Mike Rogawski

Dept of Psychiatry

Andreea Seritan

Support: NICHD, HRSA, DOD, NIA, NFXF, CDC, NFXF, Alcobra

Neuren, Roche, Novartis, Marinus

University of Colorado Health Sciences Center (Denver) Nicole Tartaglia Maureen Leehey James Grigsby ; Karen Riley at DU

RUSH-Presbyterian-St. Luke’s Medical Center (Chicago)

Elizabeth Berry-Kravis Deb Hall Christopher Goetz

*Latrobe University, Melbourne Australia*

Danuta Loesch Richard Huggins

Dept. Biochem & Molec. Medicine

Paul Hagerman Flora Tassone

Anna Ludwig

Greg Mayeur Chris Raske

Dept. Biostatistics now at UC Irvine

Danh Nguyen

Department of Pathology

Claudia Greco

Department of Rehabilitation

Veronica Martinez-Cerdeno

UC Davis School of Medicine

Collaborators