Effect of alternative metabolic fuels as a potential ALS therapy in mice and humans Csilla Ari, Craig R. Goldhagen, Angela Poff, Heather Held, Carol Landon, Nicholas Mavromates Dominic D. D’Agostino Department of Molecular Pharmacology and Physiology, Hyperbaric Biomedical Research Laboratory, Morsani College of Medicine, University of South Florida, Tampa FL Amyotrophic Lateral Sclerosis (ALS) more commonly known as Lou Gehrig’s disease, is a neurodegenerative disorder of motor neurons causing progressive muscle weakness, paralysis, and finally death from respiratory failure within 3 to 5 years after diagnosis. There is currently no cure or effective treatment for ALS. Motor neuron death results from impaired energy metabolism, which is linked pathophysiologically to mitochondrial dysfunction, oxidative stress, glutamate excitotoxicity. In normal conditions the human body will use glucose as the main metabolic fuel; however, neurodegenerative disorders are known to have impaired glucose transport and metabolism. These neurodegenerative cells require an alternative metabolic substrates and cofactors to preserve cellular function, resting membrane potential and prevent glutamate toxicity. Metabolic therapy that supplies alternative energy substrates and cofactors may enhance mitochondrial function and represent a viable therapeutic approach for ALS. In this study we hypothesized that alternative fuels in the form of ketone bodies, specifically arginine-alpha-ketoglutarate (AAKG) and the ketogenic diet (KD; 80% fat), would increase motor function, slow the progression of the disease and extend survival in a mouse model of ALS (SOD1G93A mice). Animal Model Transgenic SOD1G93A mice (Jackson Laboratory) are currently the only ALS model exhibiting all of the pathological characteristics of ALS Deanna Protocol (DP) Metabolic Therapy for ALS Composition of DP in Foof AAKG (Arginine Alpha-ketoglutarate) Primaforce, 10% GABA (Gamma-aminobutyric acid ) Primaforce, 1% CoEQ10 ( Ubiquinol)Tishcon, 0.1% Caprylic acid (MCT oil) Life enhancement, 1% Dietary Groups Control (SD) – Standard Diet SDDP – Standard Diet combined with Deanna Protocol KD – Ketogenic Diet KDDP – Ketogenic Diet combined with the Deanna Protocol Standard Diet: Low Fat and High Carbohydrates Ketogenic Diet: High Fat and Low Carbohydrates Experiments Motor Function Tests (rotarod, grip test, hanging wire test) Neurological Score (0 to 4) : 0 = no pathology Survival (defined criteria) Experimental Design Background Summary KD group had greatly improved motor function during the first stages of disease onset (weeks 5 and 6) when compared with the SD, however, the KD did not extend survival time. During the later stages of the disease (weeks 7 and 8) the SDDP group had significantly better motor function. Neurological Score in the SDDP group was improved toward late stages of disease. KD provided no significant benefit in Neurological Score alone or when combined with the Deanna Protocol. Our data shows increased survival in SDDP treatment group References Zhao W, Varghese M, Vempati P, Dzhun A, Cheng A, Wang J, Lange D, Bilski A, Faravelli I, Pasinetti GM. Caprylic triglyceride as a novel therapeutic approach to effectively improve the performance and attenuate the symptoms due to the motor neuron loss in ALS disease. PLoS One. 2012;7(11):e49191 Zhao Z, Lange DJ, Voustianiouk A, MacGrogan D, Ho L, Suh J, Humala N, Thiyagarajan M, Wang J, Pasinetti GM. A ketogenic diet as a potential novel therapeutic intervention in amyotrophic lateral sclerosis. BMC Neuroscience Apr 3;7:29 Acknowledgements This work was supported by Winning the Fight against Neurodegenerative Diseases (WFND), a 501(c)3 non- profit dedicated to raising awareness about neurodegenerative diseases (NDs), as well as seeking and funding new treatments for NDs. For more information see: Contact: Dominic D’Agostino: Csilla Ari: Results Motor Function Neurological Score Survival KD and SD+DP Enhanced Motor Function Fig2 A) KD group had significantly better result on accelerating rotarod during week 11, 15 and 16 (p=0.029, p=0.004, p=0.036, respectively) when compared to the control group, but during week 17 and 18 (p=0.039, p=0.046, respectively) only the SD+DP group performed better. B) Grip test showed better motor performance in KD group at week 15 (p=0.015), while strength was significantly better at week 17 and 18 in SD+DP group (p=0.039, p=0.046), compared to control. C) Hanging Wire Test test showed better motor performance in KD group on week 16 (p=0.036), while performance was significantly better at week 16 and 17 in SD+DP group (p=0.028, p=0.037), when compared to SD group. All data are mean ± SEM. Results Figure 3 A) Neurological Score was significantly improved in SD+DP group between day 118 and 136, suggesting delayed disease progression in SD+DP group (p˂0.05). All data are mean ± SEM. Figure 3 B) Kaplan-Meier survival plot of study groups. Animals receiving SD+DP showed significantly longer survival compared to control animals (p=0.001). Score of 0Hind legs are stretched fully when hanging by tail Score of 1Hind legs are pulled back when hanging by tail Score of 1.5Abnormal gait Score of 2Toes curled under when walking Score of 2.5Use of both hind legs while walking, but with difficulty Score of 3Pulling back legs, but still able to move them both Score of 3.5One of the hind legs paralyzed, with use of the other Score of 4Completely paralyzed or dead Table 1. Neurological score: Table contains criteria for each neurological score Figure 1: Experimental Time Line for the study Grip Test Hanging Wire Test Rotarod performance A B C In conclusion, targeting energy metabolism with a metabolic therapy produces a beneficial effect in ALS mice and is a feasible strategy that may prolong survival and quality of life of ALS patients.