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2017 Glut1 Deficiency Founda5on...1 2017 Glut1 Deficiency Founda5on Conference Summary Report...
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2017Glut1DeficiencyFounda5onConferenceSummaryReport
gratitudeandcredittoKrisEngelstadandallthespeakersforhelpingpreparethepresentationsummaries
GlucoseTransporterType1De;iciencySyndromeisregularlyreferencedusingavarietyofterms,andtheseindividualsummarieswerenoexception.Intheinterestofclarityanduniformity,we
haveusedthetermGlut1De)iciencythroughoutthesummary.
GlucoseTransporterType1De;iciencySyndromeisalsoknownandreferencedas:Glut1De;iciency,G1D,Glut1DS,Glut-1DS,Glut1,Glut-1,Glut1,GLUT1,Glut1D,andDeVivoDisease
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GeneralAssemblyPresentationsagendaorder,preparedbyKrisEngelstadandeditedbypresenters
pages
Prof.Dr.JörgKlepperGlut1De;iciencyFromPediatricstoAdulthood
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JuanPascual,MD,PhDGlut1De;iciencyin2017andBeyond
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VincentPetit,DVM,PhDNewlyDevelopedTestforGlut1De;iciency
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KarthikRajasekaran,PhDAssayingDrugsforSafetyinGlut1De;iciency
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DominicD’Agostino,PhDSignalingPropertiesandTherapeuticEffectsofKetones
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EricKossoff,MDDietTherapyforGlut1De;iciency
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MackenzieCervenka,MDKetogenicDietTreatmentsandTransitionStrategies
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UmraoMonani,PhDGeneReplacementTherapyforGlut1De;iciency
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AbrahamAl-Ahmad,PhDModelingtheBlood-BrainBarrierUsingPatientDerivedStemCells:AFocusonModelingGlucoseTransport
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2017Glut1De)iciencyFoundationConferenceSummary
TableofContents
Prof.Dr.JörgKlepperChildren’sHospitalAschaffenburgAschaffenburg,Germany
Glut1De)iciencyfromPediatricstoAdulthood
BACKGROUND:GlucoseistheessentialfuelforthebrainandentersthebrainthroughtheglucosetransporterGlut1.Withoutenoughglucosethereisanenergycrisisinthebrain:glucoseandlactatelevelsarelowindicatingGlut1De;iciency.AnovelbloodtestidentifyingthereducednumberofGlut1transportersonredbloodcells(quantitativeGlut1De;iciency)hasrecentlybeendevelopedinFrance.MutationstheSLC2A1geneoftencon;irmthediagnosisbuttheabsenceofmutationsdoesnotexcludeGlut1De;iciency.The“brainenergycrisis”resultsinthreecardinalsymptoms:epilepsy,movementdisorders,andcognitive/behavioralissues.AnycombinationandanydegreeofsymptomshavebeendescribedinGlut1De;iciency.
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Legendof)igure1:Ininfancyandearlychildhoodseizuresanddevelopmentaldelayaretheprominentsymptomsthatstabilizebeyondpuberty.Incontrast,ataxia,dystonia,andparoxysmaleventsareissuesofchildhoodandadolescence.
GLUT1DEFICIENCYTHROUGHTHEDEVELOPMENTALSTAGES:
InfantsandEarlyChildhood:TheinitialpresentationofGlut1De;iciencyisoftenaseizurewithinthe;irstsixmonthsoflife.Seizurestypesarevariableandcanincludecyanoticspells(turningblue),absence(dreaming),focal(onepartofthebody),generalized(wholebody),myoclonic(musclespasms),andastatic(dropattacks).Ininfantsparoxysmaleye-headmovementspresentasaberrantgazesaccades(jumpinglikeeyemovements)withheadandeyesmovingaround.Oftentheyarethe;irstsignofGlut1De;iciency.Ininfancyaclassical3:1ketogenicdietshouldbeused.Inearlychildhooddevelopmentalimpairmentbecomesapparent.Gaitoftenisnotnormalforage(clumsy,widebased,drunkenappearance).10%ofabsenceepilepsiesstartinginthisagehavebeenshowntobeGlut1De;iciency.
Childhood: Inchildhoodandadolescencemovementdisorderstendtoworsen.Inschoolagetherecanbeabnormalgaitsuchas:broadbasedgait,dystonia,ataxia.Cognitionshiftstowardlowercognitiverange,butnotallpatientshavecognitiveissues.Speci;icimpairmentsmaybeproblemsinvisualattention,motorskillsactivelanguage,andwholepictureprocessing(can’tseetheforestforthetrees).Incontrast,strengthsinGlut1De;iciencypatientsincludelanguagecomprehension,socialinteraction,gentleness,andslower,butconstantprogressindevelopment.Theuseofketogenicdietsisvariable,increasinglythemodi;iedAtkinsDiet(MAD)isusedinGlut1De;iciency,butdataonlong-termdevelopmentaloutcomeisnotyetavailable.
Adolescence:Inadolescence¾ofGlut1De;iciencypatientsreportparoxysmal(suddenonset)eventssuchassuddenspells,motorarrest,choreaticordystonicinvoluntarymovements,drops,orotherunspeci;ieddiscomfort.Theseepisodesoftenstartinpuberty.Triggersmaybephysicalactivity,lossofketosis,andsleepdeprivation.Oftentheseeventsoccurdespiteadequateusofketogenicdietsandthuscurrentlyaredif;iculttotreat.AdolescentsoftencomplybetterwhentheModi;iedAtkinsDietisused.Thelowglycemicindexdiet(LGIT)isnotrecommendedinGlut1De;iciency.
Adults:InadulthoodsymptomsofGlut1De;iciencyoftenstabilize.Inmostcasesepilepsyiscontrolledbymildketogenicdietsand/oranticonvulsantdrugs.Ketogenicdietsareoftenreducedtothemodi;iedAtkinsDiet(MAD)ordiscontinued–itstillremainsunclearhowlongdietarytreatment
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shouldbecontinuedinadults.Paroxysmaleventsinadultsoccurandhavebeentermed“Paroxysmalexertiondystonia(PED)”.Theyaredif;iculttotreatandmayalsopresentasmigraine,writer’scramp,andalternatinghemiplegia.
MostpatientswithGlut1De;iciencywillshowcognitiveimpairmentofvariousdegreesandwillrequireshelteredenvironments,althoughsomepatientssuccessfullyobtainedacollegedegreeandareworkingandlivingindependently.Long-termadverseeffectsofhigh-fatketogenicdiettreatmentsuchaskidneystones,growthimpairment,orcardiovascularsideeffectsremainaconcern,butpreliminaryresultsindicatethatsuchsideeffectsmaybeoverrated.Westudied10Glut1De;iciencypatientsonketogenicdiets:after10yearsonthedietlipidparametersremainedwithinthenormalrangeandultrasoundofthecarotidarteriesdidnotindicateatherosclerosis(KlepperJetal,submitted).
OUTLOOK:Glut1isexpressedinothertissuessuchasmuscle,retina,placenta,heart.PotentiallytheGlut1defectcouldalsoaffectthesetissues,butsofarnoinvolvementoftheseorganshasbeenreported-theremaybecompensatorymechanismsbyotherGlut1glucosetransportersinthesetissues.
ForpatientswithGlut1De;iciencyitisrecommendedtocontinuetheketogenicdietintoadulthood.Additionaltreatmentoptionsmaybetheuseofketoneesters,suchastriheptanoin(C7)orotherarti;icialketones.Ketoneestersserveasfueltothebrainjustasketones,buthavetheadditionaleffectofre;illingtheTCAcycle(anaplerosis)thatgeneratesenergy.C7hasbeenshowntoworkinGlut1-de;icientmiceandthe;irstclinicaltrialsinGlut1De;iciencyarecurrentlyunderway.
Dr.DeVivoandhisteamatColumbiaUniversity,NYCaresuccessfullyworkingongenetherapyforGlut1De;iciency.ResultsarepromisingusingaviralvectorcarryingtheGlut1geneintocellstocorrectthegeneticdefect,butgenetherapyinpatientswillnotbeavailableforsometime.
TogeneratemoredataaboutGlut1De;iciencyworldwideanonlinepatientregistry(www.G1DRegistry.org)hasbeengenerated.AllfamilieswithGlut1De;iciencyarerequestedtoentertheirdatatoprovidenovelinsightsintoincidence,clinicalpresentation,spectrumofmutations,dietarytreatment,andsideeffects.
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JuanPascual,MD,PhDUTSouthwesternMedicalCenter Dallas,Texas
Glut1De)iciencyin2017andBeyondHowmuchenergydoesthebrainconsumecomparedtoalightbulb?Thinkoftheenergyina60Wbulb-anadultuses500W,achilduses1500W.
Neuroscientistsdothefollowing:diagnose,comprehend,andtreat.NeuroscientistsusemanydifferentdatasourcestostudyGlut1De;iciency:mousemodels,typicalhumanbrain,Glut1De;iciencypatients.WehavealotofdataaboutpatientsintheG1DRegistry.
Forenergymetabolismthebodyhasmanywaystogettothesameplace(i.e.nourishingthebrain).Wewonderifthereisadifferentwaytonourishthebrain.Glucoseismetabolized.Neurotransmittersaremade(glutamine,glutamate,GABA):ifthereisaproblemwithglucosegettingintothebrainthenthereisaproblemwiththeconstructionofneurotransmitters(whicharethenervesignalingpartofthebrain).
Brainmetabolismisinvolvedwithtwomechanisms:1)buildingchemicals(calledanabolism)orburning/breakingdownchemicals(calledcatabolism)andthebuildingblocks(eg.glucose)mustdoboth.Anaplerosisinvolveskeepingthe;lame(energyinthebrain)going.
PETscansinGlut1De;iciencyshowlowglucoseinbrain,especiallyinthalamusandthecerebralcortex,andthisisn’tnormal.AllindividualswithGlut1De;iciencyhavethis;inding.
WhatdoestheGlut1moleculelooklike? WheredothemutationsaffecttheGlut1molecule?
Themutationstendtohappenononeareaoftheprotein.Thereseemstobenocorrelationbetweenmutationsandsymptoms.Wesaw7patientswiththeR333Wmutationandtheyareallsomewhatdifferentinphenotype.
G1DRegistry:TheG1DRegistryisusefulinobtainingdataaboutpatientsastheyentertheirowndataintotheregistry.DataenteredincludesmanyquestionsaboutpatientswithGlut1De;iciencysuchas:medicalhistory,allissues,patterns,etc.Theregistryisasecurewebsite,HIPAAcompliant,andbehinda;irewall.PascualandRonenpublishedapaperontheregistryinPediatricNeurology2015(youcan;indthisonpubmed.com)
ManytypesofGlut1De;iciencyarenotedfromthisregistryandwewantedtoknowwhatisthetypicalpatientwithGlut1De;iciencylike.
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ListedbelowiswhatapatientwithGlut1De)iciencymighthaveatvariousages:3months-intermittentinvoluntarygaze6months-fragmentaryseizures1year–absenceseizures3yearsdysarthria6years-strongsocialskillsPuberty-ameliorationandmovementdisordersAdults-obsessivecompulsivetraits
UsingmicetolearnmoreaboutGlut1De)iciency:ThemousewithG1Dcanhelpuslearnaboutthedisease.TheG1Dmousehasseizures,ataxia,lowbrainglucose.WecandoEEG’sonmiceandalsoprovideaccesstobloodveinstodeliverlabelingsubstancesatthesametime.Withthismouse,wecanstartto;indoutinformationsuchas:whereinthebraintheseseizurescomefrom?
WeknowthatthewholebrainhasEEGactivityatthesametime.WecanalsousefunctionalMRI’s(FMRI)tomeasurebrainactivity(notbrainstructure).InFMRI’sweseeregionsofthebrainthatareactivewhenyouhaveaseizures.Thesomatosensorycortexandthethalamusareespeciallyactiveduringaseizure;thisisalsowhereweseelowglucoseonPETscans.Wewillfocusourattentiononthecortexandthethalamus.
Ifyoutakeasectionofamousebrain(justasmallsection-aslongasyouhaveapartofthecortexandthethalamus)theslicecanhaveaseizure.
Weaskwhyaretheseareassohyper-excitedthattheyhaveseizures?Wecanrecordelectricalactivityfromaverysmallsliceofbraininthelaboratory.Ifthereisaproblemwithcelltocellcommunicationinthebrainaseizurecanoccur.
Twokindsofactivityinthebrainareexcitationandinhibitionandtheremustbeabalanceoryouwillhaveseizures.ExcitationisgenerallynormalinthecortexofGlut1De;iciencypatients.Whereas,inhibitionisgenerallyverylowinthepatients’cortex.Thesamethinghappensinthethalamus.
Inthethalamusthereisonespeci;iccelltypethatisdisinhibitedandisalwaysreadyto;ireatalltimes.Thecellisthereticularcellofthethalamus.ThusifwecanblockthiscelltypefrombeingdisinhibitedmaybethiscouldhelpGlut1De;iciencypatients.Wewillbelookingintothis.Andwewillthinkaboutifthereisanythingthatwecantreatpatientswiththisinmind?
Weknowthefollowingabouttreatment:• WeneedtodevelopMRIdatatolookatbrainmetabolisminmice.• WecantreatGlut1De;iciencywithalternativebrainfuel.• GlucosegoesthroughKrebscycle(theKrebscycleispartofthemetabolicpathway).
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• Triheptanoinisamediumchaintriglyceridewith7carbonatoms(naturemakesevencarbonmolecules)andthisisimportantasitcanfueltheKrebscycleinawaythatevencarbonchainscan’tdo.
WeareengagedinclinicaltrialswithG1Dpatientsandtriheptanoin:Astandardregulardietis65%carbsandproteinand35%fat.Astandardketogenicdietof4:1is90%fatand10%carbsandprotein.Triheptanoinisprovidedat35%withcarbsandproteinat60%withanextra5%essentialfats.Wearealsotrying45%triheptanoin.
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VincentPetit,DVM,PhDMETAFORABiosystemsEvryCedex,France
NewlyDevelopedTestforGlut1De)iciency
BACKGROUND:
Nutrienttransportersareusedincellsintheprocessofmakingenergy.
Weareinthebusinessofdevelopingligandsthatbindtonutrienttransporters.Wecanusethesetotrackthefunctionandeffectofthesetransporters.Wecandetermineifthereareunderoroverconsumednutrients.Wedeveloptestsformetabolismincludingenergydemandincells.
Glut1De;iciencyinvolvesabloodbrainbarrierproteincalledGlut1protein.WeknowthatthereisalongtimetodiagnosisinpatientswithGlut1De;iciency.WewantedtodevelopatestthatcutsdownthattimebyevaluatingtheGlut1proteinfunction.
Weuseredbloodcellsfromapatientandattachaspeci;icligandtotheGlut1proteininthelaboratory.ThencalculatetheamountofGlut1proteinexpressedonredcells.
Thisisasimplebloodtestthatdoesn’trequirefastinganditisfullyautomated;thusdoesn’trequiremuchtechniciantime.Wehaveareportonthistechniqueinthejournal“annalsofneurology”(2017).Therewere30patientsandcontrolsinthepaper.WedeterminedthenormalrangeofGlut1expressionlevelinthecontrolpopulation,anddemonstratedthatinmostGlut1De;iciencypatients,thevaluesdroppedbyatleast20%.SomeofthevaluesfortheGlut1De;iciencypatientsfellinthenormalrange,butnocontrolvaluewasbelow80%.Sothesensitivityofthetestisn’t100%butitisveryspeci;ic.ThisissimilartoCSFglucoseasameasure.
Weranvaliditystudies-i.e.teststoseeifourresultswouldbethesameifwere-ranthetestdata.Thetestisveryreproducible.
Overallthetestis:rapid,non-invasive(afewdropsofbloodneeded),andspeci;ic.Itmaybeusefulin;indingpatientswithnon-commonphenotypes.
Thetestisstillinproductionmode.Currentlyitisnotreimbursablebyinsurance.
WehopetomakethetestavailabletotheUSA,Europeandothercountriesassoonaspossible.
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KarthikRajasekaran,PhDUTSouthwesternMedicalCenterDallas,Texas
AssayingDrugsforSafetyinGlut1De)iciencySyndrome
Glucoseisrequiredforbrainfunction.Glucoseistransferredfromthebloodtothebrainthroughthebloodbrainbarrier.Glucoseismetabolizedthroughglycolysis.Ifthereislessglucoseenteringthebrainthenthereislessglycolysis.GlucoseisbrokendownintoacetylCo-AandproducesATPaswellasneurotransmitters.Oneoftheneurotransmittersisglutamate;whichisanexcitatoryneurotransmitter(whenneuronisexposedtoglutamateit;ires).Glutamateisalsoconvertedintoaninhibitoryneurotransmitter,gamma-aminobutyricacid(GABA).WhenaneuronisexposedtoGABAitissilent(doesn’t;ire).Neuronsneedabalancebetweenexcitationandinhibition,andseizureshappenwhenthebalanceistitledinfavorofexcitationoverinhibition.
Therapeuticoptions-Anti-EpilepticDrugs(AED’s):TherearenogoodtherapeuticoptionsforGlut1De;iciency;seizuredrugsarenotveryuseful.Sometimesnormalanti-epilepsydrugsthatapparentlyworkbyboostinginhibitioncanparadoxicallyworsenoutcomes.
Wecantestanti-epilepticdrugs(AED’s)inthelaboratorywithanimalmodelstoseewhathappens.
ThereisamousemodelofGlut1De;iciency.ThesemicearemorepronetogeneralizedtonicclonicseizureswhichisoftenoneoftheinitialpresentationsofGlut1De;iciency.Inthemousemodel,weinjectmicewithchemicalsthatcancauseseizures.WhatistheminimumamountofaseizureinducingchemicalanormalmouserequiretohaveseizuresversusGlut1De;iciencymouse?Theminimumamountatwhich50%oftheanimalshaveseizuresiscalledtheeffectivedose(ED5).We;indthiseffectivedosebyinjectinganimalswithdifferentdosesofdrugsandthenstatisticallyanalyzingtheresponseoutcomes(doseresponserelationship).Wildtype(non-diseased)miceneedmoredrugtohaveaseizurethanaGlut1De;iciencymouse.
Whenwegivethechemicalpilocarpinetoinduceseizuresinthemice,weseethatGlut1De;iciencymicearemorepronetoGTCseizures.Weevaluatewhethertriheptanoinmightpreventseizures.WealsoevaluatewhetherdiazepamcanterminateseizuresinGlut1De;iciencymice.
Diazepam:Whenpilocarpineisinjectedandweadddiazepam30secondslater-whathappens?
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Inwildtypemicethereiscessationofseizureswithdiazepam.However,ifwewaitlongenoughtostartdiazepamthereisaproblemwithseizures.
ForGlut1De;iciencymice,postpilocarpine,thereisnoresponsetodiazepam;andastheanimalagestheresponsetoevenhigherdoseofdiazepamisevenworse.Weknowthattheseanimalsdonotrespondtodiazepam.
Phenobarbital:Ifpilocarpineisinjectedandthenphenobarbital(1or30minuteslater);wegetdoseresponseinthewildtypeanimal.WegetED50valueinthewildtypemice.
InGlut1De;iciencymicethereisrespiratorydistresswithnormaldosesofphenobarbitalthatcausesED50inwildtypeanimalswithphenobarbital.
Trihpetanoin:Ontheotherhand,wehaveseenthattriheptanoinelevatestheseizurethreshold(i.emakesitmoredif;iculttohaveaseizure).TheED50doseforGlut1De;iciencyanimalsisgreaterthanwithouttriheptanoin.
AproposalforaHighThroughputscreening:TakentogetherwithdatafromDr.Klepper’sresearch,webelievethatdiazepamandphenobarbitalmayantagonizethefunctionoftheGlut1transporterpotentiallyworseningseizureoutcomes.
Notonlyisthissortofnegativeinteractionpossiblewithantiepilepsydrugs,butitisjustaspossiblewithotherdrugsthatGlut1De;iciencypatientsmaybeexposedtoforthemanagementofillnessesotherthanseizures.OurdesireandproposalistocreatealibraryofthecommonlyuseddrugsthatmaypotentiallycontraindicateGlut1function.Suchalibraryofpotentialcontraindicationofcommonlyusedoutpatientdrugsdoesnotcurrentlyexist.It’savailabilitycaninformandmakephysiciansandpatientfamiliesawareofpotentialnegativeinteractions–insomecasestheremaybeanopportunitytochooseanotherdrugfortheconditionthatdoesnothavethesenegativeeffects.
AhighthroughputwaytoidentifyharmfuldrugsbystudyingGlut1translocation.uptakeassays:WhenGlut1isonthesurfaceofthecellmembrane,itcanfunctionproperly.Whenitiswithinthecell,thenitisnotavailabletotransportglucose.WecoulduseahighthroughputlaboratoryassaytotestdrugsthatcanpotentiallyworsensymptomsinGlut1De;iciencybytranslocatingthemfromthecellsurfacetotheinsideofthecell.ThiscanbeaccomplishedusingculturedneuronsonwhichtheGlut1proteinis;luorescentlytagged,anddependinguponlocationinthecell(i.e.itspresenceonthecellsurfaceorwithinthecell)willemitastrongorweaksignal.Wecanadddifferentdrugsanddrugsindifferentconcentrationstodeterminewhichdrugsandatwhatdosemaypotentially
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antagonizeGlut1function.WecanalsousethissystemtounderstandhowlongitmaytakeforadrugtopotentiallyaffectGlut1location.
Asecondwayofidenti)icationfortheseharmfuldrugsisuptakeassays:Itisalsopossiblethatdrugsmayjustimpactglucoseuptakewithoutgettingtranslocated.Wehaveaglucoseuptakeassayusingastrocytes/neuronculturesthatcanbeexposedtodifferentconcentrationsofdifferentkindsofdrugs.Wecancreateadoseresponsecurveto;inddrugsthatinhibitglucoseuptake.Wehopeto;indagroupofdrugsthatareandareNOTtobeusedinpatientswithGlut1De;iciency.
Finallywecantestdrugsidenti;iedtoaffectGlut1translocationoruptakeintheanimalmodelofGlut1De;iciency.HerewecantestwhetherGlut1De;iciencyanimalstreatedwiththesedrugswouldbemorepronetoseizureandmovementdisorders.WecantestthesethingsinGlut1De;iciencymicewithEEG’sandalsolookformovementdisorders.Wecanlookforataxiainthesemiceona“catwalk”(atestforataxiainmice).
WereallyshouldlookatcommonpediatricmedicationsandseeiftheycauseaprobleminGlut1De;iciencypatients.Noonehasreallyevaluatedmedicationsforfever,asthma,allergies,ADHD,etc.TherearecommonlyusedmedicationsinpatientsbutnoonehasevaluatedthemforGlut1De;iciencypatients.ManyofthedrugscommonlyusedmaycauseseizuresinGlut1De;iciencypatients.WewilllookatdrugsthatGlut1De;iciencypatientsmaybeusing.Wearewaitingforfundingatthispoint.
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DominicD’Agostino,PhDUniversityofSouthFlorida,MorsaniCollegeofMedicineInstituteforHumanandMachineCognition(IHMC) Tampa,Florida
SignalingPropertiesandTherapeuticEffectsofKetones
BACKGROUND:TheUSOf;iceofNavalResearch(ONR)hassoughttoexploreandprovidemetaboliccountermeasurestoimprovethesafetyandperformanceinextremeenvironments(suchasdeepseadiving)forNavySEALs.
Navysealscanstayat50feetofseawaterdepthfor10minutesandafterthattheywillhavethepotentialforseizuresduetocentralnervoussystem(CNS)oxygentoxicity.TheNavyhasexperimentedwithseveraldrugstohelpreduceseizuresinNavydivers,suchasanti-epilepticdrugs,butthesedrugshaveunwantedsideeffectsandcanimpairwar;ightercognitionability.
ThereneedstobeastrategyforoxygentoxicityforNavySEALdiverswhouseoxygenrebreathers.
Thehyperbaricoxygenseizuremodelisimportanttouseinresearchastonic-clonicseizuresoccur;theseseizuresarereversibleandreproducible.
Wecanresearchthisinthelaboratorybyusinghyperbaricoxygenchamber;howeverrodentseizuremodelsinresearchareinformativebutnotalwayspredictive.
RESEARCH:Wecanevaluateseizuresinasliceofrodentbraintissue(inthelaboratory).Weareinterestedinthehippocampusareaforlearningandmemoryissues.
Weexposetherodentbrainslicetissuestohighlevelsofoxygen(likeaNavySEALmightneedfordeepseadives);weseeseizuresinthebrainsliceandcanstudythisphenomenonintheabsenceandpresenceofketones.Ketoneshelptoreduceseizuresevenwhenevokedbyvariousneurotoxins.
Wecanalsostudythisatthelevelofthemitochondria,inEEG’s,EKG’s,physiologicaldata,andneurologicaldata.Wecanmeasurethelatencyofseizuresinresponsetoextremeenvironmentsthroughthismethod.
Inthisresearchwenoticedthatfastingketosiscausedneuroprotectiveeffectswhensubjectedtohighlevelsofoxygen.Wewonderedwhatthebrainenergychangewasinthecontextoffasting.
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TherewasapublishedstudyfromHarvardMedicalSchoolwheresubjectswerefastedfor40days.Whenfedanormaldietmostofthefuelisfromglucose.Yetwhenfastingfor40days,2/3ofthe
brainenergymetabolismisfromketonebodies.Whenlargeamountsofinsulinisprovidedtoapersononanormaldiet,severehypoglycemiawouldresultandthisisfatal.Yetwheninsulinwasprovidedtothesefastedpatientstheyallsurvivedandwereasymptomatictohypoglycemia.Thisrepresentsadramaticdemonstrationthatthebraincanuseketonesforfueleveninthefaceofwhatwouldtypicallybeseverehypoglycemia.
Metabolictherapyprotectiontohighoxygenlevelstatescanbeachievedwithnutritionalketosis.Gettingintoketosis-involvessustainedadherencetoaverylowcarbohydratedietwherethereisadepletionofliverofglycogen.Thiscanalsobeachievedwithprolongedfasting,butthisisnotsustainable..Ketonesaltsareformulatedwithsodium,potassium,calciumandmagnesiumattachedtoketones,primarilybeta-hydroxybutyrate.Exogenousketonescancircumventdietaryestablishedketonestogetintoketosis.
Ketonesmaybeimportantsignalingmetabolitessuchas:suppressionofoxidativestress(epigenetic),suppressin;lammation(NLRP3,reducedIL1B),increasetheGABAtoglutamateratio,andincreasetheconversionofglutamatetoGABAbyactivatingglutamicaciddecarboxylase(GAD)
Thetermanapleroticappliesinthatmetabolitesarefeedintometabolicpathwaystomakeneurotransmitters.KetonescanbypassGLUT1,GLUT3andpyruvatedehydrogenasede;iciency(PDH).TheyusetheusetheMCTtransportertoenterthebrain,andthistransporterisincreasedovertimewithsustainedadherencetonutritionalketosis
Theliveristhesiteofproductionofketones.Itmakesketonesbutcan’tuseketonesassourceoffuel.Ketonescancrossthebloodbrainbarrierandthemitochondrialouterwallveryeasily.Thus,ketonesproducedendogenouslyandexogenouslyarehighlyef;icientandreadilyavailablefuelsfortissuesandorgans,especiallythebrain.
WehavedemonstratedthatKetonesupplementationdelaysoxygenseizuresinrats.Ifaketoneesterisprovided;itissimilartotheratshavingbeenfastedfor1week(i.ethelevelofketosisishigh).Thisrapid(within30minutes)andsustained(over4-8hours)ketosiswasadesiredfeatureofthemilitarybecauseitcouldrapidlyinduceastateofneuroprotection.
Thehumanapplicationwouldbeashighas1gram/kg/dayofketoneesters,dividedinto2-4doses.Within30minutesweseeahighriseinketonesandreducedglucose.BothcanbemeasuredwithaPrecisionXtrabloodglucose/ketone(BHB)meter(Abbottlabs).device.Additionally,acetoacetateandbeta-hydroxybutyratecanbemeasuredinthelaborbyavarietyofotherdevicesthatarehittingthemarket(e.g.Kaomoji).
Westudytheneuroprotectiveeffectofexogenousketonesunderthe100%oxygenmodelinrats.Thisissimilarto10timestheamountofoxygenthanwenormallyhave.RatsgivenketoneestersdemonstratedremarkableresilienceagainstCNDoxygentoxicity(tonic-clonicseizures).Weused5ATAofoxygen,whichtypicallyproducedseizureswithin10minutes(controlanimals);whereasthosetreatedwithketoneesterswereableresisttheseizuresforover1hour.This
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neuroprotectionandanti-convulsanteffectishigherthanandknowantiseizurecompoundthatweknowof.
Wefeedratswithexogenousketonesmixedwithstandarddiet(10-20%ofthefoodbyweight)
Inmicefedwithketoneestersandnormaldiet;bloodglucosegoesdownwhenketonesgoupandwearenotsurewhythishappens.KetoneestersincreasesBHBandacetoacetateina1:1ratio.Ketoneesters(1,3-butanediolacetoacetatediester)signi;icantlyelevatestheacetoacetate;thisisimportanttoseizureactivity.Elevationsofacetoacetatearealsoseenwhenketonesaltsareadministered,butnottothesamelevelsaswiththisketoneester.
Glut1De)iciencymice)indingswithketoneesters:Glut1De;iciencymiceplusketoneestersshowhighvariabilityinresponseandtheytendtodisposeofketonesfast.Thisseemstobeapositiveindicationthattheirtissue(brainespecially)arestaredoffuel.
Aglucosetolerancetestshowshowfasttheglucoseistakenupbythesystem.Similarly,a“ketonetolerancetest”isagoodindicationthatGlut1De;iciencymicehaveahighcapacitytouseketonesforfuel,andthismayresultinlowerthanexpectedlevelsinthebloodandtissues(i.e.theyareburningketones)
Whengivenketoneestersmixedinwithfood;ketonelevelsdidnotrisetothelevelstypicallyseeninnon-diseaseanimals.
Ketonesalt20%upwasmucheasiertoadministerbecausethemicedidnotself-restrictandthiswaswelltolerated.
Therewerelittlechangesinbodyweightovertimeinketoneesterswhichtastebad,somicemightnotlikethem.However,micegivenketoneesterswerebetterathangingwire(strength)testandonRotarod(motorfunction)test.Overalltheyhadmorerobustphysicalcapabilitieswheninastateofnutritionalketosiscomparedtountreated.
Ketonesupplementationinpatients:Isitsafetouseketonesaltsinpatients?Theywouldneedtoconsumealargedose.
Ketonesaltshavebeenusedfordecadesinvariousmetabolicdiseasestates.Newtechnologiesaremakingitpossibletodevelopbio-identicalketonesaltsthataremadewithabalancedmineralformulathatwouldbewelltolerated,safeandpleasanttotasteinformsthatresemblefruitpunchorachocolateshake.Thiswouldalsomakelargedosesmorefeasible.
Complianceisoneofthemainissueswiththeketogenicdietandasnewcompaniesdeveloppre-packagedfoodsand“comfortketo-foods”thiswillbemuchlessofanissue.Also,workbyDr.EricKossoffhasshownthatissomecasesthelessrestrictivemodi;iedketogenic(Atkins)diet(MAD)maybejustasgood.AMADconsumedwithMCToilandsupplementalketonescouldbetheidealstrategyfortreatmentandcompliance
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D’Agostino,page3
Theketogenicdietdoessuppressseizuresinmanydifferentdisorders;suchasAngelmansyndrome.ThereisapublishedreportofusingketoneestersintheAngelmansyndromemousemodel(2016).ResearchatUSFismovingthistherapyintoclinicaltrialsatmultiplecenters.
Resultsindicatedanelevatedpresenceofenzymesthatcanconvertmoreglutamate(excitatory)intoGABA(stabilizing)withnutritionalketosis.HighGABAlevelshaveacalmingeffectandtheabilitytosuppressseizures.
WewanttodoastudyinGlut1De;iciencypatients,especiallysinceexogenousketoneshavebeenshowntoreducesomeofthesymptomsthatmaybeassociatedwiththisdiseaseincluding,enhancingmotorfunction,reducinganxietyandalsosuppressingseizures(includingabsenceseizuresThecombinationofMediumChainTriglyceridesandketonemineralsaltshavethebiggesteffectsonanxietyreduction.TherearecommercialproductsonthemarketthatcombineBHBsalts+MCTandthesewouldbetheformulaswewouldbeinterestedintesting.
WhenapatientwithGlut1De;iciencyexercises,symptomscanworsen.Maybeifwegiveketoneestersasasourceoffuelwhenexercisingitcanshiftfuelpreferencesuchasinelitelevelathletes.Ketosisshiftsenergymetabolismfromglucosetoketoneswitha50%reductioninlactate.Thisobservationhassigni;icantimplicationsforpatientsandtheirabilitytobemoremetabolicallyresilientduringexercise.Feedingpriortoexercisecouldbeimportant.
Ketoneshavebeenshowntobeinvolvedwithseveralpowerfulsignalingpathways,leadingtotherapeuticeffects.FeedingexogenousketonesincreaseGABAtoglutamateratio,increaseinneurotransmitters,antioxidantsareelevated,decreaseinglucose(suggestsincreaseinglucosedisposal).Manyoftheseeffectsaredesirabletraitsforadrugcompound,butnutritionalketosistendstostimulatealloftheseeffects(inamildway)withlittleornosideeffects.
ImplementationofnutritionalketosisthroughdietshouldbethefrontlineapproachforGlut1De;iciency,whereasexogenousketonesupplementationwillbeavailableinthefutureasaprescriptionmedicalfood.Severalcompaniesnowsellthemasnutritionalsupplements,butonlyproductsapprovedbya3rdparty(NSF,InformedChoice,etc)shouldbeconsidered.Thereisabloodketonemeteronthemarketnow(PrecisionXtra).TheDexcomPatchstickstotheskinandpicksupglucose,andtheseresultscanbesenttoasmartphone.Thesametechnologyisunderdevelopmentforketonemonitoring.Dietinitiationofketosistakesapprox.3-10dayswhereastakingexogenousketonesisafastwaytogetintoketosisandtosustaintherapeuticlevels.
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D’Agostino,page4
EricKossoff,MDJohnsHopkinsHospital Baltimore,Maryland
DietTherapyforGlut1De)iciency
Thecurrentstateofdietarytherapyfordisorders,includingGlut1De;iciencywasdiscussed.
Alotofpapersarebeingpublishedontheketogenicdiet(KD).
Thereismore;lexibilityinthedietnowandthishelpswithexpandingtheuseofdietarytherapy.
Thereare4majorrandomizedclinicaltrialsusingKDthathavebeenpublished.
TheCochraneCollaboration(2012)isapublishedpaperthatisusefulingettinginsurancetopayfortheKDasitclassi;iesdietarytherapyasvaluableandef;icacious.
90%ofGlut1De;iciencypatientshaveatleast50%seizurereductionwiththeKDinmajorstudies.
ThereisanicepaperbyMasinoandRho2012whichexplainswhythedietworks.
TheKDisnowmore;lexibleandaccessible.Therearealotofdifferentformulasonthemarket.Youcanusetheseasbakingmixesalsoandmanycompaniesarecreatingdifferentketofoods.
Thereare4majordiets
1) Classicketogenicdiet
2) Mediumchaintriglyceridesdiet(MCT)
3) Modi;iedAtkinsdiet(MAD)-createdatHopkins
4) Lowglycemicindextreatment–createdatMassachusettsGeneral
WeusetheModi;iedAtkinsdietatHopkinsasanalternativeprimarily.Thisincludeslessfat,abitmorecarbs,moreprotein,noadmissiontohospitalandnocalorieor;luidrestrictioncomparedtotheclassicketogenicdiet.Thereisnoweighingfoodsongramscale-patientscanhave15-20gramsofcarbsperday.
Underage2yearstheketogenicdietwasslightlybetterthantheMADdietforkidswithseizures.MostcentersusetheclassicKDforchildrenunderage2.
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WhatdoweknowaboutGlut1De)iciency?
3keyissuesthatparentscommonlyaskketocentersfortheirchildrenwithGlut1De;iciencyinclude:
1) TheKDisaseffectiveastheMAD?
2) Whataretheappropriateketonelevels?
3) CanIstopthedietever?
InGlut1De;iciencywearetalkingaboutabrainenergyfailurethusgivingmoreketonescouldbebetter.Howeverthisisanecdotal.
Maybeatayoungeragehigherketonesarebetter.
Therearesomenegativestothisconceptmainlythatketonesarehighbutsomepatientsstillhavesomeseizures,suggestingit’smorethanjustketoneshelping.
WhatabouttheclassicKDversustheMADdiet?SomepatientsswitchtotheMADdietanddidbetter.Thisisallcomplicatedandcouldvaryfrompatienttopatient.Thereisn’tasimplewaytotreatallpatients.
Kossoff(2016)hasareportregardingdietarytherapyandseizuresinGlut1De)iciency:
92familiescompletedasurveyregardingtheiruseofdietarytherapyfortheirchildrenwithGlut1De;iciency.Itwascompletedatthe2015Glut1De;iciencyFoundationmeetinginOrlando.
Theagerangeofpatientswas1-24yearswithameanof9.9yearsand90patientshadbeentreatedwithdietarytherapy2patientsdidnothavedietarytherapy.
ThebreakdownofdietsutilizedwereKDn=59,MADn=29,MCTn=4,andLGITn=2.
Switchingwascommon;manyswitchedfromKDtoMAD,oftenontheirown.
SomewentfromMADtoKD.FortheKDtherewasawidevarietyforratios;manywerenoton4:1(about2/3’sofpatients),choosinglowerratios
46%saidtheirchildwasseizurefreeonthedietand80%hadagreaterthan90%reductionofseizures.Thiscon;irmsjusthoweffectivedietarytherapycanbeforchildrenwithGlut1De;iciency.
Whymightsomepatientsstillhaveseizures?Notclearfromthesurvey
Other;indings:
1) Ageatdiagnosis-theyoungerthebetteratstartingthediet.
2) Currentagemakesadifferenceinhavingseizures(youngerdidbetter).
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Kossoff,page2
3.)TheMADequalstheKDforseizureactivityinthissurveyaccordingtoparents.
4).A4:1fattocarb/proteinratiodidnotmakeadifferenceinseizures
(lowerratioimprovedseizuresequally).
5) Checkingbloodketonesversusurineketonesmakesnodifferenceinseizureoutcome.
Extrasupplementstakeninpatientsinsurvey:
Carnitine(n=62),oralcitrates(n=25),MCToil(n=20),noonewasonC736%wereonAED’s
76/76withmovementdisordersimprovedthemovementdisordersandcognitiononadiet.
Ketones:Checkingketonelevelsvariesalotamongpatients.34%checkingblood,34%saidcheckurine,21%both,and11%checkednotatall.Didn’tseemtomatterforseizurecontrol.Worthfuturestudy.
Puberty:22patientswereator;inishedpubertyand64%saidtheyhadachangeinseizureactivity.
Sideeffectsofdietarytherapyincludesomepatientswhohadgastrointestinalissuesand1personwithacholesterolissue.
5.5yearswastheaveragetimeondiet(1familyhadbeenonfor20years).
67%wereunsurewhetherthepatientshouldcomeoffthedietinthefuture.Alsoworthfuturestudy.
Sinceour2016study,therehavebeenmorelookingatthedietandGlut1:
NewstudybyAmalou(2016)
10childrenwerestartedonMADdiet(2infants). DatashowedtherewassimilarimprovementwithMADcomparedtoKD.
Japanstudy:DatashowedthattheMADdietismorepalatableforGlut1De;iciencyandwascomparableorbetterinsomepatientstoclassicKD.
G1DRegistry:Dataintheregistryconsistsof181patients.Againalotofvaryingdiets.54%wereontheKD.
Summary:
Itisoktomakeachangeas4:1KDdoesnot;itallpatients
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Kossoff,page3
OutcomesondietsarespectacularforGlut1De;iciencyandtheyareexcellentforseizures,cognitionandmovementdisorders.
Managementofdietisalsovariable,includingketonesandsupplements.
Weneedfurtherstudyforpuberty,discontinuation,correlationwithketosis,andsupplements.
InthefuturewewillevaluatecognitionandalsoadultswithGlut1De;iciency.
FuturePossibleNoveldietaryapproachestoGlut1De)iciency:
Triheptanoin
C10
Ketoneesters
Modi;iedcornstarch
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Kossoff,page4
MackenzieC.Cervenka,MDJohnsHopkinsHospital Baltimore,Maryland
KetogenicDietTreatmentsandTransitionStrategies
Glut1De;iciencywasdiscoveredinthe1990’sandthe;irstpatientsdiagnosedareallnowadults.
AdultswithGlut1De;iciencycanhaveatypicalsymptomssuchasmigraine,writer’scramp,andalternatinghemiplegiawhichmaynotberecognizedassymptomsofGlut1De;iciency.
AdultpatientswithGlut1De;iciencycanalsohavethefollowingsymptoms:chronicmildencephalopathy,infrequentseizures,varyingspasticity,ataxiaandparoxysmalexertionaldystonia(PED).
Geneticmutationsaretypicallyautosomaldominantandaremostoftendenovo(nottransmittedfromaparent).
SomepatientshaveadecreaseinseizuresduringchildhoodandwhenwemeetthemasanadulttheyareonlyhavingothertypesofeventssuchasPEDs.However,theadultclinicalpictureisoftennotsodifferentthaninchildren.Butwewanttoknowjusthowtheyaredifferentthanchildren?
Dietaryconsiderations:
ThestandardAmericandietformostadultsinoursocietyincludeseatingalotofcarbs.Thedevelopingbrainneedsmoreenergy.However,theadultneedforenergyislessthanthatofayoungchild.
PatientswithGlut1De;iciencyareontheketogenicdietbutwedon’treallyknowthequantityofketonesthesepatientsneed.
Theclassicketogenicdietis90%caloriesfromfat.Theratiooffatstocarbohydratesandproteincombinedis4:1or3:1.Themodi;iedketogenicdietandtheModi;iedAtkinsDiet(MAD)arelessrestrictivethantheclassicdietandusedbysomepatientsbuttheystillmeasureketones.Theratiooffatstocarbohydratesandproteincombinedistypically2:1or1:1.
Manyadultpatientsstartthesedietsontheirown;asmanyoftheketogenicdietcentersdon’tofferdietstoadultsandmostadultepilepsycentersdonotuseketogenicdietsfortreatment.Thisisn’talwaysthebestwaytodothings.
ItwasreportedbyPong,2012that62%ofpatientswithGlut1De;iciencybecameseizurefreeontheketogenicdiet.Compliancewas84%.
Thereislittleinliteratureregardingeffectivenessofthemodi;iedketogenicdietinadults.
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TheModi;iedAtkinsDietisusedatJohnHopkinsHospitalandseveralotheradultdietcentersnationwide.FortheMAD,adultstake20gramsnetcarbsperday(;iberdoesn’tcount!).Patientsaren’trequiredtotakeacertainamountoffat,justenoughtogetintoketosis.TheMADdietequatestoabouta1:1to2:1ratiooffatstocarbohydratesandproteincombined.Whenadultsreducecarbs,manywillgointoketosiswithjustthis.Ifthepatientsdonothaveimprovementinseizuresandothersymptoms,weaskthemtostartthinkingaboutusingaclassicketogenicdiet.
HowtheMADisusedinGlut1De)iciencypatients:
IntheG1DregistryofpatientswithGlut1De;iciency,2/3ofpatientsusedmodi;ieddiets.WeknowthattheMADcanreduceoxidativestress.
TheMADhasalsobeenusedformovementdisorders.AdultswithGlut1De;iciencyoftenhaveissueswithmovementdisordersandlessproblemswithseizures.Patientswithabetahydroxybutyratelevelof0.2-2mmol/Lhadareductioninmovementdisordersinonestudy(Leenetal.,2013).
Transitioningtoanadultdietcenterfromapediatricdietcenter:
ThetransitionmeansthatmanypatientswithGlut1De;iciencywillbemoreindependentasadults.Theymaybeaskedtochooseappropriatefoods,checkketones,andmonitorsymptoms.
Adultpatientsoftenwanttodrive.However,tobeallowedtodrive,thepatientmustbeseizurefree.Thereisarequirementforlengthoftimebeingseizurefreetogainpermissiontodriveandthesevaryfromstatetostate.Thisisalsotrueformovementdisordersthatmayimpactdrivingability.
ParentsorotheradultscanobtainguardianshipofGlut1De;iciencypatientsoncetheyturn18yearsofageiftheyarenotabletomakedecisionsforthemselves.
DisabilityinGlut1De;iciencyadultscanbesigni;icant.Adultpatientsmaybetakenoffoftheirparents’healthinsurance(agevariesbyinsurancecarrierandstate).Makesurehe/shehasMedicareandMedicaidinplace.
Transitionplanningpriortotheonsetofadultageisimportantforseveralreasons.Graduationfromthepublicschoolsystemhappensfrom18-21yearsandpatientsmayplantoparticipateindayprogramsorrequirecare/supervisionathome.Somecollegeswillhelpmakeketofoodsavailableindininghalls.
TransitioningtoAdulthood:
Atage10-13yearsstarttakingaboutatransitionplanwiththepediatricianandpediatricneurologyteam.
Atages14-15yearscontinuetoplan.
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Cervenka,page2
Atages16-17yearsstartworkingforindependenceorguardianshipand;indjobprograms.Consideradvancemeetingofthechildwiththeadultneurologist.
At18yearsinitiatethetransition.
TransitionTips:
• Planaheadtopreventgapsincare.
• Avoidreinventingthewheel(takingthesametestsortryingoldtreatmentsagainthatdidn’tworkthe;irsttime).
• Planningimprovespatientandhealthcareprovidersatisfaction.
• Haveatransitiondietclinic.Thereareseveraldietclinicsthroughthenation.
Drs.KossoffandCervenkawroteapaperon“Transitioningpediatricpatientsreceivingketogenicdietsforepilepsy”describingthisexperiencein10patientswithepilepsyonketogenicdiets(2013).
Tipstoimprovedietarycompliance:
• Considermodifyingthediettomakeitlessrestrictiveandeasiertofollow.
• Ketogenicdietresourcessuchascookingclasses,cookbooksandwebsiteswithrecipes,anddietmonitoringmobileapplicationsareavailable.
• Manyketogenicfoodsarecommerciallyavailableorasmedicalfoods(requireaprescription).
• Potentialsideeffectsofthesedietscanbeconstipationandkidneystonescanbeavoidedwithgoodhydration.
Whathappensifawomanontheketogenicdietgetspregnant?
Isthereteratogenicity(harmtothefetus)?Thereisverylittleinformationintheliteratureaboutthis(vanderLouw,2017).
Therearesomepotentiallongtermsideeffectstoavoid:
Vitaminde;iciency(knownrisk)
Carnitinede;iciency(knownrisk)
Kidneystones(knownrisk)�23
Cervenka,page3
Osteopenia/Osteoporosis(knownrisk)
Cardiovasculardisease(riskunknown)
Cerebrovascularissues(riskunknown)
Preventativemeasurestohelppreventsideeffects:
Replaceheavycreamwitholiveoilormediumchaintriglycerideoilinpatientswithelevatedlipids
Reducecaloriesinobesepatients
Multivitaminsupplements
Oralcitrates(forkidneystones)
Checkforhyperlipidemiaas(inMAD)bloodLDLandtotalcholesteroloftengoupin;irst6months,thentrendbacktonormalin1-2yearsondiettherapy.Studiesinchildrenhaveshownthatin12monthstherewassomedecreaseinvascularelasticitybutthisimprovesandwasnotsigni;icantat24months(Kapetanakis,2014;Coppola,2014).
WestillneedtolearnmoreaboutadultsusingketogenicdietsforepilepsyandGlut1De)iciency:
Howlongshouldadultsstayonthesediets?
Whataboutsupplements?
Whichdietisthebest?
Whatketonelevelsarebest?
Arethereothersideeffectsthatwedon’talreadyknowabout?
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Cervenka,page4
BothDr.UmraoMonaniandDr.AbrahamAl-AhmadarerecipientsofresearchgrantawardsfromtheGlut1De;iciencyFoundationandtheypresentedupdatesontheirworkattheNashvilleconference.DuetoKrisEngelstad’stravelschedule,shewasunabletoattendtheirpresentations.Wehavesomeresourcesrelatedtotheirtalkstosharebelow.
Dr.UmraoMonani,PhDColumbiaUniversityMedicalCenterNewYork,NewYork
Dr.MonanipresentedonGeneReplacementTherapyforGlut1De)iciency.
Dr.Monani’steamhaspublishedapaperrelatedtotheirresearchongenetherapy.Youcanaccessthefulltextarticlehere:
AbrahamAl-Ahmad,PhDTexasTechUniversityHealthSciencesCenterLubbock,Texas
Dr.Al-AhmadpresentedonModelingtheBlood-BrainBarrierusingPatient-DerivedStemCells:AFocusonModelingGlucoseTransport.
Dr.Al-Ahmadprovidedthepowerpointslidesforhispresentation,whichyoucanaccesshere.
OtherConferenceResources:Youmayalso;indadditionalconferenceresourcesatourwebsite,includingtheagenda,presentationslides,photos,andalistofexhibitorsandsponsors.
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