Medications supplements and Nutrition in ASD – A Medical Perspective on current Trends - PowerPoint Presentation

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Medications supplements and Nutrition in ASD – A Medical Perspective on current Trends

Judith Aronson-Ramos, M.D.

www.draronsonramos.com

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Gene-Environment Interactions trigger…

Robert

Hendren

– 1

st

genetic vulnerability 2

nd

GxE 3

rd

lack of EI

Immune

Abnormalities

Oxidative Stress

Disturbed Methylation

Mitochondrial Dysfunction

FFA Metabolism

Excitatory-Inhibitory Balance

Hormonal effects

May culminate in ASD in genetically susceptible individuals

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Medications

W

e are treating “target symptoms” not the core deficits of Autism

Two FDA approved medications in ASD – Risperidone (2006) , Aripiprazole (2009) - approved for “irritability – aggression, self injury, tantrums

Ongoing research into new medications which effect balance of excitatory vs. inhibitory brain signaling

Targets using effects on specific syndromes such as Fragile x, Retts,

TS – reversal of symptoms

Research Conundrum - Targeting causes of Autism in specific syndromes will likely be most transformative vs. targeting general brain circuitry (not causes) which will likely be less effective but will help more individuals

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Commonly used Meds in ASDADHD medications

SSRI and other anti-depressants

Antipsychotics – mostly second generation

Mood stabilizers

Anti-epileptics

Less commonly – antibiotics, antivirals, antifungals

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ADHD MedicationsDSM 5 – we can now have ASD with ADHD

Very high percentage of ASD individuals also have ADHD

Stimulants – Methylphenidates, Amphetamines

Non-stimulants – Clonidine, Guanfacine, and extended release forms – Intuniv (guanfacine er) and Kapvay (clonidine er)

Strattera (Atomoxetine)

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Unique to ASD

Dosage range can be different with stimulants – always start low and go slow

Exacerbation of anxiety is common

Increased perservations, obsessions, getting stuck, hyper focus

Some individuals respond optimally

ASD with ADHD is different than ADHD alone – internal vs external distractions

Evidence base – “moderate strength”

Research –RCT with methylphenidate in ASD less benefit and more side effects than ADHD alone

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Non-Stimulant Meds in ASD

Alpha agonists hold tremendous promise – Guanfacine, Intuniv (Guanfacine ER), Clonidine, Kapvay (Clonidine ER)

Data pending – some unpublished studies showing strong benefit for inattention, hyperactivity and impulsivity – little benefit for agitation and irritability

Can be used in combination with stimulants very effectively

Short acting forms great in young children with ASD

Side effects – often more manageable than stimulants

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StratteraStrattera (Atomoxetine) – stand alone medication

Research has shown very small effect sizes in ADHD

One positive study in ASD in 2012 still only 21% of patients improved

Not clinically effective to treat anxiety

Not as robust as stimulants for hyperactivity and impulsivity

Niche medication

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SSRIS

The SSRI medications are only FDA approved for depression and OCD – Sertraline, Fluoxetine, Citalopram, Escitalopram, Fluvoxamine

One SSRI is FDA approved for anxiety (Duloxetine) but all SSRIs are used for anxiety

There are no positive research studies for benefit in ASD – HOWEVER may reflect flaws of research – heterogeneity of ASD

Very commonly

used in ASD for coexisting depression, anxiety, and ocd

Safe and well tolerated

“Activation”- moody, aggressive, irritable, manic - more common in ASD

Low doses to start a must

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Atypical Antipsychotics

Two FDA approved medications –

A

ripiprazole (Abilify) and

R

isperidone (Risperdal)

Indication is irritability, aggression, agitation

Clinically we see they also show benefit for hyperactivity, defiance, and stereotyped behaviors

Doses may be lower than other psychiatric disorders

Side effects are a serious concern – weight gain, hyperprolactinemia, sedation, extrapyramidal symptoms

(movement related -tardive, dystonia, akathesia)

? Brain atrophy

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Other medications

Miscellaneous antidepressants – Wellbutrin, Effexor, Cymbalta

Antipsychotics – Geodon, Zyprexa, Seroquel, Haldol

Anti-Epileptics – Lamictal, Trileptal, Tegretol, Topamax, Depakote

Mood Stabilizers –Lithium, Neurontin

Virtually every psychotropic med has been tried in someone somewhere

If you of your child is being properly managed by a physician and is doing well on these medications there is no cause for alarm – there

is value

in

case report and

clinical

experience

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Summary of Published Medical Evidence

NOT every child or individual with ASD will benefit from medication

A large % of individuals with ASD will trial medication in their lifetime

Pharmacotherapy should never be considered the first line treatment in ASD

Published medical evidence is limited – strength of evidence is summarized below

Risperidone and Aripiprazole – HIGH

Stimulants – MODERATE

SSRI -INSUFFICENT

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the future

Disappointments with Fragile X – drugs that inhibit MGLUR5, Arbaclofen, Namenda

Medications to treat core symptoms of ASD

Oxytocin,

Gaba/Glutamate

Modulators, Mtor inhibitors (TS

), IGF 1 (Rett), Dcycloserine/Amantadine (NMDA)

Placebo effect in autism mediation trials can be as high as 30-40 % (Secretin)

Complication of subgroups of responders

With

increasing knowledge of both

neurobiology, genetics,

and autism

risk factors, more medications

are likely to

emerge

Pharmacogenetics – not ready for primetime

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Nutrition

No one specific diet has been validated with research to be beneficial in ASD

Most data is anecdotal, case reports, basic science, published studies not peer reviewed

Emerging information showing healthy eating impacts general well being

- foundation for healthy psycho-social functioning

Validated diets:

N

o dyes, preservatives, pesticide residue – ADHD; ? - GFCF

Popular diets: GFCFSFCFYF

Elimination with food diary more informative than lab testing

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Food Allergy Testing

To test true allergy measure IGE reaction to food (RAST, CAP-RAST), skin prick, oral challenge

Unproven is food sensitivity testing – IGG, provocation/neutralization, and others

Complications of interpretation – cross reactivity of proteins, outgrowing allergies, difficulties of interpretation

Food

allergy tests

can be helpful, but

decisions regarding what tests to perform and how to interpret them are

complex, costly, elimination diets may be as effective

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Nutrition Issues Specific to ASD

ASD complications with nutrition –

picky and restricted,

rigid, carbohydrate cravers, poor self regulation

, sensory issues (texture, smell, look, temperature)

Behavioral issues with food – parents indulging, children demanding

Effects

of nutrition on well being not easily

quantified or measured, invariably multiple factors contribute to behavior and emotional regulation

Self determination and control in changing dietary habits are beneficial

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nutritional Interventions

Research can lag and dietary information has always been slow in coming from medical community, BUT this does not mean every new diet is viable

New thinking about plant based diets, cholesterol and the myth of low fat, sugar vs fat in obesity, antioxidants, diet and chronic disease

Limitations of laboratory testing in guiding dietary choices needs to be understood

Work with nutritionists and allergists

Examples of dietary manipulations without lab tests -

Rotation

diet,

Elimination

diets,

followed by

challenge

Hypoallergenic

diets –

rice

, lamb, chicken, pears, apples, non-gluten grains (quinoa, millet, amaranth), beans and legumes

AVOID peanuts, eggs

, corn, wheat,

fish

, or

dairy

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Supplements & Alternatives

First Do No Harm

Any product used needs third party analysis –www.consumerlabs.com, USP(US pharmacopeia), NSF (nat’l science found.), GMP (good manuf practices) etc.

Fallacy of thinking you can just take a supplement to replace what is “missing”

Fat vs water soluble vitamins, making expensive urine

Dietary anti-oxidants v. glutathione, sulforaphane

GI issues -probiotics – 4 billion CFU (?enzymes)

Omega 3 Fatty Acids – EPA:DHA (3:2) 1-3 g per day

Multi-Vitamin/multi-mineral support– Vitamin D

Maybe

worth trying

mitochondrial support, sulforophane

, glutathione, B12 shots (3 x/week/6weeks

), NAC, Melatonin

Previously popular – IVIG, Chelation, HBOT

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Nutrition in ASD: My approach

Eat whole foods, avoid snack/junk foods, additives and sugar, monitor intake, healthy fats

3-4 servings of veg (not corn, potato), 1-2 fruit, colorful, organic (dirty 12)

3

servings of protein (clean)- meat, poultry, fish alternatives (myco, soy etc.), nuts, beans

With very picky eaters work with preferred foods and maximize nutritional value

Work with sensory related food issues (texture, smell, temperature, color)

Zone approach, eat in reverse

Use a food diary

When trying special diets keep other variables constant, blind observers, adequate trial (1-2mo)

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Putting it all Together

Healthy Diet

2Multivitamin/Mineral supplement, Omega 3 FA, Probiotic, Vitamin D

Consider GFCF trial, elimination and rotation diets, food diary

Lab testing: general metabolic panel, lipids, iron, CBC, thyroid, R/O Celiac, CMA, FragileX

http

://autism.asu.edu

/ Dr John Adams ASU

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How to know where and What to buy

Companies with a track record (Klaire, Jameison, Nordic Naturals, Solgar, Life

E

xtension)

MD’s with a track record –Andrew Weil, Sandy Newmark, *Amen, *Perlmutter

Martha Herbert M.D., The Autism

Revolution

Follow the latest research www.sfari.org, www.autismspeaks.org

Cheapest not always best

Nutraceuticals are an emerging industry

Beware of conflicts of interest in buying products from clinicians

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How to purchase Supplements Safely

Choose brands labeled with the NSF International, US Pharmacopeia

, Natural Products Association,

or Consumer Lab

seal www.consumerlabs.com, GMP-Good Manufacturing Practices

These

insignia verify that the supplement actually contains the ingredients stated on the label, and that the product doesn’t contain any contaminants or potentially harmful ingredients

.

Be wary of supplements produced outside the United States. Many are not regulated and some may contain toxic ingredients.

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Other Treatments

Meditation, Yoga, Mindfulness Based Stress Reduction (MBSR)

Attention strengthening interventions utilizing neuroplasticity

–

Cogmed

,

Neuro/Biofeedback, C8 sciences,

L

umosity

Cognitive Behavioral Therapy

Hippotherapy

Art therapy

Pet therapy

???transcranial magnets, sensory therapies (mendability.com)

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Build a Strong Foundation

Nutrition & Supplements

Exercise

Sleep

School & Work

Clean Environment – avoid toxins – cleaning products, hygiene products, household exposures

Therapy

Meaningfulness – work, volunteerism, school

Psychopharmacology +/-