Fragile X Syndrome - Dayton Children`s Hospital

Fragile X: A Family of Disorders with
Targeted Treatments
Meinhard Robinow Lecture 12-15 -10
Randi Hagerman MD
Endowed Chair in Fragile X Research
M.I.N.D. Institute
University of California at Davis Medical Center
Conflicts/Funding from NICHD, NINDS, NIA, Roche, Neuropharm,
NFXF, FRAXA, Seaside Therapeutics, Novartis, Johnson and Johnson and Forest
Fragile X Syndrome
Leading heritable form of intellectual disability
One in 130130-260 females and one in 250
250--800 males
are carriers with new forms of involvement
One in 2500 in general population with the full
Involvement is broader than just ID and includes
LD, ADHD, anxiety disorders, mood instability
Leading (known) single gene associated
with autism
3-6% of all children with autism have FXS
Fragile site
Approximately 30% of young children with
fragile X syndrome have autism
The clinical team for targeted treatments Thanks to all!
1
The Fragile X Mental Retardation 1 Gene
(FMR1)
Penagarikano et al 2007
FXS the most common inherited cause of ID
1/130-250 females
1/250-810 males
Typical
Premutation
(CGG) < 45
(CGG) 55 - 200
1/2500-3600
Full mutation
(CGG) > 200
mRNA
FMRP
Fragile X syndrome
Clinical normal
Primary Ovarian Insufficiency (POI)
Fragile X-associated
Tremor Ataxia Syndrome (FXTAS)
Depression and anxiety
ADHD and ASD
The more FMRP you have the smarter you are
85% of males with the full mutation have ID or IQ< 70
25% of females have ID but 70% have an IQ<85
Loesch et al 2004
2
Expression of the FMR1 gene
Relative FMR1 mRNA level
normal
gray
10
premutation
full mutation
FXTAS and POI
8
unmethylated
6
4
partially methylated
2
hyper-methylated
0
FMRP level
1
___FXS__________
0.5
0
0
45 55
200
>1000
CGG repeat number
Expression of the FMR1 gene
Relative FMR1 mRNA level
normal
10
gray
premutation
full mutation
FXTAS and POF
8
unmethylated
6
4
partially methylated
2
hyper-methylated
0
FMRP level
1
___FXS__________
0.5
0
0
45 55
200
>1000
CGG repeat number
The Fragile X Mutation
A family affair
Four generations
89 yr
FXTAS
cognitive decline, dementia
neuropathy
61 yr
tremor/ataxia FXTAS
nl cognition, POI
38 yr
proband
POI, anxiety
neuropathy
Muscle pain, lupus
fragile X
syndrome
+ autism
(mild)
3
Handbiting 60% Handflapping 80%
Poor eye
Contact 90%
Tactile 80%
defensiveness
Perseverative speech
or behavior in
almost allall-routines
Unusual
sensory
responses to
stimuli
FXS in all racial
and ethnic groups
Sensory Modulation or Processing
Problems in FXS
Enhanced electrodermal responses
to sensory stimuli which correlates
inversely with FMRP levels
Enhanced sympathetic activity
(Miller et al 1999)
1999)
Normals
FXS
4
Emotional & Neurocognitive
Features
Hyperactivity, impulsivity and/or short attention span
Executive function deficits: problems with organization,
shifting set, planning, inhibition, tangential speech,
perseveration
Over reactivity to stimuli: enhanced electrodermal response
to stimuli; enhanced cortisol release after stressors
Anxiety
Autism or ASD
Mood instability:
excessive outbursts, tantrums
Hyperactivity, anxiety, aggression and ASD are key
behavioral features that we work with daily but
anxiety may be the primary problem
Sympathetic
hyerarousal
GABA
underactivity
mGluR5
enhancement
ANXIETY
Avoidance
Social
deficits
Selective
mutism
Aggression
ASD or
Autism
Anxiety assessed with the ADIS (Cordiero et al submitted)
5
FXS
Typicals
Farzin et al
2009
Significant Pupil Dilation in FXS Children viewing faces
b.
* * *
Change in Pupil Diameter
(mm)
0.04
0.03
FXS
0.02
Controls
happy
0.01
0
250 500 750 1000 1250 1500 1750 2000 2250 2500 2750 3000
-0.01
0.04
* **
*
*
0.03
fearful
0.02
0.01
0
250
500
750 1000 1250 1500 1750 2000 2250 2500 2750 3000
Farzin et al 2009
-0.01
Time (ms)
MRI Comparison of Autism to FXS
• Hazlett et al 2009 JND: 52 boys with FXS,
63 autism,19 DD, 31 TD ages 18-42 mo
• FXS had enlarged caudate
• Autism had enlarged amygdala but FXS did
not, even those with FXS plus autism
• Behavior features were similar in those with
autism without FXS and autism with FXS
but the underlying brain structure was
different. So many paths to autism
6
Obvious Second Hits
Leading to Autism
• Additional genetic disorder;
n or
Down syn; the Prader Willi Phenotype
• Birth trama or Cerebral Palsy
• Seizures in 13 to 22% of males and 4 to 5%
of females (Musumeci et al 1999; Berry-Kravis et al 2002)
The PraderPrader-Willi Phenotype (PWP)
of Fragile X Syndrome
Bardoni & Mandel, 2002
Those with the PWP have a higher rate
of autism (50-70%) than those with FXS
alone and lower CYFIP levels
7
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
• Up regulation of mGluR5 pathways leading to
LTD
• Down regulation of GABAA receptors
• Dysregulation of dopamine pathways
• Enhanced APP production
• Increased oxidative stress damage to neurons
FMRP regulates the translation of
many genes at the synapse
•
•
•
•
•
•
•
•
Neuroligins
Neurorexins
Arc
Map1Kinase
PSD95
Matrix metalloproteinase 9 (MMP9)
CamKinase ll
Many others leading to down regulation of
PTEN and up regulation of mTOR
Proteins Controlled by FMRP Darnell et al 2009
Trends Neurosci. 2002 May;25(5):251
8
Lowered Brain FMRP levels in
Psychiatric Disorders
Fatemi et al Schizophrenia Research 2010
FMRP Deficit in Adult Autism Brains
Fatemi and Folsom 2010 Neuropharmacology
The Role of FMRP: binds and transports mRNAs
And regulates translation usually through inhibition
FMRP transports mRNAs
to the synapse and regulates
translation.
FMRP inhibits protein
translation with mGluR5
stimulation
Oostra 2006
9
mGluR5 theory of intellectual disability in FXS
mGluR5 stimulation
leads to LTD; FMRP
Bear et al 2004
puts the brakes on this.
So in FXS there is dramatically increased LTD
mGluR5 antagonists for FXS
– Fenobam : we have shown improvement in PPI
and behavior in single dose with 12 adults with
FXS (Berry-Kravis et al 2009 JMG)
– Roche mGluR5 antagonist RO4917523
currently in controlled trials at multiple centers
including MIND
– Novartis AFQ056 finished European trial and
now initiating US trials at multiple centers
including the MIND
– STX 107 an mGluR5 antagonist licensed by
Seaside Therapeutics; human trials in FXS
begin in January 2011
R-Baclofen= Arbaclofen: STX209
• Baclofen is racemic
• Both isomers are selective GABA-B agonists
– GABA-B: R:S potency ratio
15:1
– in vivo: R:S potency ratio 10-100:1
• R-Baclofen kinetics comparable when given alone or as
part of racemic mixture (with S-baclofen)
• R-Baclofen is more potent in blocking presynaptic
release of glutamate and therefore may be helpful in
FXS and perhaps in autism
10
mGluR Theory Excessive
Glutamatergic Transmission
STX209
GABA-B
FMRP
Pre-synaptic
Proteins
Proteins
Post -synaptic
Seaside Therapeutics
Study 22001: Overview
STX209
STX209
Period 2
Period 1
Screening
Follow-up
Washout
Placebo
Placebo
• Double-blind, randomized, placebo-controlled, 2-period crossover
• Endpoints
o Global: CGI-I; CGI-S; blinded treatment preference
o Focused: Aberrant Behavior Checklist - Irritability (ABC-I) scale; ABC-Total &
other subscales; Vineland Adaptive Behavior Scale; Visual Analog Scale of top 3
problem behaviors; other
• Down titration after completion of 4 week period
Study 22001: Design details
• Key inclusion/exclusion criteria
o Fragile X full mutation
o Age 6 – 40 years
o +/- Autism Spectrum Disorder
o ABC-Irritability criterion at Screening & Visit 1
• ≥ 12 for ages 6-11 years
• ≥ 9 for ages 12-40 years
o 3 or fewer psychoactive medications (stable dose x 4 weeks)
• Flexible titration over 2 weeks, to optimal titrated dose (OTD)
o Starting dose: 1 mg BID, then 2 BID, 3 BID, 5 BID, 10 BID
(10 mg TID permitted for subjects ≥ 12 years)
o OTD continued for remainder of 4 week treatment period
o
www.clinicaltrials.gov
NCT00788073
11
Study 22001: Analysis populations
• Full “safety” population, n = 63 (55 M, 8 F)
– 56 (89%) completers
o 3 discontinuations due to AE (1 arbaclofen; 2 PBO)
o 1 each: lost to f/u; withdrew consent; protocol deviation; other
• Per Protocol population, n = 54
– 5 excluded for prohibited concomitant medication
– 2 for failure to meet ABC-I criterion; 2 for other
• FXS + Autism subgroup (pediatric), n = 22 (19 M, 3 F)
o DSM-IV + ADI-R criteria for autism
o Analogous to subjects in risperidone/autism study
• “Low sociability” subgroup, n = 27 (24 M, 3 F)
o ABC-Social Withdrawal subscale ≥ 8 at screening and baselines
o Autism: 18 yes, 9 no
o Motivation: Frequent reports of improvements in sociability
CGI-Improvement: Autism
subgroup
“Responders”
44% vs. 6%
(p < 0.05)
CGI-Improvement: “Lower
sociability” subgroup
58% vs. 19%
p < 0.01
12
Efficacy scores: “Lower sociability” subgroup
STX209
Placebo
n=27
(mean ± SD)
n=27
(mean ± SD)
p-value
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
ABC-Social Withdrawal
Vineland Socialization domain (raw
score)
Responders (CGI-I =1 or 2, and
ABC-SW improvement ≥ 25%)
-4.3 ± 6.3
-0.4 ± 7.1
< 0.05
14.2 ± 19.0
4.6 ± 10.8
< 0.05
42%
7%
< 0.01
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, computer programs, AT devices etc.
Co-Writer and write out loud
FX tracking game
CHAT Alt CHAT 40
Absence of FMRP upregulates other
proteins throughout the brain
including MMP 9 (Bilousova et al 2009)
• Matrix metalloproteinase 9 (MMP 9) one of a
family of proteins important for synaptic structure
and plasticity
• MMP9 is significantly elevated in FXS
• Minocycline will lower MMP 9 levels and mature
synaptic connections in cultured hippocampal cells
• Studies in the FX mouse demonstrate that
minocycline treatment for 1 month at birth will
rescue the synaptic abnormalities in vivo
• Improvements also seen in anxiety on the elevated
plus maze and more strategic exploratory behavior
on the Y maze
13
Minocycline treatment induces spine
maturation with enhanced mushroom
spines in the KO mouse
Bilousova et al 2008 JMG
Minocycline Studies in FXS or Autism
•
•
•
•
•
There was dramatic response from families after the Bilousova paper was out on
line in 2008
Agustini Utari MD surveyed 50 families whose child was tx with minocycline for
>2wks and found 70% positive response especially in language and limited side
effects (Utari et al 2010 AJIDD).
Positive open trial in FXS in Toronto with Paribello age > 13 years
Trial of minocycline in autism at NIMH
Controlled double blind trial of minocycline for FXS (each arm lasts 3 months) at
the MIND (NFXF funded)
19 yo boy with FXS
took minocycline
for 1 year
Targeted Treatment of
Fragile X Syndrome
cAMP
Agonists
others
GABA
Agonists
Ganaxolone
Arbaclofen
Antioxidants
Vit E, C, folate
NAC, omega 3s
mGluR5
Antagonists
Fenobam
STX107
AFQ056
RO4917523
Minocycline
14
Autism in premutation
carriers: is there a developmental
component of the premutation ?
Tassone et al 2000
Aziz et al 2003
Goodlin-Jones et al 2004
Farzin et al 2006
Boys with the premutation are at high
risk for ADHD and autism or ASD:
A developmental form of RNA toxicity?
•
•
ADHD (CGI>15 and DSM-IV)
– 93% (13/14) of probands
– 38% (6/13) of nonprobands
– 13% (2/16) of controls
ASD (DSM-IV and ADOS/ADI)
– 73% (11/14) of probands*
• 29% (4/14) Full autism
• 50% (7/14) PDDNOS
– 8% (1/13) of nonprobands
• 8% (1/13) Full autism
– None of controls
Farzin et al, 2006 J Dev Beh Pediatrics
Two brothers with the FMR1 premutation ages 6 and 7.
Boy on right presented as proband with autism and ADHD
and his brother has anxiety and ADHD.
Follow-up after 4 years brothers
with the premutation
• Youngest brother with
ADHD, anxiety and social
deficits responded well to
sertraline: “miracle drug”
now in normal classroom,
friends and normal IQ
• Oldest brother with autism
and ADHD did not do well
with sertraline (activation so
D/C), developed seizures,
now with severe autism and
low verbal abilities
15
Bailey et al 2008 study of >1,200 FXS families
Spectrum of Premutation Involvement
Background
gene effects
Cellular
dysregulation
Upregulation of
heatshock proteins
Kinase activation
FMR1 CGG-repeat Sequestration of
toxic RNA “trigger” DROSHA, Sam68
Mitochondrial
dysfunction
Inclusion formation
Neuropathology
Environmental
effects
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
Migraine
Memory problems, foggy thinking
Hypertension ,erectile dysfunction
FXTAS
tremor, ataxia, Parkinsonism
autonomic dysfunction, EF deficits,
memory and cognitive decline
Adult Male Carriers
• 45% with Masters or higher education (Grigsby et al 2006)
• Verbal comprehension significantly higher than controls (Loesch
et al 2003)
• Older male carriers (40% Jacquemont et al 2004 JAMA) and
some female carriers (8% Coffey et al 2008-16% RodriquezRavenga et al 2009) have the fragile X-associated tremor/ataxia
syndrome (FXTAS)
16
CGG
repeats
Fragile XX-associated Tremor
Ataxia Syndrome (FXTAS)
excess, toxic
mRNA
(
< 45
(normal)
nucleolus
55
55--200
Current Research Efforts:
inclusion
Loss of brain volume
Intranuclear inclusions
• How does the RNA trigger
the disease
process? New targets for
treatment
• Treatment trials
ongoing/planned
based on our current
Distribution of the Intranuclear
Inclusions in FXTAS
Strong parallels in human and mouse
Broad distribution throughout brain and spinal cord
- in brain, exclusively in nuclei of neurons and astrocytes
Also found in numerous peripheral tissues
- ganglion cells of adrenal medulla
- dorsal root ganglia
- paraspinal sympathetic ganglia
- myenteric ganglia of the stomach/intestine
- subepicardial autonomic ganglia of the heart
- testicular (Leydig) cells
- anterior and posterior pituitary
- thyroid
- islets of langerhans (glucagon producing cells)
Greco et al., 2002 Brain; Willemsen et al., 2003 Hum Mol Genet; Greco et al., 2006 Brain
Greco et al., 2007 J Urology; Brouwer et al., 2008 Psychoneuroendocrinology
Godken et al., 2009 Neuropathology
Medical history of 146 women with
the premutation:20.6-84.5y (mean 45.3 y)
69 controls ages 18-87 (mean 51.9y)
(Coffey et al 2008
AJMG)
17
Medical History 146 women carriers
Control
N=69
Non FXTAS
N=128
Control
N=39
0%
0%
0%
100%
POF
5.6%
19.0%**
5.9%
13.3%**
FXTAS
FXTAS
N=18
Thyroid Problems
10.1%
17.3%
15.4%
50.0% **
Diabetes
0.0%
3.9%
0%
11.1%
Lupus
0.0%
2.4%
0%
5.9%
Hypertension
10.1%
16.4%
18%
61.1% **
MS
0.0%
4.8%
0%
17.7%
Fibromyalgia
5.0%
8.3%
9.4%
43.8% **
Muscle Pain
8.9%
25.6%**
10.7%
76.5% **
Tremor
1.5%
11.7%**
0%
89%**
Problems
Walking/Balance
1.5%
8.6%
2.6%
83.3%**
Neuropathy Sx
11.9%
45.2%**
18.9%
83.3%**
**Fisher’s exact test for 2×2 contingency table analysis p<0.05
Coffey et al 2008 AJMG
RNA toxicity can start before FXTAS and the
premutation mice develop inclusions after 21
weeks well before neurological symptoms
Accumulative
toxicity
Developmental toxicity
Childhood
Toxicity to
The limbic system
and reproductive
system
Mid adulthood
Hypertension
Neuropathy
Impotence
Autonomic
Dysfunction
Tremor, Ataxia
Cognitive decline
FXTAS
Geriatrics
Increasing age
White matter disease in the pons
In FXTAS
18
RNA Toxicity occurs even before
FXTAS
• Higher rates of psychopathology in adults
reported by Roberts et al 2008
• Bourgeois et al 2010: utilization of the
SCID: Lifetime mood disorder in 65% of
FXTAS and 42% of non FXTAS pres;
lifetime anxiety disorder in 52% of FXTAS
and 47% of non FXTAS pres
• Insula sign of white matter disease can
occur even before the onset of FXTAS
Insula Sign on T2 in early FXTAS
A
B
62 yo
52, 68 repeats
Probable FXTAS
57 yo
52 repeats
Diabetes, hypertension, migraine
Subclinical tremor
tandem walk instability
Only Premutation Involvement
No Full Mutations
61 y
C
D
E
3
37 yo
56 repeats
Anxiety, Depression
Breast cancer, Thyroid
tumor, Uterine tumors
Mitral valve prolapse
39 yo
54 repeats
Anxiety
Benign thyroid tumors
34 yo
67 repeats
Anxiety, Depression
Mathematics problems
Hypertension, Raynaud’s
phenomenon
F
2
12 yo 6 mo
61 repeats
Autism
ADHD
Anxiety
11 yo
69 repeats
ASD
ADHD
Anxiety
9 yo 7 mo
69 repeats
Anxiety
ADHD
Shyness
= FXTAS
= Carrier
A summarized pedigree of a family with fragile X premutations demonstrating a broad spectrum of clinical involvement
throughout generations (Chonchiaya et al 2009 JDBP)
19
Treatment of Symptomatic Carriers
• Treat depression and anxiety with SSRIs
• Exercise and SSRIs stimulate neurogenesis to repair
the brain: a dynamic process in aging
• Treat hypertension and hypothyroidism
• Avoid stress and elective surgery when possible
• Stop smoking and drinking excessively
• Antioxidants ie vit C, folate, vit E, fresh fruit, acai
berry, green tea
• Treatment of FXTAS: tremor-consider primidone, beta
blockers, botox injections; cognitive changesmemantine for memory, confusion and neuroprotection
venlafaxine (Effexor XR) to enhance attention,EF;
Duloxetine (Cymbalta) for fibromyalgia or pain sxs.
• Deep brain stimulation can improve tremor
Aging in FXS
No FXTAS but we have seen
Parkinsonism and this is reported in other
disorders e.g. 22q11 del syndrome
Utari et al 2010 JND
Loss and Disorientation of Purkinje Cells
in the Cerebellum
Greco et al 2010 submitted
H&E, 400x,
20
Calbindin binding studies in the
cerebellum in older males with FXS
CONTROL
CASE #3
Case
3
40X
40X
100X
100X
Newborn Screening for FX mutations initiated
in 11-2008 in Sacramento (UCDMC) and
Chicago (Rush University)
utilizing the Tassone blood spot method
(Tassone et al J Molecular Diagnostics 2008)
Language
Seeing
and
Hearing
Mental Images
Higher Reasoning
Facial
Recognition
Memory
What is the best intervention for babies with FXS ?
Combining intensive intervention
( Denver Early Start Program) with targeted Rxs
21
The National Fragile X Foundation has Treatment
Information on line
Next Conference: Miami July 2012
PO Box 190488
San Francisco, CA 94119 USA
Telephone: 800800-688688-8765
Fax: 925925-938938-9315
Email: [email protected]
Web: www.FragileX.org
M.I.N.D. Institute
Susan Rivera
Louise Gane
Susan Harris
Faraz Farzin
Weeresak Chonchiaya
David Hessl
Jennifer Cogswell
Agustini Utari
Patrick Adams
Michele Ono
Sarah Coffey
TonySimon
Dept. Radiology
James Brunberg
Dept. Pathology
Claudia Greco
NTRI Researchers
Isaac Pessah
Rob Williamson
Rob Berman
Dept. Neurology
Lin Zhang
John Olichney
Ricardo Maselli
Grace FentonFenton-Farrell
Dept of Psychiatry
Jim Bourgeois
Andreea Seritan
Collaborators
UC Davis School of Medicine
Dept. Biochem & Molec.
Molec. Medicine
Paul Hagerman Flora Tassone
Chris Iwahashi
Anna Ludwig
Dolores GarciaGarcia-Arocena
Greg Mayeur
Chris Raske
Dept. Biostatistics
Danh Nguyen
University of Washington and UC Davis Fragile X Research
Center NICHD Funded
Charles Laird
Mike Guralnick Gwen Glew
University of Colorado Health Sciences Center (Denver)
Maureen Leehey
Deborah Hall
James Grigsby
RUSH--Presbyterian
RUSH
Presbyterian--St. Luke’s Medical Center (Chicago)
Elizabeth BerryBerry-Kravis
Christopher Goetz
Waisman Center
Center--University of Wisconson
Len Abbeduto
*Latrobe University, Melbourne Australia*
Danuta Loesch
Richard Huggins
Support: NICHD, NINDS, NIA, NFXF, CDC, NFXF
Neuropharm,, Roche, Novartis, Seaside Therapeutics
Neuropharm
22