Mitochondrial Disorders and Cerebral Folate Deficiency in Autism Spectrum Disorder

1. Mitochondrial Disorders and Cerebral Folate Deficiency in Autism Spectrum Disorder Richard E. Frye, M.D., Ph.D. Director of Autism Research Associate Professor of Pediatrics Arkansas Children’s Hospital

2. The Rise in Autism CDC estimates the prevalence of Autism Spectrum Disorder is as high as 7 per 1,000 or 1 in 150! Debate over whether this is due to a shift in diagnosis or a true rise in the number of cases. Does it matter?? Either way there are a lot of children that need care.

4. Autism Defined

6. The Etiology of Autism: More than Genetic Disorders Estimated Prevalence of Genetic Abnormalities Cytogenetic Abnormalities 5% Fragile X 5% Rett Syndrome (Females only) 5% (~1% overall) Chromosomal Microarray 10% Total 21% This leaves about 79%+ children with ASD without an identified genetic diagnosis. . (Schaefer and Mendelson, Genetics in Medicine, 2008)

7. New Understanding of Autism • Autism is defined as a collection of symptoms • Symptoms of Autism are associated with underlying medical disorders in may cases • In many cases, Autism is a multisystemic disorder with primary neurological manifestations. • The rise in Autism cases is probably due to complex interactions between genetics, environment and the dynamics of physiological development.

8. Mitochondrial Dysfunction and Cerebral Folate Deficiency/Insufficiency is becoming recognized as highly prevalent in autism spectrum disorder This talk will review • Evidence for Mitochondrial Dysfunction in Autism Spectrum Disorder • Biomarkers for mitochondrial dysfunction • Importance of cerebral folate deficiency/insufficiency and the folate receptor autoantibody • How cerebral folate deficiency/insufficiency is diagnosed and treated

9. Evidence for MitochondrialDisease and Dysfunction in Autism Spectrum Disorder

12. Biomarkers of Abnormal • Energy Metabolism • in Children with • Neurodevelopmental Disorders • A review of metabolic studies from 133 consecutive patients evaluated in a • medically-based autism clinic • Examined a wide range of metabolic markers in children with autism including markers of fatty-acid oxidation disorders

13. 6 Biomarkers Reviewed 4 Groups with high prevalence Identified Lactate, Alanine-to-Lysine & Acyl-Carnitine 34.3% with AST 53.0%

15. Acyl-Carnitine Elevation Group 3-hydroxy-3-methylglutaryl is a metabolite of Acetyl-CoA, the starting point of the citric acid cycle. Suggests that the citric acid cycle is working inefficiently. It can also be seen in 3-hydroxy-3-methylglutaryl-CoA lyase deficiency but at much higher levels.

16. Muscle Biopsy of child with acyl-carnitine elevations

17. Altered brain phospholipid and acylcarnitine profiles in propionic acid infused rodents: further development of a potential model of autism spectrum disorders. J Neurochem. 2010 Apr;113(2):515-29. Derrick MacFabe et al.

19. Defining Mitochondrial Disease • Several systematic criteria are used to diagnose mitochondrial disease. • Here we consider the Morava et al. (2006) criteria which uses the following findings: • Clinical • Metabolic and neuroimaging • Mitochondrial morphological • Patients are classified into 4 categories: • Not likely (<=1) • Possible (2-4 points) • Probable (5-7 points) • Definite (>=8 points). • Score of 3+ suggests a muscle or skin biopsy should be done

20. (Frye and Rossignol, Ped Research, 2011)

21. (Frye and Rossignol, Ped Research, 2011)

22. (Frye and Rossignol, Ped Research, 2011)

25. Weissman et al 2008 Review of 25 children diagnosed with autism eventually diagnosed with a mitochondrial disorder High rate of non-neurologic symptoms High rate of fatigability – 68% Unusual regression -- 60%

26. Pyruvic Acid CMA MitoMet mtDNA point mutations Start Supplements L-Carnitine (Carnitor) Ubiquinol (Douglas Labs) B-Complex (Supra-Nu Thera) Suspect Mitochondrial Disorder Morning Fasting CMP Lactic Acid Amino Acids Ammonia Acyl-Carnitine Creatine Kinase Urine Organic Acids CO2 LFTs Glucose No Diagnosis If Lab Abnormal Repeat to Confirm Muscle Biopsy Histology Electron Microscopy Electron Transport Chain Studies mtDNA Content Studies Suspect Fatty Acid Disorder RBC Zinc & Copper, Biotin Triglyceride & Cholesterol Panel Urine Acyl-Glycine & Ketones More Specific Diagnosis Testing of Specific Genes mtDNA sequencing No Diagnosis Skin Biopsy with Fatty-acid oxidation and electron transport chain studies, MitoMet Specific Therapy

27. A New Type of Mitochondrial Disorder:Complex IV Hyperfunction.

28. Electron Transport Chain StudiesFrom 14 Children with ASD and Mitochondrial Diseasedefined by Morava et al. criteria

29. Corrected ETC Function

30. Maximum Corrected ETC Function by Subject

31. Why Is Mitochondrial Disease Associated with Autism?

32. Brain growth peaks just after the first year of life. Brain growth requires energy. A deficit in energy during this essential time may result in a failure in brain development

33. Mitochondrial Dysfunction Environmental Toxins Genetic Defects Increased Free Radicals Cell Damage and Death

34. Treatment of Mitochondrial Disorders

35. Treatment of Mitochondrial Disease

37. Treatment of Mitochondrial Disease • Prevention of Regression • Avoid Dehydration • Avoid Fever • Avoid Viral Illness • Avoid Specific Drugs

38. Treatment of Mitochondrial Disease • Prevention of Regression 28 patients with ASD and mitochondrial disease. 17 individuals had a history of regression 71% (12 of 17) regressed with fever 24% (4 of 17) fever followed vaccination

39. Drug Interactions • Antibiotics to avoid: • Linezolid and other oxazolidinone antibiotics • Rifampin • Tetracycline • Chloramphenicol • Imipenem • Cephalogycin • Beta-lactam (penicillin and cephalosporin)  • Other substances to avoid : • Alcohol • Cigarette smoke • monosodium glutamate • Acetaminophen • Antipsychotics • Fasting • Dehydration • Sleep Deprivation • Antibiotics that are probably okay: • Fluoroquinolones (Ciprofloxacin, floxin, levaquin), • Macrolides (azithromycin, clarithromycin, erthromycin) • Cephaloglycin, • Bactrim

40. Preventive Strategies: Drug Interactions

41. Treatment of Mitochondrial Disease • Diets • Ketogenic Diet • Modified Atkins Diet • Complex Carbohydrate Supplementation

42. Treatment of Mitochondrial Disease • Secondary Effects of Mitochondrial Disorders • Gastrointestinal Dysfunction- Dysmotility • Thyroid Dysfunction • Adrenal Dysfunction • Immune System Dysfunction • Cardiovascular Dysfunction • Brain Dysfunction • Cerebral Folate Deficiency • Seizures • Neurotransmitter Deficiencies • Acetylcholine • Excitatory-Inhibitory Balance

43. Cerebral Folate Deficiency

44. Antibodies to the FR1 (Folate Receptor 1) block folate from crossing the blood-brain barrier. Since this is an energy dependent process disorder of energy metabolism will also reduce folate transport into the central nervous system (Ramaekers and Quadros, in press)

45. Symptoms of Classic Cerebral Folate Deficiency (Ramaekers et al., NEJM, 2005)

46. Conditions Associated with Autism and Cerebral Folate Deficiency

47. Ramaekers et al., 2007 Neuropediatrics 38(6):276-81

48. The Expanding Association between Autism and Cerebral Folate Deficiency

49. More than half of children with Autism Spectrum Disorder referred to two autism specialty clinics test positive for antibodies to the folate transporter (n=93) Frye et al, Molecular Psychiatry, 2012

50. 75% of children with Autism Spectrum Disorder referred to two autism specialty clinics test positive for one of the two antibodies to the folate transporter Frye et al, Molecular Psychiatry, 2012