Molecular Targets for Core Symptom Deficits in ASD and Early Data

Supporting Novel Therapeutics

Evdokia Anagnostou, MD

Clinician Scientist, Bloorview Research Institute

Assistant Professor, Department of Pediatrics, University of Toronto

Disclosures

•Consulting: Neuropharm, Proximagen, NOVARTIS, Seaside Therapeutics

•Collaborations: SIEMENS

•Funding: DOD, CIHR, Autism Speaks, PSI, ALVA foundation, HRSA, NeuroDevNet, Ontario Brain Institute

Social-communicationDeficits

Repetitive behaviors / restricted interests

Impulsive aggression

Affective lability

ASDAnxiety/depression

Sensory-motor dysfunction

epilepsy

GI dysfunction, sleep dysfunction,

ADHD – “like”

LearningAttentionMemory

Current approaches

Medications to target symptom domains based on phenotypic overlap of such domains with other disorders, i.e.

– SSRI for repetitive behaviors (from OCD)

– Atypical antipsychotics for maladaptive behaviors (irritability and aggression across several other disorders)

– Stimulants, non-stimulants for inattention (overlap with ADHD)

Suggested new approaches

• 1. Target emerging molecular targets

• 2. Target neuro-circuitry of interest

Genomics of ASD

• Basic science is becoming ripe for translation

– Genetics

– Pinto et al. Functional impact of global rare copy number variation

in autism spectrum disorders. Nature. 2010 Jul 15;466(7304):368-72.

Treatment

– Use the new knowledge from genetics, imaging, animal models and novel technologies to develop novel treatments

– Where is the lesion?

– Distributed-Pervasive

– What is the lesion?

– functional and structural disconnectivity

– dynamic

NMDA inhibitors: memantine

Compounds by NOVARTISROCHESeaside Therapeutics

IGF1 small molecule analog

rapamycin

Arbaclofen

Fragile X syndrome

• Most common inherited cause of Intellectual disability and ASD

• Common other co-morbidites

– Anxiety disorders

– ADHD like

– Irritability aggression

– Epilepsy

– Sensory dysregulation

– GI dysfunction

– Macro-orchidism

– Dysmorphic faces

Fragile X

transcriptional silencing of the FMR1 gene

loss of the protein FMRP, an RNA binding protein that inhibits protein synthesis

Fmr1- mouse

Levenga et al

Adesei et al

Benjamini et al

Agent Reduces Autism-like Behaviors in MiceBoosts Sociability, Quells Repetitiveness

• NIH Study: Silverman, et al. (April 25, 2012). Science Translational Medicine.

• GRN-529 is a member of a class of agents that inhibit activity of a subtype of receptor protein on brain cells for glutamate (m-Glu R 5 inhibitors)

• BTBR mice (potential ASD model) injected with GRN-529 showed reduced levels of repetitive self-grooming and spent more time around – and sniffing nose-to-nose with – a strange mouse.

• GRN-529 almost completely stopped repetitive jumping in another strain of mice.

STX209 for fragile X syndrome:Analysis in “low sociability”

subgroupSTX209

(mean ± SD)Placebo

(mean ± SD) p-value

ABC-Social Withdrawal -4.3 ± 6.3 -0.4 ± 7.1 < 0.05

Vineland – Socialization (raw) 14.2 ± 19.0 4.6 ± 10.8 < 0.05

CGI-I 2.7 ± 1.1 3.5 ± 1.2 < 0.01

CGI-S -1.0 ± 1.1 -0.3 ± 0.9 = 0.01

Treatment preference (clinician) 63% 19% < 0.01

Treatment preference (parent) 67% 19% = 0.001

Responders (CGI-I =1 or 2, andABC-SW improvement ≥ 25%) 42% 7% < 0.01

16

n=27ABC-Social Withdrawal ≥ 8 at screening and baseline

Fig. 3 (A and B) A comparison of the effect of AFQ056 and placebo treatments on the change from baseline to day 19 or 20 on the ABC-C score in individual patients with (A) full methylation at the FMR1 promoter and (B) partial methylation at the FMR1 promoter.

S. Jacquemont et al., Sci Transl Med 2011;3:64ra1

Published by AAAS

1. Identification of potential molecular target: genomics or other

2. Model human mutation in animal model

3. Preclinical trial

4. Clinical trial in syndrome related to molecular target identified

5. Clinical trial in syndrome sharing biology with 4.

Drug approval

Drug approval

Anagnostou , Nature 2013

deviation from an optimal range of synaptic protein synthesis, irrespectively of direction, may lead to behavioral and cognitive difficulties

Behavior can not distinguish adequately

Urgent need to identify relevant biomarkers fro stratification

Co clinical trials ?

Courtesy, Jason Lerch

Approach 2: target neurocircuitry of interest

• Oxytocin

Oxytocin and ASD

• Decrease blood levels oxytocin in autism

and

• Absence of normal developmental increase in oxytocin blood levels with age in autism

– Altemus et al 1994, Modahl et al 1998, Green et al 2001, Kosfeld et al, 2005, Kirsch et al, 2005

• Gene expression studies:– Increased methylation of CpG islands known to regulate

OXTR expression in peripheral blood and temporal cortex. (Gregory et al BMC medicine 2009)

– Weksberg laboratory has replicated increased OXTR DNA methylation in an independent cohort of 40 ASD patients and 20 controls.

Ex 1 Ex 2 Ex 3 Ex 4Intron 3

rs53576 rs225498 (A)Chinese Han (Wu et al. 2005)Japanese (Liu et al. 2010)

rs225498 (G)Caucasian-Chicago (Jacob et al. 2007)

rs2268494Caucasian-Israel (Lerer et al. 2007) rs1042778

rs2268493Caucasian-Yale (Yrigollen et al. 2008)

German HF-ASD (Wermter et al. 2009)--haplotype 5’to Intron 3

Ex 1

Irish, Portugese & UK x 2 and Slovak --mixed results 5’, 3’ and exon 3 (Chakrabarti et al 2009, Kelemenova et al 2010, Tansey et al. 2010--SNPs in Intron 3 related to gene expression)

Genetic Associations: OXTR & ASD

5’ 3’

Pilot Study of INOT vs. Placebo in adults with ASD (Anagnostou et al 2012, Mol Autism)

Social Cognition B 6 week B p Mean (SD) Week 0 Mean (SD) Week 6  d

RMET Oxytocin Placebo

----- 22% 0.0040.002*

48% (20%)74% (14%)

61% (24%)63% (12%)  1.2

DANVA-Face

Oxytocin Placebo

2.33 13.98 .381 32.6 (8.8)39.1 (8.4)

33.5 (6.4)37.4 (7.4)

0.33 

DANVA- Paralanguage Oxytocin Placebo

1.96 11.76 .351 27.8 (5.7)34.1 (3.0)

30.5 (2.7)35.2 (4.7)  0.38

Social Function

CGI-Social

Oxytocin Placebo

.582 30% Improved11% Improved

OR=3.4 

SRS Oxytocin Placebo

.58 3.48 .664 92.3 (29.9)84.5 (23.3)

111.4 (13.5)96.5 (13.0)  0.34

Repetitive Behaviours

YBOCS Oxytocin Placebo

-.16 .96 .220 12.0 (3.9)10.3 (2.5)

9.4 (2.9)8.1 (2.5)

.13

RBS-R Higher Order

Oxytocin Placebo

----- 4.57 .301 17.0 (10.6)20.0 (10.8)

17.7 (16.2)17.8 (13.3)

-.22

RBS-R Lower Order

Oxytocin Placebo

----- -2.25 .045.065*

5.8 (4.6)4.9 (3.7)

2.4 (2.3)3.7 (2.6)

.64

Quality of Life

WOQOL-emotional

Oxytocin Placebo

----- 9.5% .034.031*

47.8% (16.3%)65.2% (12.3%)

59.5% (16.0%)63.2% (12.3%)

.84

Maximum tolerated dose study of INOT in children and adolescents with ASDAnagnostou, Brian, Jacob et al

• Two goals:

– MTD:

– Dose range: 0.2, 0.26. 0.33. 0.4 IU/kg/dose

– 3 patient increments

– Measures sensitive to change

– Pilot large battery

Efficacy

Variable Estimate (0-12 weeks)

CL 0-12pvalue

0-24 pvalue

Abc_SWSrs_total_rawSrs_total_tscoreEyes_hardLfi_match_maker_idasi_general_anxiety_rawasi_general_anxiety_tscoreasi_sep_anx_rawasi_sep_anx_tscoreIr_em_irony_1ordSrst_social_totBasc_Bsi_raw Basc_Bsi_tscoreBasc_socskills_rawBasc_socskills_tscore Basc_func_comm_rawBasc_func_comm_tscore

 

3.020.89.8-0.14-10.933.3211.001.077.50-1.64-1.3620.644.29-1.47-2.84-2.44-4.10 

0.04;5.968.1;33.53.8; 15.8-0.82; -1.99-19.28;-2.591.29; 5.363.97; 18.030.25; 1.890.22; 14.78-3.02; -0.27-2.72; 0.0083.40; 37.870.46; 8.12-2.65;-0.29-5.31; -0.38-3.67; -1.22-6.23; -1.97 

0.050.0020.0020.70.010.0030.0040.010.040.020.050.020.030.020.030.00040.0006 

0.20.060.060.0090.10.20.10.50.20.010.70.020.030.10.20.010.01 

Funded trials in North America

• Anagnostou et al:

– Oxytocin vs. placebo for children and adolescents with ASD; funding source: DOD; phase II

– Open label, dose finding

– Randomized controlled trial (subcontract UIC)

– Includes genomics, epigenetics, blood levels

– Oxytocin vs. placebo adults with ASD; funding Source: CIHR; phase IIb

– Includes genomics, epigenetics, blood levels

• Sikich et al:

– Oxytcoin vs placebo in children with ASD; funding source: NICHD, phase IIb

ASD Research

Early interventionTechnology-based intervention

Study Biology

Develop Novel TreatmentsGenetics

Imaging

Nervous system

Change brain structure and function

New drugs

From disability to possibility

Thank you to the families who participated in the studies

discussed