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

Disclosures • I am currently carrying out treatment trials for those with FXS for CBD (Zynerba), metformin Advances in Targeted Treatments for FXS and ASD (Azrieli Foundation), AFQ056 in the FX‐LEARN trial (NICHD), and initiating the Gaboxadol 18th Annual Developmental Disabilities: An Update for Health trial (Ovid) next month Professionals, March 14-15, 2019 • I have consulted with Zynerba regarding FX Randi Hagerman MD treatment trials Distinguished Professor of Pediatrics Endowed Chair in Fragile X Research MIND Institute UC Davis Medical Center Overview Learning Objectives • Know the relationship between FXS and I will give an overview of the latest treatment trials for Autism and FXS and a future look at Autism Spectrum Disorder treatments for both disorders. • 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

Defining clinical targets for therapeutics A New Age of Targeted Treatments Autism/ASD associated phenotypes • This is a new age of targeted treatments to reverse the •Genetic disorders with ASD association neurobiological abnormalities for intellectual disability - Symptom diversity/prevalence/severity - Diverse background genotypes – Fragile X syndrome: mGluR5 antagonists, GABA agonists, Obesity o 16p11.2 deletion & duplication syndromes Sleep Deficits o Fragile X Syndrome minocycline, arbaclofen, lovastatin, trofinetide, metformin Hyper- Pain Sensory o Tuberous Sclerosis tension Disorders GI o 22q11.2 deletion syndrome – Angelman syndrome: minocycline, Gaboxadol Disorders Mood o Rett Syndrome o Prader-Willi syndrome – Prader-Willi Syndrome: Growth Hormone, Oxytocin Intellectual Social Disability o Cornelia de Lange syndrome Social Communication Deficits Anxiety o Smith-Lemli-Opitz syndrome Deficits – Tuberous sclerosis: mTOR inhibitors: Rapamycin Attention o 48,XXYY syndrome o Moebius syndrome Hyperactivity – Rett syndrome: Trofinetide, Anavex 2-73 o Jacobsen syndrome Language Repetitive Repetitive o Phelan-McDermid syndrome Impairment Behaviors Behaviors o 2q37 deletion syndrome o FOXG1 syndrome • Autism and FXS have similarities in GABA and glutamate Tantrums o Myhre syndrome o 3p deletion syndrome Seizures Self Injury imbalances, common pathways ie mTOR, miRNA dysregulation, Irritability o SYNGAP1-related intellectual disability Aggression o Kleefstra syndrome mitochondrial abnormalities, oxidative stress, synaptic plasticity o 1q21.1 microdeletion syndrome deficits, environmental toxicity, and FMRP deficits. o Timothy syndrome Core Clinical Features •Environment/environmental exposure history Associated CNS Symptoms •Diet and/or enterotype (microbiome) Somatic Symptoms Adapted from Ring, 2016 Fragile X Syndrome and Autism/ASD Basic Workup for ASD FMRP deficits may be a unifying feature among neuropsychiatric disorders, ASD • Fragile X ( FMR1 ) DNA testing • With Fragile X syndrome (FXS), 60% of boys and 20% of girls have ASD ; • CGH array (replaced FISH and Karyotyping) 10% of boys with premutation have ASD • Whole Exome Sequencing (WES) or Sequencing a battery of • ASD , depression , bipolar disorder all observed to have deficits of FMRP ASD genes in brain (Fatemi et al 2010,2011,2012) o yield 50% with a mutation (Jiang et al 2013) ; if negative • In schizophrenia , FMRP deficits correlate with age of onset and IQ then WGS (Kovacs et al 2013; Keleman et al 2013) • Purkinje cells derived from Tuberous sclerosis (TSC) patients display • EEG is essential if there is history of seizures, staring spells hypoexcitability and synaptic deficits associated with reduced FMRP levels or unexpected aggression without a precipitating stimulus 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

Early life seizures displaces FMRP from Lowered Brain FMRP levels in dendritic puncta Psychiatric Disorders Fatemi et al 2010,2012,2014 Bernard, Costanos, Benke 2012; Bernard et al 2013 • Early life seizures lead to a shift of 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 (green puncta) in dendrites of rat hippocampus (60d) (A) Control; (B) After early life seizures, FMRP has many functions and its absence causes FMRP controls Brd4 which regulates dysregulation of several systems known to be associated epigenetic changes 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 GABA A 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 targets multiple mRNAs Intersecting Epigenetic Mechanisms associated with ASD, schizophrenia and Keil and Lein (2016) Environ Epigenet, 2016, 1–15 mood disorders (Fernandez et al 2014) 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 binds multiple mRNAs to Main synaptic functions associated with ASD (down)regulate their protein expression Bourgeron (2015) Nat Rev 16:551- 563 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 They found 3,593 FMRP mRNA targets, of which 939 genes were two- to sixfold enriched Dysregulated mTOR signaling increases the risk Among the highly enriched FMRP targets were 93 genes independently of autism in patients with implicated in ASD, including mTOR and TSC2. mutations in neurofibromin They found genes involved in Angelman , Prader–Willi , Rett , and (NF1), tuberous sclerosis 1 (TSC1), TSC2 or Cornelia de Lange syndromes. phosphatase and tensin  Molecular link to tie together elements of clinically overlapping disorders, homologue (PTEN), among others and identify connections between FXS and its associated phenotypes.

Handbiting 60% Two different mutations in the same FMR1 gene Two different mutations in the same FMR1 gene Poor eye Handflapping 80% Contact 90% 1/130-250 females 1/250-810 males 1/3600-5000 Tactile 80% defensiveness Typical Typical Premutation Premutation Full mutation Full mutation (CGG) < 45 (CGG) (CGG) (CGG) (CGG) (CGG) Unusual < 45 55 - 200 55 - 200 > 200 > 200 sensory responses to stimuli mRNA mRNA Perseverative speech or behavior in Usually happy almost all-routines FMRP FMRP Fragile X syndrome (FXS) Fragile X syndrome (FXS) Primary Ovarian Insufficiency (FXPOI) Primary Ovarian Insufficiency (FXPOI) Obesity in 30% Clinical Clinical normal Fragile X-associated Fragile X-associated Prader-Willi Tremor Ataxia Syndrome (FXTAS) Tremor Ataxia Syndrome (FXTAS) Phenotype in<10% FX-associated Neuropsychiatric Disorders FX-associated Neuropsychiatric Disorders Severe obesity and (FXAND): Depression, anxiety, ADHD, (FXAND): Depression, anxiety, ADHD, hyperphagia OCD, chronic fatigue, chronic pain OCD, chronic fatigue, chronic pain Dramatic Up-regulation of Proteins in the CNS without FMRP Bassell and Gross 2008 mGluR theory of FXS Bear et al 2004