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Palmitoylethanolamide as adjunctive therapy for autism: Efficacy and safety results from a randomized controlled trial
Accepted Manuscript Palmitoylethanolamide as adjunctive therapy for autism: Efficacy and safety results from a randomized controlled trial Mona Khalaj, Amene Saghazadeh, Elham Shirazi, Mohammad-Reza Shalbafan, Kaveh Alavi, Mitera Hakim Shooshtari, Fatemeh Yousefi Laksari, Maryamalsadat Hosseini, Mohammad-Reza Mohammadi, Shahin Akhondzadeh PII:
S0022-3956(17)31405-X
DOI:
10.1016/j.jpsychires.2018.04.022
Reference:
PIAT 3364
To appear in:
Journal of Psychiatric Research
Received Date: 22 December 2017 Revised Date:
28 April 2018
Accepted Date: 30 April 2018
Please cite this article as: Khalaj M, Saghazadeh A, Shirazi E, Shalbafan M-R, Alavi K, Shooshtari MH, Laksari FY, Hosseini M, Mohammadi M-R, Akhondzadeh S, Palmitoylethanolamide as adjunctive therapy for autism: Efficacy and safety results from a randomized controlled trial, Journal of Psychiatric Research (2018), doi: 10.1016/j.jpsychires.2018.04.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Palmitoylethanolamide as Adjunctive Therapy for Autism:
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Efficacy and Safety Results from a Randomized Controlled Trial
Mona Khalaja MD., Amene Saghazadehb MD., Elham Shirazia MD., Mohammad-Reza Shalbafan a MD., Kaveh Alavia MD., Mitera Hakim Shooshtaria MD., Fatemeh Yousefi Laksaria b
MD., Shahin
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MA., Maryamalsadat Hosseinia MD., Mohammad-Reza Mohammadi
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Akhondzadeh b Ph.D.
The first three authors contributed equally to this study.
a
Mental Health Research Center, School of Behavioral Sciences and Mental Health,
b
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Tehran Institute of Psychiatry, Iran University of Medical Sciences, Tehran, Iran. Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences,
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Tehran, Iran.
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Correspondence to: Prof. Shahin Akhondzadeh Ph.D., Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, South Kargar Street, Tehran 13337, Iran. Tel: 98-21-55412222, Fax: +98-21-55419113, Email: [email protected]
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Abstract Inflammation as well as glutamate excitotoxicity have been proposed to participate in the propagation of autism. Palmitoylethanolamide (PEA) is an endocannabinoid proven to
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prevent glutamatergic toxicity and inhibit inflammatory responses simultaneously. The present randomized, parallel group, double-blind placebo-controlled trial is the first study depicted to probe the efficacy of co-treatment with risperidone and PEA over 10 weeks in
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children with autism. Seventy children (aged 4 to 12 years) with autism and moderate to severe symptoms of irritability were randomly assigned to two treatment regimens. The
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study outcomes were measured using the Aberrant Behavior Checklist-Community Edition (ABC-C). At trial endpoint (week 10), combination of PEA and risperidone had superior efficacy in ameliorating the ABC-irritability and hyperactivity/noncompliance symptoms (Cohen’s d, 95% confidence interval (CI) = 0.94, 0.41 to 1.46, p = 0.001) compared with a
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risperidone plus placebo regimen. Interestingly, effect of combination treatment on hyperactivity symptoms was also observed at trial midpoint (week 5) but with a smaller effect size (d = 0.53, p = 0.04) than that at the endpoint (d = 0.94, p = 0.001). Meanwhile,
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there was a trend toward significance for superior effect of risperidone plus PEA over
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risperidone plus placebo on inappropriate speech at trial endpoint (d = 0.51, p = 0.051). No significant differences existed between the two treatment groups for the other two ABC-C subscales (lethargy/social withdrawal and stereotypic behavior). The findings suggest that PEA may augment therapeutic effects of risperidone on autism-related irritability and hyperactivity. Future studies are warranted to investigate whether PEA can serve as a stand-alone treatment for autism.
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Keywords: Autism; Endocannabinoid system; Hyperactivity; Inflammation; Irritability;
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Palmitoylethanolamide; Randomized controlled trial
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1. Introduction Autism is a neurodevelopmental condition characterized by core deficits in socialization, communication, restricted interests and repetitive behaviors (Rivet and Matson, 2011). due
to
anatomical
and
functional
cortical
abnormalities
(especially
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underconnectivity (Just et al., 2006) and impaired synaptic function (Akhondzadeh, 1999; Darnell et al., 2011)), autistic patients are prone to a variety of affective, cognitive, and
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socialization consequences (Baron-Cohen, 1988). Further, the economic consequences of autistic disorders are not confined to the disease itself but are also related to concomitant
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behavioral (conduct problems, anxiety, stress, and hyperactivity) (Lecavalier et al., 2006), psychiatric (mood and sleep disorders) (Kim et al., 2000; Reiersen and Todd, 2008) and physical problems (infections, gastrointestinal problems, and autoimmunity) (Adams et al., 2011; Singh et al., 2002; Vojdani et al., 2003). Altogether, as the prevalence of this disease
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has grown over the past two decades (Hansen et al., 2015), albeit largely due to the changes in reporting practices, so has the stigma attached to autistic disorders (Gray, 2002).
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Although the exact etiology of autism has remained elusive, inflammation (Rossignol and
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Frye, 2012) and glutamate excitotoxicity (Kern and Jones, 2006) are among the most mooted mechanisms of disease propagation. Altered concentrations of inflammatory markers (Masi et al., 2015) have been frequently reported in patients with autism. Additionally, these patients have high or low glutamate levels in serum, plasma, and brain tissue (Purcell et al., 2001; Shimmura et al., 2011; Shinohe et al., 2006). Consistently, clinical trials provide evidence of clinical improvement by glutamatergic modulators (NAcetylcysteine, piracetam, and memantine) (Akhondzadeh et al., 2008; Ghaleiha et al., 4
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2013; Hardan et al., 2012) and anti-inflammatory compounds (celecoxib, flavonoid luteolin, and simvastatin) (Asadabadi et al., 2013; Moazen-Zadeh et al., 2017; Taliou et al., 2013). Hence, it is not surprising to suppose, or even assume that the immune-glutamatergic
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system is the main culprit in autism spectrum disorders (Blaylock and Strunecka, 2009). Palmitoylethanolamide (PEA) is a saturated N–acylethanolamide belonging to the family of endocannabinoids. Broadly speaking, endocannabinoids are endogenous ligands binding to
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cannabinoid receptors and thereby engaging in respective neuromodulatory activities (Di Marzo et al., 1998). PEA, in particular, has been reported to possess anti-inflammatory
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(Solorzano et al., 2009; Verme et al., 2005), antidepressant (Yu et al., 2011), anti-epileptic (Lambert et al., 2001), and anti-hyperanalgesic (Jaggar et al., 1998) properties. More precisely, ischemic injury models attribute a potential role to PEA in protecting neural cells against glutamate toxicity. The ability of PEA to prevent glutamatergic toxicity and inhibit
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inflammatory responses simultaneously has been applied to multifarious medical conditions including pain (Hesselink and Hekker, 2012; Indraccolo and Barbieri, 2010), spinal cord injury (Genovese et al., 2008), and acute inflammation (Costa et al., 2002).
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Notably, neither serious adverse effects nor drug interactions are observed with this
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natural compound. Overall, it fulfils the criteria for a favorable candidate as an adjunctive therapeutic agent for autism. Early evidence has been presented by autistic rats that exhibited significant change in hippocampal PEA levels in response to social challenge (Kerr et al., 2013). Recently, murine studies (Bertolino et al., 2017) revealed effectiveness and safety of PEA in treatment of autism modelled by sodium valproate administration. Consistently, case-reports have corroborated that PEA, alone (Antonucci et al., 2015) or in combination with other natural 5
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supplements (such as Luteolin (Bertolino et al., 2017)), can refine overall autism severity (Antonucci et al., 2015) and, in particular, it can ameliorate language (Antonucci et al., 2015) and behavioral (Bertolino et al., 2017) problems.
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On the basis of evidence presented above, the present study aimed to evaluate the efficacy and safety of PEA as adjunctive therapy to risperidone in children with autism over a 10-
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week period.
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2. Materials and Methods 2.1.
Trial design and setting
The protocol of the present trial was delineated consistent with ethical principles
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developed by the Declaration of Helsinki (World Medical, 2008). After approval of the protocol by the institutional review board / ethics committee (IRB/IEC) of Tehran University of Medical Sciences (Code No. IR.TUMS.REC.1395.1555), the trial commenced on
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February, 2017. It was planned as a 10-week randomized, parallel group, double-blind placebo-controlled trial. The trial was carried out among patients attending two Children's
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Outpatient Clinics at tertiary hospitals (Roozbeh and Aliasghar Hospitals) in Iran. Prior to enrollment in the study, written informed consent was obtained from the parents or legal guardians of children. The trial completely closed in October, 2017. This trial is registered
IRCT201702171556N96. 2.2.
Participants
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with the Iranian Registry of Clinical Trials (IRCT; http://www.irct.ir) number
Subjects were children 4–12 years old meeting the DSM-V (Diagnostic and Statistical
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Manual of Mental Disorders, fifth edition) criteria (Association, 2013) for diagnosis of an
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autism spectrum disorder (ASD). In addition, children selected must have had irritability symptoms of at least moderate severity, defined as scores greater than or equal to 12 on the Aberrant Behavior Checklist-Community (ABC-C) Irritability subscale (Aman et al., 1995). Diagnosis was initially confirmed by two expert child psychiatrists
based on
behavioral observations of the child and semi-structured interviews with the parents (Autism Diagnostic Interview-Revised) (Lord et al., 1994). Before commencing the trial,
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parents or legal guardians of children were informed about the study, scheduled visits, and their right to withdraw from the study at any time. Children in whom the symptoms at enrollment were not pronounced enough to be
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considered for treatment with risperidone were ineligible for the trial. Also children were excluded if they had (a) concomitant prominent psychiatric disorders, (b) preexisting medical or disease conditions (particularly epileptic disorders and febrile seizures), (c)
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severe intellectual disability, (d) history of alcohol/drug abuse, (e) tardive dyskinesia, or (f) history of antipsychotic medication or behavior therapy within the past 6 months before
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enrollment to this trial. In order to adhere to the ethical guidelines and avoid asking patients to stop taking any medication prior to entry, only children who were drug-free for at least six weeks before beginning of the study due to other reasons (discontinuation of drugs by their parents) were included in the present trial. In addition, to complete clinical
2.3.
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examination, liver and kidney parameters were assessed for each eligible child. Randomization, allocation, concealment, and blinding
Randomization was performed by a radomization operator who was not otherwise
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involved in this trial. Randomization codes were kept secure until data curation was
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completed. Among the 62 children enrolled in the study, 31 were randomly assigned to a combination of risperidone and PEA (first arm or arm A) and 31 subjects were randomized to the risperidone plus placebo group (second arm or arm B). Participants and their parents were blinded to group allocations. 2.4.
Interventions
Participants in both groups similarly received risperidone (Risperdal; Janssen Pharmaceuticals, Beerse, Belgium). It was started with an initial dose of 0.5 mg and 8
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stepwise 0.5-mg weekly increases for the first 3 weeks were implemented. Maximum dose of risperidone was 1 mg/d for children weighing less than 20 kg and 2 mg/d for those with a body weight equal to or greater than 20 kg. Additionally, individuals allocated into arm A
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(first arm) were administered 600 mg PEA twice daily. The placebo pills were similar in appearance (shape, size, and color) and taste to PEA. During the trial period, participants were instructed to avoid any other kind of intervention (medications and cognitive
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behavioral intervetions). Drug adherence was evaluated on the basis of parental reports
2.5.
Study assessment
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and by pill counts at each visit.
Study outcomes were measured using the Aberrant Behavior Checklist-Community Edition (ABC-C) (Aman et al., 1995). The ABC scale was originally developed in 1985 (MianEl and Singh, 1985) to assess the efficacy of different therapeutic protocols on behavioral
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outcomes in mentally retarded subjects. It is a 58-item scale that includes five subscales: irritability (15 items), lethargy (16 items), stereotypy (7 items), hyperactivity (16 items), and inappropriate speech (4 items). The primary outcome of interest to the present trial
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was change in score on the ABC-irritability subscale. The secondary outcomes were change
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in scores on the other ABC subscales. Study visits were scheduled at baseline (Day 1), midpoint (Week 5), and completion (Week 10). 2.6.
Safety
At each baseline and follow-up visit, adverse effects were monitored by the responsible child psychiatrist using a checklist after the first open-ended question about any adverse event (Noorbala et al., 1999; Akhondzadeh et al., 2000) and complete clinical (weight and height) and paraclinical (electrocardiogram and serum leptin and prolactin) parameters were 9
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documented. In the meantime, occurrence of side effects was recorded by a phone call to the parents one week after beginning treatment regimens. In addition, participants were provided with a phone number to the 24-hour medical help line for medical advice about
2.7.
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side effects. Sample size
The initial sample size of 46 was calculated considering a number of assuptions: (a) mean
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difference of 4 between the two groups on the ABC-C irritability subscale with a standard deviation (SD) of 4, (b) power of 90%, and (c) two-sided significance level of 5 %. Given an
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attrition rate of 30%, the final sample size was increased to 60. Number of participants required in each arm was 30 considering the 1:1 ratio of sample size (first arm: second arm). 2.8.
Statistical analysis
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Continuous data (age, weight, overall scale score, and score on subscales) were presented as mean ± SD and compared between groups using an independent t-test with Levene’s test for equality of variance. The categorical data (gender and response rate) were translated
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into numeric values (as percentage values) and compared between groups using Freeman-
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Halton extension of Fisher’s exact test. The overall response rate was the sum of participants with partial and complete responses which were defined as ≥ 25 % and ≥ 50 % reductions in the ABC-irritability subscale score, respectively. To test for any difference between two treatment arms, the mean difference in change score (between baseline and each point of follow-up evaluation) and respective confidence intervals (95% CI) were calculated. The Cohen’s d (95% CI) measure was used to determine the effect size of mean difference. The repeated-measures ANOVA (with the Greenhouse-Geisser correction for 10
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nonsphericity) was executed to investigate the therapeutic efficacy over time and also possible interaction between time and treatment (time × treatment). When there was missing data, the intention-to-treat (ITT) approach was applied. All the statistical tests
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were carried out using the IBM SPSS Statistics 24.0.0 (IBM Corporations) in a two-tailed
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approach with significance level of 0.05.
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3. Results 3.1.
Participant baseline characteristics
A total of 112 potential children 4-12 years of age with a diagnosis of autism were initially
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screened for study eligibility of whom 25 did not meet the inclusion criteria, eight met the exclusion criteria, and nine refused to participate. Seventy subjects (62.5%) were eventually enrolled in the study and were randomized into two treatment groups with an
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equal allocation ratio of 1:1: A) risperidone plus PEA and B) risperidone plus placebo. The mean age was 6.8 (SD =2.1) years in arm A and was 7.4 (SD= 2.4) years in arm B. As noted
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in Table 1, participants in the two study arms did not differ in demographic and baseline clinical characteristics (age, sex, weight, ESRS score, ABC-irritability, lethargy, stereotypy, hyperactivity, and inappropriate speech subscales). The mean dose of risperidone in arm A and B at end of treatment was 1.45 (SD=0.21) and 1.48 (SD=0.59), respectively. Overall, 8
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patients (four from each treatment arm) withdrew from the treatment trial early before the first follow-up visit (week 5). Figure 1 shows the number of patients who were screened, enrolled, and completed the trial. Clinical outcomes
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3.2.
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Table 2 summarizes the mean scores on each of the follow-up visits for ABC subscales by treatment group and presents the results of analyses of within-subjects and of betweensubjects.
Repeated-measure ANOVA across three points of time revealed significant improvement for all the ABC subscales (irritability: F = 155.17, df = 1.96, p < 0.001, lethargy: F = 27.26, df = 1.56, p < 0.001, stereotypic behavior: F = 32.62, df = 1.33, p < 0.001, hyperactivity: F = 48.82, df = 1.53, p < 0.001, and inappropriate speech: F = 6.98, df = 1.5, p = 0.004) within 12
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the two groups combined. Also, the analyses of time-treatment interactions showed a significantly higher effectiveness for combination of risperidone plus PEA versus combination of risperidone plus placebo over time regarding irritability (p = 0.002) and
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hyperactivity (p < 0.001) subscales. There was no significant variation between subjects in symptoms improvement.
As shown in Table 3, mean change in the irritability score at endpoint in individuals
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allocated to Arm A (risperidone plus PEA) was significantly different (mean difference (MD), 95% CI = −3.48, −5.38 to −1.59, p < 0.001) from that in subjects assigned to Arm B
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(risperidone plus placebo) with the large effect size of 0.94. However, there was no difference (p = 0.203) between the two treatment groups in mean change of irritability at week 5. Regarding hyperactivity/noncompliance symptoms, the effect of combination treatment of risperidone and PEA over risperidone plus placebo was significantly
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pronounced at both midpoint (MD, 95% CI = −1.58, −3.09 to −0.73) and endpoint (MD, 95% CI = −4.65, −7.17 to −2.12). However, there was greater therapeutic effect at week 10 (d = 0.94) as compared to week 5 (d = 0.53). Meanwhile, there was a trend toward
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significance (p = 0.051) for the superior effect (d = 0.51) of risperidone plus PEA over
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risperidone plus placebo on inappropriate speech at the trial endpoint (MD, 95% CI = −0.74, −1.49 to 0.00).
Comparison of response rate between the two treatment groups demonstrated significant difference for ABC-irritability (p = 0.026), hyperactivity/noncompliance (p < 0.0018), and inappropriate speech (p = 0.05) subscales at week 10 (Table 4).
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3.3.
Adverse events
No serious side effects were observed in either treatment groups. Overall, the most common side effects reported were headache (6%) and increased appetite (6%). There
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was no significant difference in the frequency of adverse effects between groups (Table 5). Additionally, the mean change in ESRS symptoms in the combination treatment group was not significantly different from that in the risperidone plus placebo group at both midpoint
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= 0.00, −0.21 to 0.21, p = 1.000, t (df) = 0.00 (60)).
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(MD, 95% CI = 0.07, −0.09 to 0.22, p = 0.399, t (df) = 0.85 (60)) and endpoint (MD, 95% CI
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4. Discussion The healthcare system offers a multidisciplinary therapeutic approach for management of patients with autism (Huffman et al., 2011). Accordingly, educational and behavioral
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interventions are referred to as the standard care for children with autism. While pharmacological and complementary-alternative medicine (CAM) treatments are recommended as adjunctive therapy to the standard care. Different classes of psychotropic
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drugs can be considered for children and adolescents with autism depending on their behavioral problems (Leskovec et al., 2008). Among which two atypical antipsychotics,
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risperidone and aripiprazole, have been approved by the Food and Drug Administration (FDA) for treating irritability symptoms related to autism.
Risperidone is the weakest atypical antipsychotic (Seeman, 2002) that simultaneously exerts antagonistic effects on dopamine (especially D2 receptors) and serotonin (especially
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5-HT2A) receptors (Leysen et al., 1994). It was first approved for schizophrenia in 1993. A decade later, studies emerged suggesting its promising effects in treating behavioral problems, especially aggression, hyperactivity, and irritability, in autism (McCracken et al.,
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2002). To prescribe this drug for children or adolescents with autism is, however, a matter
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of concern for two reasons. The first concern is regarding the dose-dependent generation of adverse effects including increased appetite and weight gain, anxiety, fatigue, drowsiness, dizziness, drooling, increased pulse rate and systolic blood pressure (McCracken et al., 2002; Ratzoni et al., 2002; Shea et al., 2004; Troost et al., 2005) and even withdrawal dyskinesia in long-term usage (Malone et al., 2002). The second concern is about the therapeutic effects. The short-term (4-8 weeks) response rate is estimated at about 70% (Malone et al., 2002; McCracken et al., 2002; Troost et al., 2005) and the long15
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term (6 months) response rate is at 90% (Malone et al., 2002; Nagaraj et al., 2006). Of note, the discontinuation rate due to incomplete short-term therapeutic response is about 10% (Research Units on Pediatric Psychopharmacology Autism, 2005). So, adjunctive therapy
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with agents that act through other mechanisms might present opportunities for breakthroughs in autism treatment.
The present randomized controlled trial found that adding PEA to risperidone is associated
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with greater improvement of symptoms on the ABC-irritability and hyperactivity subscales as compared to the risperidone plus placebo regimen. There was no significant difference
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between the two treatment groups for the other three ABC subscales (lethargy, stereotypic behavior, and inappropriate speech). However, all the subscales were significantly improved over the course of the trial when the two groups were combined.
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The selective action of PEA on attention deficit hyperactivity disorder (ADHD)-like behaviors in autism is similarly observed in other clinical trials with N-Acetylcysteine (Nikoo et al., 2015), Memantine (Ghaleiha et al., 2013), Galantamine (Ghaleiha et al., 2014),
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and omega-3 fatty acid (Bent et al., 2014). The role of all these medications in targeting neuroinflammation and modulating neurotransmitters (dopamine, serotonin, and
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glutamate) and their receptors is well-appreciated. As well, autism has been associated with inflammation (Rossignol and Frye, 2012) and glutamate dysfunction (Purcell et al., 2001). It is, thus, possible to attribute the behavior-modifying effects of PEA to its antiinflammatory and glutamate-modulating effects. The exact mechanism behind the behavior-modifying effects is yet open to question.
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N-palmitoylethanolamide or palmitoylethanolamide (PEA) is an endogenous saturated fatty amide that can act as ligand for cannabinoid receptors. Thus, PEA is regarded as an endocannabinoid. The nervous system relies on glia cells, especially microglia cells, to
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produce PEA and subsequently degrade it (Muccioli and Stella, 2008). Induction of PEA production by microglia cells seems to serve as a compensatory mechanism in different conditions particularly CNS injury and neurodegenerative diseases (Esposito and
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Cuzzocrea, 2013). PEA has been shown to modulate different neural activities, mainly nociception, neuroinflammation, and neurotoxicity, through its interaction with different
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nuclear and membrane receptors (such as the peroxisome proliferator-activated receptors (PPARs)) (Paterniti et al., 2013; Verme et al., 2005) and cannabinoid1 (CB1) receptors (Okine et al., 2016)). Animal studies have also indicated potential role of PEA to prevent neural damage during seizure (Lambert et al., 2001) and stroke (Kallendrusch et al., 2012)
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and to improve depressant-like behaviors particularly immobility (Yu et al., 2011). Clinical research has hitherto corroborated the efficacy and safety of systemic PEA in
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treatment of glaucoma and ocular hypertension (Costagliola et al., 2014; Gagliano et al., 2011; Pescosolido et al., 2011; Strobbe et al., 2013), and in treatment of neuropathic
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(Keppel Hesselink and Kopsky, 2015; Truini et al., 2011), inflammatory (Marini et al., 2012), and pathological pain (Cremon et al., 2017; Gatti et al., 2012; Giammusso et al., 2017; Lo Monte et al., 2013), and atopic dermatitis (Noli et al., 2015). PEA, in cream form, proved to be effective in treatment of chronic pruritus (Stander et al., 2006), atopic eczema (Eberlein et al., 2008), and asteatotic eczema (Yuan et al., 2014) and also in the prevention of UV-induced photodamage (Kemeny et al., 2007). Human studies have linked higher concentrations of PEA in saliva to obesity (Matias et al., 2012) and in muscle samples to 17
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myalgia (Ghafouri et al., 2011). As well, blood levels of PEA, which are elevated during pain, might represent increasing levels of stress (Degenhardt et al., 2007). Whether PEA
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concentration profile can be measured as a biomarker for autism remains to be addressed. Our findings are consistent with two case-report studies existing in this regard. The first report of PEA administration to children with autism was published by Antonucci and his
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collaborators (Antonucci et al., 2015) in 2015. The authors treated two Italian boys diagnosed with autistic disorder with PEA alone. The first case (13 years of age) had
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experienced several allergic and atopic episodes and laboratory examination of his blood was remarkable for high IgE, low CD57+ natural killer cell counts, high percentage of lymphocytes, low percentage of neutrophils, and high absolute lymphocyte levels. The cognitive effects of PEA treatment for a month (300 mg daily for the first week and 600 mg
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daily for the next three weeks) were noticeable to everyone dealing with the patient from his parents to his teachers. The patient exhibited significant language gain as measured by mean length of utterance (MLU) and the disease severity dropped by 26 percent as
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reflected in the Childhood Autism Rating Scale (CARS). The second patient (15 years of age) was diagnosed with autism at 3 years of age and had experienced two epileptic episodes
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(the first one occurred at 6 years of age). PEA treatment for three months resulted in significant improvement regarding language, cognition, and behavioral domains. The patient demonstrated a greater than 50 percent reduction in the Autism Treatment Evaluation Checklist (ATEC) score. Another study (Bertolino et al., 2017) has recently reported the efficacy and safety of co-ultramicronized PEA plus Luteolin in an autistic child (10 years old) who had suffered from several febrile episodes and abruptly developed autism-related behavioral symptoms one month after experiencing the first fever. He 18
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underwent psychotherapy, psychomotor, and speech therapy programs which were unsuccessful. One-year treatment with PEA in combination with Luteolin contributed to improvement in behavioral, motor, and social performance. However, contrary to the
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previous report, Bertolino and his colleagues observed no significant improvement in the patient’s speech.
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The rat model of autism indicated an increase in hippocampal PEA in response to social challenge (Kerr et al., 2013). Additionally, administration of PEA (alone or in combination
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with Luteolin) significantly contributed to improvement of behavioral impairments, neurogenesis, and synaptic plasticity in mice models of autism (Bertolino et al., 2017), depression (Yu et al., 2011), and Alzheimer’s disease (D'Agostino et al., 2012). Neuroimaging (Suzuki et al., 2013) and postmortem (Morgan et al., 2010) studies
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demonstrated increase in activity and number of microglia cells in brain of patients with autism. Since microglia cells are a source of natural PEA, it is, therefore, not ambitious to think of increased PEA as a compensatory mechanism in autism.
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Studies have highlighted the role of PEA to promote waking probably via increasing the extracellular levels of dopamine (Murillo-Rodríguez et al., 2011). Further, one-year
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treatment with PEA substantially reduced frequency of enuresis (from 91% to 2.4%) (Bertolino et al., 2017) in one autistic child. Since treatment with risperidone has been associated with drowsiness and with enuresis (Hergüner and Mukaddes, 2007), it was possible to hypothesize that co-administration of PEA with risperidone might help to reduce adverse effects associated with risperidone use. The present trial, however, showed no difference between groups in terms of the frequency of adverse events.
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Despite its originality, the study has also some limitations. First that patients received PEA at a fixed dosage of 600 mg twice daily. While flexible-dose regimens are generally preferred to fixed-dose regimens. Second that PEA was administered as adjunctive therapy
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and so whether PEA as standalone treatment is sufficient for patients with autism remains recondite. Third that the present trial had a relatively short follow-up period of 10 weeks. In addition to addressing the above-mentioned limitations, our vision for the future is to
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investigate whether (a) PEA concentration profile can be measured as a biomarker for autism, (b) PEA is able to accelerate the therapeutic effects of risperidone, and (c) PEA can
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be used to reduce the adverse effects of risperidone treatment in children and adolescents with autism. 5. Conclusion
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To the best of our knowledge, the present randomized controlled trial is the first clinical study conducted to investigate the efficacy and safety of PEA as adjunctive therapy to risperidone in children with autism over a 10-week period. The findings suggest that PEA
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might augment the efficacy of risperidone in the treatment of autism-related irritability and hyperactivity. However both treatment groups (risperidone plus PEA vs. risperidone alone)
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showed a similar degree of improvement in the other three ABC subscales (lethargy, stereotypic behavior, and inappropriate speech).
Acknowledgment This study was funded by Tehran University of Medical Sciences and Health Services (grant number 33135). Conflict of interest Authors declare no conflict of interest.
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Legend
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Fgiure 1: Flow diagram of patients
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Table 1, Baseline characteristics of study participants: Risperidone plus Palmitoylethanolamide (PEA) vs risperidone plus placebo
7.42 (2.35) 25 (80.65) 26.00 (8.24) 0.13 (0.34)
21.97 (5.06) 20.71 (6.18) 12.00 (4.1) 27.97 (5.70) 5.81 (2.93)
20.97 (6.8) 19.84 (8.20) 11.16 (5.50) 25.87 (8.98) 5.19 (3.46)
Test of differences p = 0.31, t = −1.026, df = 60 p = 0.55 p = 0.30, t = −1.045, df = 60 p = 0.69, t = −0.395, df = 60 p = 0.51, t = 0.657, df = 60 p = 0.64, t = 0.472, df = 60 p = 0.5, t = 0.682, df = 60 p = 0.28, t = 1.098, df = 60 p = 0.45, t = 0.753, df = 60
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6.84 (2.1) 22 (70.97) 23.71 (9.00) 0.1 (0.30)
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Age in years: Mean (SD) Male no. (%) Weight in kg: Mean (SD) ESRS score: Mean (SD) ABC-C subscales scores: Mean (SD) Irritability Lethargy/social withdrawal Stereotypic behavior Hyperactivity/noncompliance Inappropriate speech
Risperidone plus placebo (n = 31)
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Risperidone plus PEA (n = 31)
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Table 2, Treatment responses of participants: results of within-subjects and between-subjects analyses Time × treatment interaction
Time
Mean
SD
Mean
SD
F
df
5.1 6.8
17.1 17.5
6.9 7.2
11.9 14.4
3.9 5.9
150.002
1.96
6.2 8.2
18.2 18.3
5.4 8.7
17.5 16.7
5.7 7.4
27.255
1.56
4.1 5.5
10.0 10.1
4.6 5.5
9.1 9.6
4.6 5.3
5.7 9
24.2 23.7
6.5 9.1
20.6 23.1
7.5 8.9
2.9 3.5
5.4 5.1
2.8 3.4
4.9 5
2.6 3.4
Between subjects
P
F
df
P
F
df
P
< 0.001
6.698
1.96
0.002
0.176
1
0.677
0.622
1.56
0.500
0.094
1
0.076
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SD
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Week 10
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< 0.001
1.33
< 0.001
2.686
1.33
0.094
0.006
1
0.937
48.823
1.53
< 0.001
10.367
1.53
< 0.001
0.000
1
0.991
1.5
< 0.001
3.008
1.5
0.069
0.094
1
0.760
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32.617
6.977
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Mean Irritability 22 Risperidone plus PEA Risperidone plus placebo 21 Lethargy/social withdrawal Risperidone plus PEA 20.7 Risperidone plus placebo 19.8 Stereotypic behavior Risperidone plus PEA 12 Risperidone plus placebo 11.2 Hyperactivity/noncompliance Risperidone plus PEA 28 Risperidone plus placebo 25.9 Inappropriate speech Risperidone plus PEA 5.8 Risperidone plus placebo 5.2
Week 5
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Outcome
Baseline
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Table 3, Treatment effects on outcome measures over the course of trial Mean difference (95% CI)
t (df)
−1.32 (−3.38 to 0.74) −3.48 (−5.38 to −1.59)
−1.58 (2.45) −3.13 (3.59)
−0.90 (−2.53 to 0.73) −0.13 (−2.28 to 2.03)
−1.06 (1.69) −1.61 (2.43)
−1.29 (45.47) −3.69 (60)
P
Cohen’s d (95% CI)
0.203 < 0.001
0.33 (−0.18 to 0.83) 0.94 (0.41 to 1.46)
−1.11 (60) −0.12 (60)
0.272 0.905
0.28 (−0.22 to 0.78) 0.03 (−0.47 to 0.53)
−0.97 (−2.02 to 0.08) −1.26 (−2.73 to 0.21)
−1.84 (60) −1.71 (55.21)
0.07 0.093
0.47 (−0.04 to 0.97) 0.43 (−0.07 to 0.94)
−2.23 (3.1) −2.77 (4.36)
−1.58 (−3.09 to −0.73) −4.65 (−7.17 to −2.12)
−2.1 (60) −3.68 (60)
0.04 0.001
0.53 (0.02 to 1.04) 0.94 (0.41 to 1.46)
−0.06 (0.44) −0.19 (1.56)
-0.39 (-0.83 to 0.05) -0.74 (-1.49 to 0.00)
−1.79 (39.13) −1.99 (60)
0.081 0.051
0.45 (−0.06 to 0.96) 0.51 (−0.00 to 1.01)
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−3.52 (2.66) −6.58 (3.02)
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Irritability Week 5 −4.84 (5.04) Week 10 −10.06 (4.31) Lethargy/social withdrawal Week 5 −2.48 (3.82) Week 10 −3.26 (4.80) Stereotypic behavior Week 5 −2.03 (2.39) Week 10 −2.87 (3.29) Hyperactivity/noncompliance Week 5 −3.81 (2.83) Week 10 −7.42 (5.52) Inappropriate speech Week 5 −0.45 (1.12) Week 10 −0.94 (1.37)
Risperidone plus placebo (n = 31)
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Risperidone plus PEA (n = 31)
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Outcome
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Mean (SD) change in score
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Table 4, Comparison of response rate between treatment arms No of patients (%)
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Lethargy/social withdrawal Week 5 Lethargy/social withdrawal Week 10 Stereotypic behavior Week 5 Stereotypic behavior Week 10 Hyperactivity/ noncompliance Week 5 Hyperactivity/ noncompliance Week 10 Inappropriate speech Week 5 Inappropriate speech Week 10
Risperidone plus placebo (n = 31) 22 (71) 8 (25.8) 1 (3.2) 9 (29) 17 (54.8) 5 (16.1) 26 (83.9) 5 (16.1) 0 (0) 21 (67.7) 10 (32.3) 0 (0) 24 (77.4) 6 (19.4) 1 (3.2) 19 (61.3) 10 (32.3) 2 (6.4) 26 (83.9) 4 (12.9) 1 (3.2) 24 (77.4) 6 (19.4) 1 (3.2) 31 (100) 0 (0) 0 (0) 29 (93.6) 1 (3.2) 1 (3.2)
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Irritability Week 10
Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete
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Irritability Week 5
Risperidone plus PEA (n = 31) 19 (61.3) 8 (25.8) 4 (12.9) 1 (3.2) 22 (71) 8 (25.8) 25 (80.7) 5 (16.1) 1 (3.2) 23 (74.2) 5 (16.1) 3 (9.7) 20 (64.5) 6 (19.4) 5 (16.1) 17 (54.8) 7 (22.6) 7 (22.6) 25 (80.7) 6 (19.4) 0 (0) 10 (32.3) 15 (48.4) 6 (19.4) 30 (96.8) 0 (0) 1 (3.2) 23 (74.2) 6 (19.4) 2 (6.4)
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Fisher p
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Degree of response
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Outcome Time
0.411
0.026
0.866
0.099
0.257
0.193
0.62
0.0008
0.5
0.05
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Table 5, Frequency of adverse effects No. of patients (%)
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Dizziness Sedation Abdominal pain Increased appetite Headache Diarrhea Rash Constipation
Risperidone plus placebo (n = 31) 0 (0) 2 (6.45) 1 (3.23) 2 (6.45) 3 (9.68) 2 (6.45) 1 (3.23) 0 (0)
5
Fisher P-value 1.000 1.000 1.000 1.000 0.612 1.000 1.000 0.492
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Risperidone plus PEA (n = 31) 0 (0) 1 (3.23) 2 (6.45) 2 (6.45) 1 (3.23) 1 (3.23) 0 (0) 2 (6.45)
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Adverse event
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S0022-3956(17)31405-X
DOI:
10.1016/j.jpsychires.2018.04.022
Reference:
PIAT 3364
To appear in:
Journal of Psychiatric Research
Received Date: 22 December 2017 Revised Date:
28 April 2018
Accepted Date: 30 April 2018
Please cite this article as: Khalaj M, Saghazadeh A, Shirazi E, Shalbafan M-R, Alavi K, Shooshtari MH, Laksari FY, Hosseini M, Mohammadi M-R, Akhondzadeh S, Palmitoylethanolamide as adjunctive therapy for autism: Efficacy and safety results from a randomized controlled trial, Journal of Psychiatric Research (2018), doi: 10.1016/j.jpsychires.2018.04.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Palmitoylethanolamide as Adjunctive Therapy for Autism:
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Efficacy and Safety Results from a Randomized Controlled Trial
Mona Khalaja MD., Amene Saghazadehb MD., Elham Shirazia MD., Mohammad-Reza Shalbafan a MD., Kaveh Alavia MD., Mitera Hakim Shooshtaria MD., Fatemeh Yousefi Laksaria b
MD., Shahin
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MA., Maryamalsadat Hosseinia MD., Mohammad-Reza Mohammadi
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Akhondzadeh b Ph.D.
The first three authors contributed equally to this study.
a
Mental Health Research Center, School of Behavioral Sciences and Mental Health,
b
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Tehran Institute of Psychiatry, Iran University of Medical Sciences, Tehran, Iran. Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences,
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Tehran, Iran.
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Correspondence to: Prof. Shahin Akhondzadeh Ph.D., Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, South Kargar Street, Tehran 13337, Iran. Tel: 98-21-55412222, Fax: +98-21-55419113, Email: [email protected]
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Abstract Inflammation as well as glutamate excitotoxicity have been proposed to participate in the propagation of autism. Palmitoylethanolamide (PEA) is an endocannabinoid proven to
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prevent glutamatergic toxicity and inhibit inflammatory responses simultaneously. The present randomized, parallel group, double-blind placebo-controlled trial is the first study depicted to probe the efficacy of co-treatment with risperidone and PEA over 10 weeks in
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children with autism. Seventy children (aged 4 to 12 years) with autism and moderate to severe symptoms of irritability were randomly assigned to two treatment regimens. The
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study outcomes were measured using the Aberrant Behavior Checklist-Community Edition (ABC-C). At trial endpoint (week 10), combination of PEA and risperidone had superior efficacy in ameliorating the ABC-irritability and hyperactivity/noncompliance symptoms (Cohen’s d, 95% confidence interval (CI) = 0.94, 0.41 to 1.46, p = 0.001) compared with a
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risperidone plus placebo regimen. Interestingly, effect of combination treatment on hyperactivity symptoms was also observed at trial midpoint (week 5) but with a smaller effect size (d = 0.53, p = 0.04) than that at the endpoint (d = 0.94, p = 0.001). Meanwhile,
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there was a trend toward significance for superior effect of risperidone plus PEA over
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risperidone plus placebo on inappropriate speech at trial endpoint (d = 0.51, p = 0.051). No significant differences existed between the two treatment groups for the other two ABC-C subscales (lethargy/social withdrawal and stereotypic behavior). The findings suggest that PEA may augment therapeutic effects of risperidone on autism-related irritability and hyperactivity. Future studies are warranted to investigate whether PEA can serve as a stand-alone treatment for autism.
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Keywords: Autism; Endocannabinoid system; Hyperactivity; Inflammation; Irritability;
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Palmitoylethanolamide; Randomized controlled trial
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1. Introduction Autism is a neurodevelopmental condition characterized by core deficits in socialization, communication, restricted interests and repetitive behaviors (Rivet and Matson, 2011). due
to
anatomical
and
functional
cortical
abnormalities
(especially
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However,
underconnectivity (Just et al., 2006) and impaired synaptic function (Akhondzadeh, 1999; Darnell et al., 2011)), autistic patients are prone to a variety of affective, cognitive, and
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socialization consequences (Baron-Cohen, 1988). Further, the economic consequences of autistic disorders are not confined to the disease itself but are also related to concomitant
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behavioral (conduct problems, anxiety, stress, and hyperactivity) (Lecavalier et al., 2006), psychiatric (mood and sleep disorders) (Kim et al., 2000; Reiersen and Todd, 2008) and physical problems (infections, gastrointestinal problems, and autoimmunity) (Adams et al., 2011; Singh et al., 2002; Vojdani et al., 2003). Altogether, as the prevalence of this disease
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has grown over the past two decades (Hansen et al., 2015), albeit largely due to the changes in reporting practices, so has the stigma attached to autistic disorders (Gray, 2002).
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Although the exact etiology of autism has remained elusive, inflammation (Rossignol and
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Frye, 2012) and glutamate excitotoxicity (Kern and Jones, 2006) are among the most mooted mechanisms of disease propagation. Altered concentrations of inflammatory markers (Masi et al., 2015) have been frequently reported in patients with autism. Additionally, these patients have high or low glutamate levels in serum, plasma, and brain tissue (Purcell et al., 2001; Shimmura et al., 2011; Shinohe et al., 2006). Consistently, clinical trials provide evidence of clinical improvement by glutamatergic modulators (NAcetylcysteine, piracetam, and memantine) (Akhondzadeh et al., 2008; Ghaleiha et al., 4
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2013; Hardan et al., 2012) and anti-inflammatory compounds (celecoxib, flavonoid luteolin, and simvastatin) (Asadabadi et al., 2013; Moazen-Zadeh et al., 2017; Taliou et al., 2013). Hence, it is not surprising to suppose, or even assume that the immune-glutamatergic
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system is the main culprit in autism spectrum disorders (Blaylock and Strunecka, 2009). Palmitoylethanolamide (PEA) is a saturated N–acylethanolamide belonging to the family of endocannabinoids. Broadly speaking, endocannabinoids are endogenous ligands binding to
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cannabinoid receptors and thereby engaging in respective neuromodulatory activities (Di Marzo et al., 1998). PEA, in particular, has been reported to possess anti-inflammatory
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(Solorzano et al., 2009; Verme et al., 2005), antidepressant (Yu et al., 2011), anti-epileptic (Lambert et al., 2001), and anti-hyperanalgesic (Jaggar et al., 1998) properties. More precisely, ischemic injury models attribute a potential role to PEA in protecting neural cells against glutamate toxicity. The ability of PEA to prevent glutamatergic toxicity and inhibit
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inflammatory responses simultaneously has been applied to multifarious medical conditions including pain (Hesselink and Hekker, 2012; Indraccolo and Barbieri, 2010), spinal cord injury (Genovese et al., 2008), and acute inflammation (Costa et al., 2002).
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Notably, neither serious adverse effects nor drug interactions are observed with this
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natural compound. Overall, it fulfils the criteria for a favorable candidate as an adjunctive therapeutic agent for autism. Early evidence has been presented by autistic rats that exhibited significant change in hippocampal PEA levels in response to social challenge (Kerr et al., 2013). Recently, murine studies (Bertolino et al., 2017) revealed effectiveness and safety of PEA in treatment of autism modelled by sodium valproate administration. Consistently, case-reports have corroborated that PEA, alone (Antonucci et al., 2015) or in combination with other natural 5
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supplements (such as Luteolin (Bertolino et al., 2017)), can refine overall autism severity (Antonucci et al., 2015) and, in particular, it can ameliorate language (Antonucci et al., 2015) and behavioral (Bertolino et al., 2017) problems.
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On the basis of evidence presented above, the present study aimed to evaluate the efficacy and safety of PEA as adjunctive therapy to risperidone in children with autism over a 10-
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week period.
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2. Materials and Methods 2.1.
Trial design and setting
The protocol of the present trial was delineated consistent with ethical principles
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developed by the Declaration of Helsinki (World Medical, 2008). After approval of the protocol by the institutional review board / ethics committee (IRB/IEC) of Tehran University of Medical Sciences (Code No. IR.TUMS.REC.1395.1555), the trial commenced on
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February, 2017. It was planned as a 10-week randomized, parallel group, double-blind placebo-controlled trial. The trial was carried out among patients attending two Children's
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Outpatient Clinics at tertiary hospitals (Roozbeh and Aliasghar Hospitals) in Iran. Prior to enrollment in the study, written informed consent was obtained from the parents or legal guardians of children. The trial completely closed in October, 2017. This trial is registered
IRCT201702171556N96. 2.2.
Participants
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with the Iranian Registry of Clinical Trials (IRCT; http://www.irct.ir) number
Subjects were children 4–12 years old meeting the DSM-V (Diagnostic and Statistical
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Manual of Mental Disorders, fifth edition) criteria (Association, 2013) for diagnosis of an
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autism spectrum disorder (ASD). In addition, children selected must have had irritability symptoms of at least moderate severity, defined as scores greater than or equal to 12 on the Aberrant Behavior Checklist-Community (ABC-C) Irritability subscale (Aman et al., 1995). Diagnosis was initially confirmed by two expert child psychiatrists
based on
behavioral observations of the child and semi-structured interviews with the parents (Autism Diagnostic Interview-Revised) (Lord et al., 1994). Before commencing the trial,
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parents or legal guardians of children were informed about the study, scheduled visits, and their right to withdraw from the study at any time. Children in whom the symptoms at enrollment were not pronounced enough to be
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considered for treatment with risperidone were ineligible for the trial. Also children were excluded if they had (a) concomitant prominent psychiatric disorders, (b) preexisting medical or disease conditions (particularly epileptic disorders and febrile seizures), (c)
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severe intellectual disability, (d) history of alcohol/drug abuse, (e) tardive dyskinesia, or (f) history of antipsychotic medication or behavior therapy within the past 6 months before
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enrollment to this trial. In order to adhere to the ethical guidelines and avoid asking patients to stop taking any medication prior to entry, only children who were drug-free for at least six weeks before beginning of the study due to other reasons (discontinuation of drugs by their parents) were included in the present trial. In addition, to complete clinical
2.3.
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examination, liver and kidney parameters were assessed for each eligible child. Randomization, allocation, concealment, and blinding
Randomization was performed by a radomization operator who was not otherwise
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involved in this trial. Randomization codes were kept secure until data curation was
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completed. Among the 62 children enrolled in the study, 31 were randomly assigned to a combination of risperidone and PEA (first arm or arm A) and 31 subjects were randomized to the risperidone plus placebo group (second arm or arm B). Participants and their parents were blinded to group allocations. 2.4.
Interventions
Participants in both groups similarly received risperidone (Risperdal; Janssen Pharmaceuticals, Beerse, Belgium). It was started with an initial dose of 0.5 mg and 8
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stepwise 0.5-mg weekly increases for the first 3 weeks were implemented. Maximum dose of risperidone was 1 mg/d for children weighing less than 20 kg and 2 mg/d for those with a body weight equal to or greater than 20 kg. Additionally, individuals allocated into arm A
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(first arm) were administered 600 mg PEA twice daily. The placebo pills were similar in appearance (shape, size, and color) and taste to PEA. During the trial period, participants were instructed to avoid any other kind of intervention (medications and cognitive
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behavioral intervetions). Drug adherence was evaluated on the basis of parental reports
2.5.
Study assessment
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and by pill counts at each visit.
Study outcomes were measured using the Aberrant Behavior Checklist-Community Edition (ABC-C) (Aman et al., 1995). The ABC scale was originally developed in 1985 (MianEl and Singh, 1985) to assess the efficacy of different therapeutic protocols on behavioral
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outcomes in mentally retarded subjects. It is a 58-item scale that includes five subscales: irritability (15 items), lethargy (16 items), stereotypy (7 items), hyperactivity (16 items), and inappropriate speech (4 items). The primary outcome of interest to the present trial
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was change in score on the ABC-irritability subscale. The secondary outcomes were change
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in scores on the other ABC subscales. Study visits were scheduled at baseline (Day 1), midpoint (Week 5), and completion (Week 10). 2.6.
Safety
At each baseline and follow-up visit, adverse effects were monitored by the responsible child psychiatrist using a checklist after the first open-ended question about any adverse event (Noorbala et al., 1999; Akhondzadeh et al., 2000) and complete clinical (weight and height) and paraclinical (electrocardiogram and serum leptin and prolactin) parameters were 9
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documented. In the meantime, occurrence of side effects was recorded by a phone call to the parents one week after beginning treatment regimens. In addition, participants were provided with a phone number to the 24-hour medical help line for medical advice about
2.7.
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side effects. Sample size
The initial sample size of 46 was calculated considering a number of assuptions: (a) mean
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difference of 4 between the two groups on the ABC-C irritability subscale with a standard deviation (SD) of 4, (b) power of 90%, and (c) two-sided significance level of 5 %. Given an
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attrition rate of 30%, the final sample size was increased to 60. Number of participants required in each arm was 30 considering the 1:1 ratio of sample size (first arm: second arm). 2.8.
Statistical analysis
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Continuous data (age, weight, overall scale score, and score on subscales) were presented as mean ± SD and compared between groups using an independent t-test with Levene’s test for equality of variance. The categorical data (gender and response rate) were translated
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into numeric values (as percentage values) and compared between groups using Freeman-
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Halton extension of Fisher’s exact test. The overall response rate was the sum of participants with partial and complete responses which were defined as ≥ 25 % and ≥ 50 % reductions in the ABC-irritability subscale score, respectively. To test for any difference between two treatment arms, the mean difference in change score (between baseline and each point of follow-up evaluation) and respective confidence intervals (95% CI) were calculated. The Cohen’s d (95% CI) measure was used to determine the effect size of mean difference. The repeated-measures ANOVA (with the Greenhouse-Geisser correction for 10
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nonsphericity) was executed to investigate the therapeutic efficacy over time and also possible interaction between time and treatment (time × treatment). When there was missing data, the intention-to-treat (ITT) approach was applied. All the statistical tests
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were carried out using the IBM SPSS Statistics 24.0.0 (IBM Corporations) in a two-tailed
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approach with significance level of 0.05.
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3. Results 3.1.
Participant baseline characteristics
A total of 112 potential children 4-12 years of age with a diagnosis of autism were initially
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screened for study eligibility of whom 25 did not meet the inclusion criteria, eight met the exclusion criteria, and nine refused to participate. Seventy subjects (62.5%) were eventually enrolled in the study and were randomized into two treatment groups with an
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equal allocation ratio of 1:1: A) risperidone plus PEA and B) risperidone plus placebo. The mean age was 6.8 (SD =2.1) years in arm A and was 7.4 (SD= 2.4) years in arm B. As noted
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in Table 1, participants in the two study arms did not differ in demographic and baseline clinical characteristics (age, sex, weight, ESRS score, ABC-irritability, lethargy, stereotypy, hyperactivity, and inappropriate speech subscales). The mean dose of risperidone in arm A and B at end of treatment was 1.45 (SD=0.21) and 1.48 (SD=0.59), respectively. Overall, 8
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patients (four from each treatment arm) withdrew from the treatment trial early before the first follow-up visit (week 5). Figure 1 shows the number of patients who were screened, enrolled, and completed the trial. Clinical outcomes
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3.2.
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Table 2 summarizes the mean scores on each of the follow-up visits for ABC subscales by treatment group and presents the results of analyses of within-subjects and of betweensubjects.
Repeated-measure ANOVA across three points of time revealed significant improvement for all the ABC subscales (irritability: F = 155.17, df = 1.96, p < 0.001, lethargy: F = 27.26, df = 1.56, p < 0.001, stereotypic behavior: F = 32.62, df = 1.33, p < 0.001, hyperactivity: F = 48.82, df = 1.53, p < 0.001, and inappropriate speech: F = 6.98, df = 1.5, p = 0.004) within 12
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the two groups combined. Also, the analyses of time-treatment interactions showed a significantly higher effectiveness for combination of risperidone plus PEA versus combination of risperidone plus placebo over time regarding irritability (p = 0.002) and
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hyperactivity (p < 0.001) subscales. There was no significant variation between subjects in symptoms improvement.
As shown in Table 3, mean change in the irritability score at endpoint in individuals
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allocated to Arm A (risperidone plus PEA) was significantly different (mean difference (MD), 95% CI = −3.48, −5.38 to −1.59, p < 0.001) from that in subjects assigned to Arm B
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(risperidone plus placebo) with the large effect size of 0.94. However, there was no difference (p = 0.203) between the two treatment groups in mean change of irritability at week 5. Regarding hyperactivity/noncompliance symptoms, the effect of combination treatment of risperidone and PEA over risperidone plus placebo was significantly
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pronounced at both midpoint (MD, 95% CI = −1.58, −3.09 to −0.73) and endpoint (MD, 95% CI = −4.65, −7.17 to −2.12). However, there was greater therapeutic effect at week 10 (d = 0.94) as compared to week 5 (d = 0.53). Meanwhile, there was a trend toward
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significance (p = 0.051) for the superior effect (d = 0.51) of risperidone plus PEA over
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risperidone plus placebo on inappropriate speech at the trial endpoint (MD, 95% CI = −0.74, −1.49 to 0.00).
Comparison of response rate between the two treatment groups demonstrated significant difference for ABC-irritability (p = 0.026), hyperactivity/noncompliance (p < 0.0018), and inappropriate speech (p = 0.05) subscales at week 10 (Table 4).
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3.3.
Adverse events
No serious side effects were observed in either treatment groups. Overall, the most common side effects reported were headache (6%) and increased appetite (6%). There
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was no significant difference in the frequency of adverse effects between groups (Table 5). Additionally, the mean change in ESRS symptoms in the combination treatment group was not significantly different from that in the risperidone plus placebo group at both midpoint
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= 0.00, −0.21 to 0.21, p = 1.000, t (df) = 0.00 (60)).
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(MD, 95% CI = 0.07, −0.09 to 0.22, p = 0.399, t (df) = 0.85 (60)) and endpoint (MD, 95% CI
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4. Discussion The healthcare system offers a multidisciplinary therapeutic approach for management of patients with autism (Huffman et al., 2011). Accordingly, educational and behavioral
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interventions are referred to as the standard care for children with autism. While pharmacological and complementary-alternative medicine (CAM) treatments are recommended as adjunctive therapy to the standard care. Different classes of psychotropic
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drugs can be considered for children and adolescents with autism depending on their behavioral problems (Leskovec et al., 2008). Among which two atypical antipsychotics,
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risperidone and aripiprazole, have been approved by the Food and Drug Administration (FDA) for treating irritability symptoms related to autism.
Risperidone is the weakest atypical antipsychotic (Seeman, 2002) that simultaneously exerts antagonistic effects on dopamine (especially D2 receptors) and serotonin (especially
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5-HT2A) receptors (Leysen et al., 1994). It was first approved for schizophrenia in 1993. A decade later, studies emerged suggesting its promising effects in treating behavioral problems, especially aggression, hyperactivity, and irritability, in autism (McCracken et al.,
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2002). To prescribe this drug for children or adolescents with autism is, however, a matter
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of concern for two reasons. The first concern is regarding the dose-dependent generation of adverse effects including increased appetite and weight gain, anxiety, fatigue, drowsiness, dizziness, drooling, increased pulse rate and systolic blood pressure (McCracken et al., 2002; Ratzoni et al., 2002; Shea et al., 2004; Troost et al., 2005) and even withdrawal dyskinesia in long-term usage (Malone et al., 2002). The second concern is about the therapeutic effects. The short-term (4-8 weeks) response rate is estimated at about 70% (Malone et al., 2002; McCracken et al., 2002; Troost et al., 2005) and the long15
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term (6 months) response rate is at 90% (Malone et al., 2002; Nagaraj et al., 2006). Of note, the discontinuation rate due to incomplete short-term therapeutic response is about 10% (Research Units on Pediatric Psychopharmacology Autism, 2005). So, adjunctive therapy
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with agents that act through other mechanisms might present opportunities for breakthroughs in autism treatment.
The present randomized controlled trial found that adding PEA to risperidone is associated
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with greater improvement of symptoms on the ABC-irritability and hyperactivity subscales as compared to the risperidone plus placebo regimen. There was no significant difference
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between the two treatment groups for the other three ABC subscales (lethargy, stereotypic behavior, and inappropriate speech). However, all the subscales were significantly improved over the course of the trial when the two groups were combined.
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The selective action of PEA on attention deficit hyperactivity disorder (ADHD)-like behaviors in autism is similarly observed in other clinical trials with N-Acetylcysteine (Nikoo et al., 2015), Memantine (Ghaleiha et al., 2013), Galantamine (Ghaleiha et al., 2014),
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and omega-3 fatty acid (Bent et al., 2014). The role of all these medications in targeting neuroinflammation and modulating neurotransmitters (dopamine, serotonin, and
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glutamate) and their receptors is well-appreciated. As well, autism has been associated with inflammation (Rossignol and Frye, 2012) and glutamate dysfunction (Purcell et al., 2001). It is, thus, possible to attribute the behavior-modifying effects of PEA to its antiinflammatory and glutamate-modulating effects. The exact mechanism behind the behavior-modifying effects is yet open to question.
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N-palmitoylethanolamide or palmitoylethanolamide (PEA) is an endogenous saturated fatty amide that can act as ligand for cannabinoid receptors. Thus, PEA is regarded as an endocannabinoid. The nervous system relies on glia cells, especially microglia cells, to
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produce PEA and subsequently degrade it (Muccioli and Stella, 2008). Induction of PEA production by microglia cells seems to serve as a compensatory mechanism in different conditions particularly CNS injury and neurodegenerative diseases (Esposito and
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Cuzzocrea, 2013). PEA has been shown to modulate different neural activities, mainly nociception, neuroinflammation, and neurotoxicity, through its interaction with different
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nuclear and membrane receptors (such as the peroxisome proliferator-activated receptors (PPARs)) (Paterniti et al., 2013; Verme et al., 2005) and cannabinoid1 (CB1) receptors (Okine et al., 2016)). Animal studies have also indicated potential role of PEA to prevent neural damage during seizure (Lambert et al., 2001) and stroke (Kallendrusch et al., 2012)
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and to improve depressant-like behaviors particularly immobility (Yu et al., 2011). Clinical research has hitherto corroborated the efficacy and safety of systemic PEA in
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treatment of glaucoma and ocular hypertension (Costagliola et al., 2014; Gagliano et al., 2011; Pescosolido et al., 2011; Strobbe et al., 2013), and in treatment of neuropathic
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(Keppel Hesselink and Kopsky, 2015; Truini et al., 2011), inflammatory (Marini et al., 2012), and pathological pain (Cremon et al., 2017; Gatti et al., 2012; Giammusso et al., 2017; Lo Monte et al., 2013), and atopic dermatitis (Noli et al., 2015). PEA, in cream form, proved to be effective in treatment of chronic pruritus (Stander et al., 2006), atopic eczema (Eberlein et al., 2008), and asteatotic eczema (Yuan et al., 2014) and also in the prevention of UV-induced photodamage (Kemeny et al., 2007). Human studies have linked higher concentrations of PEA in saliva to obesity (Matias et al., 2012) and in muscle samples to 17
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myalgia (Ghafouri et al., 2011). As well, blood levels of PEA, which are elevated during pain, might represent increasing levels of stress (Degenhardt et al., 2007). Whether PEA
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concentration profile can be measured as a biomarker for autism remains to be addressed. Our findings are consistent with two case-report studies existing in this regard. The first report of PEA administration to children with autism was published by Antonucci and his
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collaborators (Antonucci et al., 2015) in 2015. The authors treated two Italian boys diagnosed with autistic disorder with PEA alone. The first case (13 years of age) had
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experienced several allergic and atopic episodes and laboratory examination of his blood was remarkable for high IgE, low CD57+ natural killer cell counts, high percentage of lymphocytes, low percentage of neutrophils, and high absolute lymphocyte levels. The cognitive effects of PEA treatment for a month (300 mg daily for the first week and 600 mg
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daily for the next three weeks) were noticeable to everyone dealing with the patient from his parents to his teachers. The patient exhibited significant language gain as measured by mean length of utterance (MLU) and the disease severity dropped by 26 percent as
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reflected in the Childhood Autism Rating Scale (CARS). The second patient (15 years of age) was diagnosed with autism at 3 years of age and had experienced two epileptic episodes
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(the first one occurred at 6 years of age). PEA treatment for three months resulted in significant improvement regarding language, cognition, and behavioral domains. The patient demonstrated a greater than 50 percent reduction in the Autism Treatment Evaluation Checklist (ATEC) score. Another study (Bertolino et al., 2017) has recently reported the efficacy and safety of co-ultramicronized PEA plus Luteolin in an autistic child (10 years old) who had suffered from several febrile episodes and abruptly developed autism-related behavioral symptoms one month after experiencing the first fever. He 18
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underwent psychotherapy, psychomotor, and speech therapy programs which were unsuccessful. One-year treatment with PEA in combination with Luteolin contributed to improvement in behavioral, motor, and social performance. However, contrary to the
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previous report, Bertolino and his colleagues observed no significant improvement in the patient’s speech.
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The rat model of autism indicated an increase in hippocampal PEA in response to social challenge (Kerr et al., 2013). Additionally, administration of PEA (alone or in combination
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with Luteolin) significantly contributed to improvement of behavioral impairments, neurogenesis, and synaptic plasticity in mice models of autism (Bertolino et al., 2017), depression (Yu et al., 2011), and Alzheimer’s disease (D'Agostino et al., 2012). Neuroimaging (Suzuki et al., 2013) and postmortem (Morgan et al., 2010) studies
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demonstrated increase in activity and number of microglia cells in brain of patients with autism. Since microglia cells are a source of natural PEA, it is, therefore, not ambitious to think of increased PEA as a compensatory mechanism in autism.
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Studies have highlighted the role of PEA to promote waking probably via increasing the extracellular levels of dopamine (Murillo-Rodríguez et al., 2011). Further, one-year
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treatment with PEA substantially reduced frequency of enuresis (from 91% to 2.4%) (Bertolino et al., 2017) in one autistic child. Since treatment with risperidone has been associated with drowsiness and with enuresis (Hergüner and Mukaddes, 2007), it was possible to hypothesize that co-administration of PEA with risperidone might help to reduce adverse effects associated with risperidone use. The present trial, however, showed no difference between groups in terms of the frequency of adverse events.
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Despite its originality, the study has also some limitations. First that patients received PEA at a fixed dosage of 600 mg twice daily. While flexible-dose regimens are generally preferred to fixed-dose regimens. Second that PEA was administered as adjunctive therapy
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and so whether PEA as standalone treatment is sufficient for patients with autism remains recondite. Third that the present trial had a relatively short follow-up period of 10 weeks. In addition to addressing the above-mentioned limitations, our vision for the future is to
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investigate whether (a) PEA concentration profile can be measured as a biomarker for autism, (b) PEA is able to accelerate the therapeutic effects of risperidone, and (c) PEA can
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be used to reduce the adverse effects of risperidone treatment in children and adolescents with autism. 5. Conclusion
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To the best of our knowledge, the present randomized controlled trial is the first clinical study conducted to investigate the efficacy and safety of PEA as adjunctive therapy to risperidone in children with autism over a 10-week period. The findings suggest that PEA
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might augment the efficacy of risperidone in the treatment of autism-related irritability and hyperactivity. However both treatment groups (risperidone plus PEA vs. risperidone alone)
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showed a similar degree of improvement in the other three ABC subscales (lethargy, stereotypic behavior, and inappropriate speech).
Acknowledgment This study was funded by Tehran University of Medical Sciences and Health Services (grant number 33135). Conflict of interest Authors declare no conflict of interest.
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Suzuki, K., Sugihara, G., Ouchi, Y., Nakamura, K., Futatsubashi, M., Takebayashi, K., Yoshihara, Y., Omata, K., Matsumoto, K., Tsuchiya, K.J., 2013. Microglial activation in young adults with autism spectrum disorder. JAMA psychiatry 70(1), 49-58.
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palmitoylethanolamide. Molecular pharmacology 67(1), 15-19. Vojdani, A., Pangborn, J.B., Vojdani, E., Cooper, E.L., 2003. Infections, toxic chemicals and dietary
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peptides binding to lymphocyte receptors and tissue enzymes are major instigators of autoimmunity in autism. International Journal of Immunopathology and Pharmacology 16(3), 189199.
World Medical, A., 2008. Declaration of Helsinki. Ethical principles for medical research involving human subjects. http://www. wma. net/e/policy/b3. htm.
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Yu, H.-L., Deng, X.-Q., Li, Y.-J., Li, Y.-C., Quan, Z.-S., Sun, X.-Y., 2011. N-palmitoylethanolamide, an endocannabinoid, exhibits antidepressant effects in the forced swim test and the tail suspension test in mice. Pharmacological Reports 63(3), 834-839.
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Yuan, C., Wang, X.M., Guichard, A., Tan, Y.M., Qian, C.Y., Yang, L.J., Humbert, P., 2014. N-
palmitoylethanolamine and N-acetylethanolamine are effective in asteatotic eczema: results of a randomized, double-blind, controlled study in 60 patients. Clinical interventions in aging 9, 1163-
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Legend
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Fgiure 1: Flow diagram of patients
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Table 1, Baseline characteristics of study participants: Risperidone plus Palmitoylethanolamide (PEA) vs risperidone plus placebo
7.42 (2.35) 25 (80.65) 26.00 (8.24) 0.13 (0.34)
21.97 (5.06) 20.71 (6.18) 12.00 (4.1) 27.97 (5.70) 5.81 (2.93)
20.97 (6.8) 19.84 (8.20) 11.16 (5.50) 25.87 (8.98) 5.19 (3.46)
Test of differences p = 0.31, t = −1.026, df = 60 p = 0.55 p = 0.30, t = −1.045, df = 60 p = 0.69, t = −0.395, df = 60 p = 0.51, t = 0.657, df = 60 p = 0.64, t = 0.472, df = 60 p = 0.5, t = 0.682, df = 60 p = 0.28, t = 1.098, df = 60 p = 0.45, t = 0.753, df = 60
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6.84 (2.1) 22 (70.97) 23.71 (9.00) 0.1 (0.30)
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Age in years: Mean (SD) Male no. (%) Weight in kg: Mean (SD) ESRS score: Mean (SD) ABC-C subscales scores: Mean (SD) Irritability Lethargy/social withdrawal Stereotypic behavior Hyperactivity/noncompliance Inappropriate speech
Risperidone plus placebo (n = 31)
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Risperidone plus PEA (n = 31)
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Table 2, Treatment responses of participants: results of within-subjects and between-subjects analyses Time × treatment interaction
Time
Mean
SD
Mean
SD
F
df
5.1 6.8
17.1 17.5
6.9 7.2
11.9 14.4
3.9 5.9
150.002
1.96
6.2 8.2
18.2 18.3
5.4 8.7
17.5 16.7
5.7 7.4
27.255
1.56
4.1 5.5
10.0 10.1
4.6 5.5
9.1 9.6
4.6 5.3
5.7 9
24.2 23.7
6.5 9.1
20.6 23.1
7.5 8.9
2.9 3.5
5.4 5.1
2.8 3.4
4.9 5
2.6 3.4
Between subjects
P
F
df
P
F
df
P
< 0.001
6.698
1.96
0.002
0.176
1
0.677
0.622
1.56
0.500
0.094
1
0.076
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SD
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< 0.001
1.33
< 0.001
2.686
1.33
0.094
0.006
1
0.937
48.823
1.53
< 0.001
10.367
1.53
< 0.001
0.000
1
0.991
1.5
< 0.001
3.008
1.5
0.069
0.094
1
0.760
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32.617
6.977
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Mean Irritability 22 Risperidone plus PEA Risperidone plus placebo 21 Lethargy/social withdrawal Risperidone plus PEA 20.7 Risperidone plus placebo 19.8 Stereotypic behavior Risperidone plus PEA 12 Risperidone plus placebo 11.2 Hyperactivity/noncompliance Risperidone plus PEA 28 Risperidone plus placebo 25.9 Inappropriate speech Risperidone plus PEA 5.8 Risperidone plus placebo 5.2
Week 5
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Outcome
Baseline
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Table 3, Treatment effects on outcome measures over the course of trial Mean difference (95% CI)
t (df)
−1.32 (−3.38 to 0.74) −3.48 (−5.38 to −1.59)
−1.58 (2.45) −3.13 (3.59)
−0.90 (−2.53 to 0.73) −0.13 (−2.28 to 2.03)
−1.06 (1.69) −1.61 (2.43)
−1.29 (45.47) −3.69 (60)
P
Cohen’s d (95% CI)
0.203 < 0.001
0.33 (−0.18 to 0.83) 0.94 (0.41 to 1.46)
−1.11 (60) −0.12 (60)
0.272 0.905
0.28 (−0.22 to 0.78) 0.03 (−0.47 to 0.53)
−0.97 (−2.02 to 0.08) −1.26 (−2.73 to 0.21)
−1.84 (60) −1.71 (55.21)
0.07 0.093
0.47 (−0.04 to 0.97) 0.43 (−0.07 to 0.94)
−2.23 (3.1) −2.77 (4.36)
−1.58 (−3.09 to −0.73) −4.65 (−7.17 to −2.12)
−2.1 (60) −3.68 (60)
0.04 0.001
0.53 (0.02 to 1.04) 0.94 (0.41 to 1.46)
−0.06 (0.44) −0.19 (1.56)
-0.39 (-0.83 to 0.05) -0.74 (-1.49 to 0.00)
−1.79 (39.13) −1.99 (60)
0.081 0.051
0.45 (−0.06 to 0.96) 0.51 (−0.00 to 1.01)
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−3.52 (2.66) −6.58 (3.02)
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Irritability Week 5 −4.84 (5.04) Week 10 −10.06 (4.31) Lethargy/social withdrawal Week 5 −2.48 (3.82) Week 10 −3.26 (4.80) Stereotypic behavior Week 5 −2.03 (2.39) Week 10 −2.87 (3.29) Hyperactivity/noncompliance Week 5 −3.81 (2.83) Week 10 −7.42 (5.52) Inappropriate speech Week 5 −0.45 (1.12) Week 10 −0.94 (1.37)
Risperidone plus placebo (n = 31)
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Risperidone plus PEA (n = 31)
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Outcome
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Mean (SD) change in score
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Table 4, Comparison of response rate between treatment arms No of patients (%)
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Lethargy/social withdrawal Week 5 Lethargy/social withdrawal Week 10 Stereotypic behavior Week 5 Stereotypic behavior Week 10 Hyperactivity/ noncompliance Week 5 Hyperactivity/ noncompliance Week 10 Inappropriate speech Week 5 Inappropriate speech Week 10
Risperidone plus placebo (n = 31) 22 (71) 8 (25.8) 1 (3.2) 9 (29) 17 (54.8) 5 (16.1) 26 (83.9) 5 (16.1) 0 (0) 21 (67.7) 10 (32.3) 0 (0) 24 (77.4) 6 (19.4) 1 (3.2) 19 (61.3) 10 (32.3) 2 (6.4) 26 (83.9) 4 (12.9) 1 (3.2) 24 (77.4) 6 (19.4) 1 (3.2) 31 (100) 0 (0) 0 (0) 29 (93.6) 1 (3.2) 1 (3.2)
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Irritability Week 10
Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete Less than partial Partial Complete
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Irritability Week 5
Risperidone plus PEA (n = 31) 19 (61.3) 8 (25.8) 4 (12.9) 1 (3.2) 22 (71) 8 (25.8) 25 (80.7) 5 (16.1) 1 (3.2) 23 (74.2) 5 (16.1) 3 (9.7) 20 (64.5) 6 (19.4) 5 (16.1) 17 (54.8) 7 (22.6) 7 (22.6) 25 (80.7) 6 (19.4) 0 (0) 10 (32.3) 15 (48.4) 6 (19.4) 30 (96.8) 0 (0) 1 (3.2) 23 (74.2) 6 (19.4) 2 (6.4)
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Fisher p
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Degree of response
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Outcome Time
0.411
0.026
0.866
0.099
0.257
0.193
0.62
0.0008
0.5
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Table 5, Frequency of adverse effects No. of patients (%)
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Dizziness Sedation Abdominal pain Increased appetite Headache Diarrhea Rash Constipation
Risperidone plus placebo (n = 31) 0 (0) 2 (6.45) 1 (3.23) 2 (6.45) 3 (9.68) 2 (6.45) 1 (3.23) 0 (0)
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Fisher P-value 1.000 1.000 1.000 1.000 0.612 1.000 1.000 0.492
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Risperidone plus PEA (n = 31) 0 (0) 1 (3.23) 2 (6.45) 2 (6.45) 1 (3.23) 1 (3.23) 0 (0) 2 (6.45)
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Adverse event
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