Disclosures I am currently carrying out treatment trials for those - - PDF document

Advances in Targeted Treatments for FXS and ASD

18th Annual Developmental Disabilities: An Update for Health Professionals, March 14-15, 2019 Randi Hagerman MD Distinguished Professor of Pediatrics Endowed Chair in Fragile X Research MIND Institute UC Davis Medical Center

Disclosures

• I am currently carrying out treatment trials for

those with FXS for CBD (Zynerba), metformin (Azrieli Foundation), AFQ056 in the FX‐LEARN trial (NICHD), and initiating the Gaboxadol trial (Ovid) next month

• I have consulted with Zynerba regarding FX

treatment trials

Overview

I will give an overview of the latest treatment trials for Autism and FXS and a future look at treatments for both disorders.

Learning Objectives

• Know the relationship between FXS and

Autism Spectrum Disorder

• Name 2 medications that are targeted

treatments for FXS

• Name 2 new medications for ASD
• List the CGG repeat number of the full

mutation and the premutation of fragile X mutations and know the mechanisms of involvement

A New Age of Targeted Treatments

• This is a new age of targeted treatments to reverse the

neurobiological abnormalities for intellectual disability – Fragile X syndrome: mGluR5 antagonists, GABA agonists, minocycline, arbaclofen, lovastatin, trofinetide, metformin – Angelman syndrome: minocycline, Gaboxadol – Prader-Willi Syndrome: Growth Hormone, Oxytocin – Tuberous sclerosis: mTOR inhibitors: Rapamycin – Rett syndrome: Trofinetide, Anavex 2-73

• Autism and FXS have similarities in GABA and glutamate

imbalances, common pathways ie mTOR, miRNA dysregulation, mitochondrial abnormalities, oxidative stress, synaptic plasticity deficits, environmental toxicity, and FMRP deficits.

Defining clinical targets for therapeutics

Autism/ASD associated phenotypes

• Genetic disorders with ASD association
• Symptom diversity/prevalence/severity
• Diverse background genotypes
• 16p11.2 deletion & duplication syndromes
• Fragile X Syndrome
• Tuberous Sclerosis
• 22q11.2 deletion syndrome
• Rett Syndrome
• Prader-Willi syndrome
• Cornelia de Lange syndrome
• Smith-Lemli-Opitz syndrome
• 48,XXYY syndrome
• Moebius syndrome
• Jacobsen syndrome
• Phelan-McDermid syndrome
• 2q37 deletion syndrome
• FOXG1 syndrome
• Myhre syndrome
• 3p deletion syndrome
• SYNGAP1-related intellectual disability
• Kleefstra syndrome
• 1q21.1 microdeletion syndrome
• Timothy syndrome
• Environment/environmental exposure history
• Diet and/or enterotype (microbiome)

Adapted from Ring, 2016

Social Deficits Repetitive Behaviors Core Clinical Features

Social Communication Deficits Repetitive Behaviors

Associated CNS Symptoms Somatic Symptoms GI Disorders Pain Obesity Hyper- tension

Language Impairment Sleep Deficits Sensory Disorders Mood Anxiety Hyperactivity Attention Self Injury Tantrums Aggression Seizures Intellectual Disability Irritability

Basic Workup for ASD

• Fragile X (FMR1) DNA testing
• CGH array (replaced FISH and Karyotyping)
• Whole Exome Sequencing (WES) or Sequencing a battery of

ASD genes

• yield 50% with a mutation (Jiang et al 2013) ; if negative

then WGS

• EEG is essential if there is history of seizures, staring spells
• r unexpected aggression without a precipitating stimulus

Fragile X Syndrome and Autism/ASD

FMRP deficits may be a unifying feature among neuropsychiatric disorders, ASD

• With Fragile X syndrome (FXS), 60% of boys and 20% of girls have ASD;

10% of boys with premutation have ASD

• ASD, depression, bipolar disorder all observed to have deficits of FMRP

in brain (Fatemi et al 2010,2011,2012)

• In schizophrenia, FMRP deficits correlate with age of onset and IQ

(Kovacs et al 2013; Keleman et al 2013)

• Purkinje cells derived from Tuberous sclerosis (TSC) patients display

hypoexcitability and synaptic deficits associated with reduced FMRP levels and reversed by rapamycin (Sundberg et al 2018)

• Hypoxia at birth lowers FMRP levels
• Seizures can worsen autism symptoms in FXS, ASD, Neurofibromatosis,

TSC, and in FMR1 premutation carriers (Chonchiaya et al 2011; Berry- Kravis et al 2012; Van Eeghen et al 2012)

• Seizures dysregulate FMRP at the synapse

Lowered Brain FMRP levels in Psychiatric Disorders

Fatemi et al 2010,2012,2014

Early life seizures displaces FMRP from dendritic puncta

FMRP (green puncta) in dendrites of rat hippocampus (60d) (A) Control; (B) After early life seizures,

Bernard, Costanos, Benke 2012; Bernard et al 2013

• Early life seizures lead to a shift
• f FMRP away from

dendrites/dendritic spines toward the neuronal cell body

• This shift creates a functional

deficiency of FMRP in dendrites (Bernard et al 2013)

FMRP has many functions and its absence causes dysregulation of several systems known to be associated with autism

• Transporter of mRNAs to the synapse
• Controls (usually suppression of) translation of many

mRNAs related to synaptic plasticity

• Absence of FMRP

– causes increased protein production throughout the brain including MMP9 levels – Up regulation of mGluR5 pathways leading to long term depression (LTD) – Down regulation of GABAA receptors – Dysregulation of dopamine pathways – Enhanced APP production – Increased oxidative stress damage to neurons – Enhanced release of neurotransmitters presynaptically – Dysfunctional epigenetic regulation

Korb et al 2017 Cell

FMRP controls Brd4 which regulates epigenetic changes

Intersecting Epigenetic Mechanisms

Keil and Lein (2016) Environ Epigenet, 2016, 1–15

Emerging model:

• Genetic substrate confers increased susceptibility to environmental factors

that interfere with normal neurodevelopment.

• It is the interaction between genes and the environment that determines

individual ASD risk, clinical phenotype, and/or treatment outcome. Evidence includes:

• Incomplete penetrance within individuals expressing a given ASD-linked gene

mutation

• Incomplete concordance for autism among monozygotic twins

Wong et al., 2014

• Among 50 pairs of ASD discordant monozygotic twins, >50 genes are

differentially methylated between the twin diagnosed with ASD and the non- symptomatic twin.

• The changes in DNA methylation at differentially methylated CpG sites also

correlated with total childhood autism symptoms test scores.

FMRP targets multiple mRNAs

associated with ASD, schizophrenia and mood disorders

(Fernandez et al 2014)

FMRP binds multiple mRNAs to (down)regulate their protein expression

They found 3,593 FMRP mRNA targets, of which 939 genes were two- to sixfold enriched Among the highly enriched FMRP targets were 93 genes independently implicated in ASD, including mTOR and TSC2. They found genes involved in Angelman, Prader–Willi, Rett, and Cornelia de Lange syndromes.

• Molecular link to tie together elements of clinically overlapping disorders,

and identify connections between FXS and its associated phenotypes. Ascano et al. (2012) Nature 492:382-388. Two related measures used to isolate all of the mRNAs that are bound by FMRP:

RIP-CHIP: ribonucleoprotein immunoprecipitation followed by microarray analysis (RIP-chip) PAR-CLIP: 4-thiouridine (4SU) photoactivatable ribonucleoside- enhanced crosslinking and immunoprecipitation

Main synaptic functions associated with ASD

Dysregulated mTOR signaling increases the risk

• f autism in patients with

mutations in neurofibromin (NF1), tuberous sclerosis 1 (TSC1), TSC2 or phosphatase and tensin homologue (PTEN), among

• thers

Bourgeron (2015) Nat Rev 16:551- 563

Two different mutations in the same FMR1 gene Two different mutations in the same FMR1 gene

Fragile X syndrome (FXS) Primary Ovarian Insufficiency (FXPOI) Fragile X-associated Tremor Ataxia Syndrome (FXTAS) FX-associated Neuropsychiatric Disorders (FXAND): Depression, anxiety, ADHD, OCD, chronic fatigue, chronic pain Fragile X syndrome (FXS) Primary Ovarian Insufficiency (FXPOI) Fragile X-associated Tremor Ataxia Syndrome (FXTAS) FX-associated Neuropsychiatric Disorders (FXAND): Depression, anxiety, ADHD, OCD, chronic fatigue, chronic pain

mRNA mRNA FMRP FMRP Clinical Clinical

Typical Premutation Full mutation Typical Premutation Full mutation

(CGG) (CGG) < 45 < 45 55 - 200 55 - 200 (CGG) (CGG) > 200 > 200 (CGG) (CGG) normal

1/130-250 females 1/250-810 males 1/3600-5000

Handbiting 60% Handflapping 80%

Poor eye Contact 90% Tactile 80% defensiveness

Unusual sensory responses to stimuli

Perseverative speech

• r behavior in

almost all-routines

Obesity in 30% Prader-Willi Phenotype in<10% Severe obesity and hyperphagia

Usually happy

Dramatic Up-regulation of Proteins in the CNS without FMRP

Bassell and Gross 2008 mGluR theory of FXS Bear et al 2004

Arbaclofen

Lovastatin

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,
• bjective 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

Minocycline Studies in FXS or Autism

• Bilousova et al 2009 demonstrated that minocycline lowers MMP9

levels in FXS and improved behavior and cognition in the FX mouse

• Utari et al (2010) surveyed 50 families with FXS Tx with

minocycline for >2wks and found 70% positive response especially in language and limited side effects (check ANA).

• Positive open trial in FXS in Toronto with age > 13 years (Paribello

et al 2010)

• Trial of minocycline in autism at NIMH (Sue Swedo PI)

19 yo boy with FXS took minocycline for 1 year

Controlled cross-over double-blind trial of minocycline, significant improvement on CGI and VAS measures (Leigh et al 2013 JDBP)

Intent to Treat Analysis Minocycline = 2.49 ±0.13 Placebo = 2.97 ±0.13 p= 0.0173 1 2 3 4 5 6 7

x

n

Improvements in ERP as biomarker

Habituation improved to repetitive clicks on minocycline vs placebo Schneider et al 2013 J of Psychopharm

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 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

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 Post hoc testing of the 60% with ASD demonstrated significant improvement in EL rawwith sertraline vs placebo (p=0.029) Post hoc testing demonstrated a significant improvement in EL raw score in those with ASD on Sertraline vs placebo (p=0.029)

Low dose sertraline (2.5 mg to 5mg) controlled trial in ASD 2-6 y without FXS

• Mullen Scales of Early Learning (MSEL), PLS5, Vineland

II (VABS), Aberrant Behavior Checklist-Community (ABC), Preschool Anxiety Scale-R (PAS-R), Social Reciprosity Scale-2 (SRS), CGI-I

• Visual Analogue Scale for 3 measures:

– OCD /anxiety sxs; – language/ communication; – hyperactivity/hyperarousal and aggression

• CGI-I was done at 3 months also with examination
• Primary outcome measures were: MSEL expressive

language raw score and MSEL combined age score

• Weekly calls for first month and then monthly calls for AE

and completing the ABC irritability scale (FDA required)

CGI-I at 6 months (p=0.77)

1 2 3 4 5 6 7 8 9 10 Very Much Improved Much Improvied Minimally Improvied No Change Minimally Worse Much Worse Very Much Worse Number of Subjects CGI_I Rating Scale

CGI_I at 6 Months

Placebo Sertraline

Outcome measures: Mullen

p=0.547 p=0.298

None of the other outcome measures demonstrated a significant difference

Why did sertraline work better in FXS than in idiopathic ASD?

• Anxiety is a more significant problem in FXS

than in ASD

• Anxiety may be a major driver of ASD in those

with FXS because anxiety leads to social isolation.

• The level of anxiety correlated with the

severity of autism in children with FXS (Cordiero et al 2011)

ASD vs FXS: Anxiety is a driver for ASD in FXS (Hong et al 2019 JND)

FXS with less fixation on the eyes

In FXS, more anxiety, less eye contact but increased interest in social scene preference so maybe hypervigilant to social interactions (Hong et al 2019 JND)

Metformin a type 2 diabetes med

• Known to help overeating and obesity
• Can prevent cognitive deficits in diabetics
• 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)

• Helpful in open label study of 7 with FXS (ages 4 to 60)

including PWP, obese and non obese and all improved language and behavior (Dy et al 2017)

Metformin targets multiple pathways and improves longevity

Barzilai et al 2016 Cell Metabol

Controlled trial of metformin in FXS

• Ages 6 to 25yo with FXS private foundation

funding, FDA granted IND for this research

• Randomized, double blind controlled trial

lasting 4 months so baseline, 2 month and 4 month visits to the MIND or 2 sites in Canada (Edmonton –Dr Boldec and Montreal –Dr Jacquemont) 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 eye tracker, molecular biomarkers (MMP9, S6 kinase)

• TB's mom is a pediatrician at a

large university medical center and wanted to try her son on low dose metformin at age 2yo

• He had a good response (he

could barely stack 3 blocks prior and after 2 weeks on metformin he was stacking 10 blocks)

• she put videos of his

improvement on the web and she talked to other parents

Metformin in Young Children

Metformin in Children Ages 2‐7

Aberrant Behavior Checklist Scores Pre‐ and Post‐Metformin

1 2 3 4 5 Baseline After 4 mos. Baseline After 4 mos. Baseline After 3 mos. Baseline After 3 mos. Baseline After 7 mos. ABC Composite Score 15 7 109 39 29 20 32 28 113 59

• I. Irritability

8 3 32 12 12 8 4 6 40 19

• II. Lethargy

1 20 4 1 4 3 23 12

• III. Stereotypy

2 11 5 4 4 10 5

• IV. Hyperactivity

4 4 29 13 13 9 16 12 29 14

• V. Inappropriate Speech

6 2 2 2 9 8

• VI. Social Avoidance

11 3 1 1 4 3 2 1 6 7 8 9 Baseline After 1 mos. Baseline After 8 mos. Baseline After 7 mos. Baseline After 6 mos. ABC Composite Score 22 20 33 48 67 59 62 51

• I. Irritability

5 3 14 17 21 25 29 22

• II. Lethargy

1 11 5

• III. Stereotypy

2 2 1 9 6 9 8

• IV. Hyperactivity

12 11 17 27 22 16 17 14

• V. Inappropriate Speech

3 6 2 4 6 7 7

• VI. Social Avoidance

1

Metformin may reverse the IQ decline and prevent macroorchidism in FXS

Metformin for 1 year improved IQ in 2 adult males

A 12yo boy with PWP of FXS was treated for 2 years with metformin

• his weight percentiles normalized
• at 14yo he was Tanner stage 3

with normal sized testicles

Additional new treatments for FXS and ASD

• IGF1 analogue: Trofinetide was beneficial in FXS in controlled

trial and beneficial in Rett syndrome

• Gaboxadol: a GABA A agonist: enrolling 13 to 22yo FXS
• Cannabidiol: CBD (not THC) will likely be helpful for ASD,

FXS and premutation involvement especially for anxiety, sleep disturbances and pain (GABAA agonist); Zynerba controlled trial with gel of CBD is initiated now after an open label study demonstrated efficacy in Australia

• 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 with positive results.

Epidiolex approved for Dravet syndrome and uncontrollable seizures

Zynerba (CBD cream) Open Label in Australia

CBD Gummies are 25 mg per gummie Oxytocin nasal spray bid in ASD

(Parker et al 2017)

those with the lowest pretreatment oxytocin levels benefited the most on the SRS

Yoga and Mindfulness Meditation improves GABA inhibition

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, digital programs such as PILI, 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 Norman Brule Lauren Plummer Kathy Angkustsiri David Hessl Susan Rivera Andrea Schneider Mary Jae Leigh Sarah Dufek Michele Ono Patrick Adams Aisha Lott Laura Potter Sumra Afaz Hazel Biag Yingatrana McClennon Maria Diez Len Abbeduto

• 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 UCSF Andreea Seritan

Support: NICHD, HRSA, DOD, NIA, NFXF, CDC, NFXF, Azrieli Foundation

University of Colorado Health Sciences Center (Denver)

Nicole Tartaglia Maureen Leehey James Grigsby ; Karen Riley at DU

RUSH- (Chicago)

Elizabeth Berry-Kravis Deb Hall Christopher Goetz

*Latrobe University, Melbourne Australia*

Danuta Loesch Richard Huggins

Canada: University of Alberta in Edmonton –Francois Bolduc St Justine Hospital Quebec _Sebastien Jacquemont Indonesia: Diponegoro University, Samarang

Sultana Hussein, Tri Indah Winarni, Agustini Utari

• Dept. Biochem & Molec. Medicine

Paul Hagerman Flora Tassone Glenda Espinal Department of Rehabilitation Veronica Martinez-Cerdeno

Colombia: Universidad del Valle: Wilmar Saldarriaga CES Universidad: Juan Esteban

Philippines: Angel Dy , Laurdes

Tanchenco, Jeanne Dy, Melinda Tan

UC Davis School of Medicine

Collaborators