AADCd Family Workshop 2; PS128 Study: The Possible Benefits for AADCd Children

AADCd Family Workshop 2: Transcript PS128 Study; The Possible Benefits for AADCd Children

Dr Wang-Tso Lee Taiwan

Transcript ...

Lisa Hello everyone. Dr Lee welcome. Firstly thank you all for joining today. My name is Lisa Flint, founder of The AADC Research Trust and mum to 23 year old Jake who has AADC. Together with my colleague Julie and all of you we are celebrating 15 YEARS this year of patient advocacy, raising global awareness and funding critical disease research.

I am sorry because of time constraints we can't go round and introduce everybody one by one as much as we'd like to.

The subject today is on Probiotic PS128, with extremely high interest and we hope you find this workshop really helpful.

Let's begin by welcoming and introducing our presenter. Dr Wang-Tso Lee has been working with the Trust for over ten years. He is a child neurologist from Taiwan, working on neurotransmitter diseases and other movement disorders and I am going to hand over to him now for his presentation on PS128.

Dr Wang-Tso Lee Thank you for your kind introduction. I am Dr Lee from Taiwan. I'm very happy to share my experience in PS128 in children with AADCd. Because of Covid 19 we can't meet in person so I hope in the future I get the chance to visit London to meet all of you in person to discuss the treatment of AADCd in children. So today I want to talk about the use of PS128 in children with AADC.

Slide 1 First I want to mention about AADC. I know all of you understand the process for AADCd and you know that the enzymes over here, when the enzymes have any defect it will lead to a defect in the synthesis of serotonin and also dopamine.

Slide 2 You know that dopamine is very important and is distributed all over the brain, especially the striatum area and also the frontal cortex so when there is defect dopamine it will effect the function of the brain.

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Slide 3 Serotonin is also distributed all over the brain and when there is any defect in the synthesis of serotonin it will also effect the whole brain function.

Slide 4 Norepinephrine and epinephrine are also distributed across the brain so when there is any defect in those it will also effect the brain function.

Slide 5 For AADC the older symptoms come from deficiency of dopamine, serotonin noradrenaline and adrenaline so you will get different kinds of symptoms.

Dopamine deficiency leads to Parkinsonism, dystonia and decreased motor activity. For serotonin it's related to sleep problems, memory and learning impairment and also behavioural problems. And norepinephrine and epinephrine lead to autonomic dysfunction.

Autonomic dysfunction is important in AADCd and the phenotype can be mild, intermediate or severe.

Slide 6 Autonomic dysfunction is very important because the patient may have ptosis, mitosis, excessive sweating or temperature instability

Slide 7 And for treatment of AADCd we can use some dopamine agonist or MAO inhibitor to treat a patient we can also use an anticholinergic and we can use pyridoxine and folinic acid and also use melatonin for sleep problems. The treatment of choice should be gene therapy.

Slide 8 This figure just summarises all the possible treatment for a patient with AADCd. You can use the dopamine agonist or any medication to increase the amount of the dopamine and also serotonin to solve this problem but of course the gene therapy is a treatment of choice. Or you can just inject the virus into the brain to send the AADC gene to the brain to solve this problem.

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Slide 9 But how about other issues about the gene therapy.

Do all of the neurological situations improve after gene therapy - no. The severe symptoms may become moderate and moderate symptoms may become mild symptoms and the mild symptoms may show improvement but there are still some symptoms related to AADCd. So do we need post gene therapy medication. The answer is yes. We should give some medication after gene therapy. But what is the disadvantage of the present treatment. Some of the patients with AADCd after treatment with medication may have some unwanted side effects so sometimes they don’t respond very well. So we must think about other treatment choices.

Slide 10 The so called use of Probiotic comes from the concept of Parkinson's disease. In the patient's of Parkinson's disease we know the microbiota in the intestine will effect the brain function. The so called microbiota is the group of micro bacteria in the intestine, so the micro bacteria in the intestine will affect the brain function.

This makes us think about whether changing the population of micro bacteria in the intestine will change the brain function.

Slide 11 Here are some neuro developmental disorders like Autism. There are some publications in the past that say a change in microbiota in the gut shows a change in behaviour and also some physiological function in the brain. So we have gathered some evidence from past study. The change of microbiota may change the behaviour of physiological function of the brain.

Slide 12 So what is the relationship between the brain and the intestine.

Slide 13 We know that there are a lot of micro-organisms in our intestine. At least 1000 different species of known bacteria in our GI tract so there is synthesis of the different metabolites. These metabolites may effect the brain function.

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Slide 14 Here is a so called microbiota-gut-brain-axis. The intestine metabolites may affect the brain function and the brain may control the function of the intestine so they are bidirectional inference of the brain and intestine.

Slide 15 So first the possible mechanism. We know in the microbiota-gut-axis there are different mechanisms. They can affect the brain function or the intestine function using maybe the immune system, some metabolite or some neurotransmitters.

Slide 16 So there are different kinds of mechanism that lead to the bidirectional inference of brain and intestinal micro bacteria we call gut microbiota. So we call this the microbiota-gut-brain-axis.

Slide 17 Probiotics are the candidate species of live bacteria when ingested in adequate amounts can have a beneficial health effect on the host. So sometimes we call probiotics 'psychobiotic' because the probiotic will effect the behaviour and also the emotion of the brain.

Slide 18 There is some evidence that supports the so called microbiota-gut-brain-axis. In past studies when there is no bacteria in the intestine it will affect the behaviour of the animal and when there was a specific strain of bacteria in the intestines of the animal it changed the behaviour of the animal or even changed the behaviour of the human. So we wondered if we change the population of bacteria in the intestine will it change the function of the brain. So there is real evidence from past studies, for example when we used antibiotics to treat patients it will change the behaviour of the brain and also the spinal cord. It may be that the intestinal micro bacteria will have some affect on the brain.

Slide 19 So there are different mechanisms. And different studies in the past mention about the possibility of changing the intestinal micro bacteria and then change the brain function.

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Slide 20 There are different kinds of mechanisms and different kinds of disease will be affected by gut-microbiota for example, maybe some psychiatric disorder, pain, neurogenetic disorder, obesity, addiction, epilepsy, stroke, and also inflammatory bowel disease. So different types of disease may be affected by gut microbiota.

How about the neurological disorder like ADHD, OCD, depression, schizophrenia, bipolar disorder, anorexia nervosa? They will be effected by gut microbiota.

Parkinson's disease, Alzheimer disease, dementia, Huntington's disease, will also be affected by microbiota. And rare diseases in children like Rett Syndrome and AADCd will also be effected.

Slide 21 In our study we used PS128 to treat the patients with AADCd and different kinds of neurological disorders. PS128 is one kind of probiotic that has been approved by Taiwan FDA and it is got from a special vegetable in Taiwan.

Slide 22 There are some studies in the past using PS128 in animals. From the animal study we found the PS128 can change the behaviour of the animal. They can decrease the depression, also anxiety, in the animal. They also increased motor activity in the animal.

Slide 23 The most important part, we are changing some metabolites and also inflammatory factors in animal. For example, it can decrease inflammation in the animal. It will also change some metabolites and neurotransmitters in the brain.

For example, in early stress life, serotonin and dopamine would be decreased, but after treatment with PS128 you can see a significant increase in the amount of dopamine and serotonin. Even after treatment with PS128 it will stop some neurological conditions. It will increase the level of serotonin and dopamine in the brain.

Slide 24 This last study in mice also shows that treatment with PS128 increased the level of in dopamine metabolites and serotonin metabolites in the brain. It means that PS128 can really increase the level of dopamine and serotonin in the brain Page 5

and also can improve neurological symptoms of anxiety or depression.

Slide 25 So we conduct one study in animals to see where the PS128 can have some benefit in an AADCd conditional KO mice. We generated this conditional KO mice, under the support of The AADC Research Trust, several years ago we used this animal to test whether the PS128 will have some benefit on the mice.

Slide 26 After treatment you can see this figure. The left panel is the control mice, the normal mice. Before treatment these lines shows the tracking and tracing of the movement of the mice. So you can see before treatment in the normal mice the movement is very well and after treatment there is no significant change in the movement. But this is the KO mice, the AADCd mice, you can see the motor movement is very poor. There is no significant movement from the mice but after treatment with the PS128 the movement becomes much better, so it means that PS128 can improve the motor function in AADCd mice.

Slide 27 So we also did some histologic study to see what the mechanism. We can see in the histologic study the neuronal differentiation. The neuronal process will be changed. Before the treatment with PS128 for the KO mice the neuronal differentiation is not very well, but after treatment with the PS128 the neuronal differentiation becomes much better. It means that treatment with PS128 will improve neuronal differentiation.

Slide 28 We just think about what’s the potential mechanism because, is the past study, some studies have shown that use of PS128 can increase the level of dopamine and serotonin in the brain. So we think about if treatment with PS128 in the AADC animal model will also lead to an increase of dopamine and serotonin in the brain. We check the brain for the measurement of neurotransmitter in the brain and we can find that, in KO mouse model treatment with PS128, you can see that the amount has increased a lot. This is the dopamine and this is the serotonin.

Even the serotonin increased after treatment with PS128. It means that it increased the level of the dopamine and serotonin in the brain. The striatum, the most important part, also has a similar situation. The treatment with the PS128 also increased the level of dopamine and serotonin in the brain.

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Slide 29 So we think about whether we can use PS128 in humans. First we used in a disease called Rett Syndrome. It is one kind of neuro degenerative disorder. A patient with Rett syndrome can also have dystonia . We wanted to see if PS128 will increase the level of dopamine and serotonin in the brain and improve the dystonia condition in a patient with Rett syndrome. So we did a double-blind study.

Slide 30 Some patients had placebo and some patients had PS128 to compare to see after treatment with PS128 if there is some improvement.

Slide 31 We hypothesised that there is some dysfunction in the gut microbiota in some neurological disorder like Parkinson's disease, so if we used the probiotic to change the condition, to change the population of bacteria, in the intestine it will also change the function of the brain. So if we treat it with the probiotic it will improve neurological function in the brain.

Slide 32 After treatment for just four months you can see the dystonia improved in the patient with Rett Syndrome. Also the cognition had borderline improvement. The most important part, their daily activity improved, according to the description of the families. It means that in Rett Syndrome patients, after treatment with PS128, there is improvement in dystonia, cognition and daily activity. I remember some family mentioned to me, that before treatment, the patient could not turn on the light, but after six months of the treatment, the patient can turn the light on by themselves because their cognition was improved. They can also pay attention to their family. Before treatment they could not pay attention to their family but after treatment they can pay attention to their family. So we are seeing improvement in dystonia and cognition.

Slide 33 We wondered if we would see improvement in patients with AADCd. So we started an open-label trial of PS128 in children with AADC. Because I couldn't get enough patients for a double-blind controlled study, so I did an open-label trial.

Open-label trial means that every patient will take PS128 for a fixed period and we check before and after treatment to see whether there is any Page 7

improvement after treatment with PS128. We check whether dystonia will be improved, and the same for motor function, autonomic function like sweating, cognition, sleep condition. These are the families major concern.

Slide 34 These are some preliminary data. I am sorry I have been busy so I can't summarise all of the data which is not published yet. So I can mention some preliminary findings that I read this morning.

I found that after treatment, the most prominent improvement was in the sleep condition. Most of the patients after treatment with PS128, their sleep condition gets improved.

Autonomic function also gets improved. Before the treatment there is excessive sweating but after treatment with PS128 there is less sweating.

There is also improvement with dystonia, but I would say that before treatment, I checked the patient myself, but because of Covid 19 issues, after treatment I could not do this in person so I did this by video. I asked the family to do some positions according to my directions and I checked to see if there is improvement in dystonia. It is my judgement that for some patients there is real improvement in dystonia.

Motor function is less improved in most of the patients. After treatment with PS128 most patients still cannot walk but for some patients, for example one of my patients with AADCd, after treatment with PS128 the activity, the motor activity became much better according to his family. So in some patients maybe motor function can improve, but for most there is not much improvement, but I am not sure if there is more physical therapy or longer duration of the treatment the motor function will get improvement.

The cognition really improved in some patients. Before treatment some patients did not have any words but after treatment some patients managed some words.

The most prominent improvement after treatment is over the autonomic function; for example, there is less sweating and sometimes even the OGCs get improved.

There is also improvements in sleep condition, mild improvement in dystonia, mild improvement in motor function for some patients and in cognition, a lot of them mention about improvement in cognition after treatment.

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Slide 35 Lastly my take home message. We have different kinds of treatment for patients with AADCd. You can treat it with dopamine agonists or MAO inhibitors, you can treat it with gene therapy. But after gene therapy patients may still need more of the medication or different medications. Sometimes the patient doesn't tolerate the medical treatment well, so we can consider using the probiotic to treat a patient with AADCd. PS128, from the study in animals, and also from the human study, preliminary data already shows that after treatment with PS128, there is some improvement in cognition, autonomic function and sleep conditions. So maybe in the future we can use the PS128 probiotic to treat the patient with AADCd. I am sorry I can only show you a short introduction into PS128. I cannot show you all the data related to PS128 and to AADCd. This is my email address. If you have some questions or if you would like to discuss the treatment of PS128 in a patient with AADCd, I am very happy to answer any questions. Thank you very much.

Q&A Julie Hi Dr Lee, the first question is, is PS128 only available in Taiwan?

Dr Wang-Tso Lee PS128 is now available in China. It is not available in USA but it is in China. In the future maybe it will be available in other countries.

Julie Lactobacillus plantarum W62 ...

Dr Wang-Tso Lee This is one strain of bacteria. There are different kinds of species of bacteria in the intestine. PS128 is just one strain of species of micro bacteria in the intestine.

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Julie So that particular one, Lactobacillus plantarum W62, is available in Austria, would you recommend that they use that?

Dr Wang-Tso Lee I have to say that lactobacillus, they have different kinds of this. They are different kinds of probiotic, so if you want to choose the suitable probiotic you have to have the animal study to prove it is effective for patients with AADCd. Some probiotic may be effective for inflammatory disease, some for GI tract, like constipation and sometimes for asthma. But for this PS128 has had several animal studies to show that it is effective in treating the animal with the neurological disorder like depression, anxiety and in my study I showed the efficacy of PS128 in AADCd KO mice.

Julie Is the dose the same for everyone, for example would a one year old have the same dose as a thirteen year old?

Dr Wang-Tso Lee Up to two years old you can take the same doses.

Julie Is there any chance you could have too much? Could you overdose on it?

Dr Wang-Tso Lee In fact even if below two years old you can take the same dose. Probiotic is good bacteria for humans so if you are an immune-competent child the probiotic will not be harmful to you. So even if you take a lot of probiotic you should be ok.

Julie Should all AADCd children try PS128 and would you recommend it strongly after gene therapy?

Dr Wang-Tso Lee You can use the medications for example, dopamine agonists or MAO inhibitor Page 10

but if the response to this drug treatment is not very good or you cannot tolerate this treatment you can try probiotic PS128.

Lisa Can you try PS128 with MAOi and dopamine agonists? It's ok in combination, you can still have all of those drugs together? Could you have MAOi, the dopamine agonist and PS128?

Dr Wang-Tso Lee Yes you can combine them. In clinical trial nearly all the patients take dopamine agonist simultaneously.

Julie Do you think AADCd parent carriers would benefit from trying PS128?

Dr Wang-Tso Lee The parent carriers, theoretically PS128 may have some benefit, because they can increase the level of the dopamine in the brain. In a carrier of AADCd symptoms may appear after forty or fifty, or even older. So if you treat with PS128 from an earlier stage you will increase the level of dopamine. Maybe the symptoms will appear later.

Julie Is there a study that shows types of foods or chemicals that may not be beneficial to AADC children's GI tract?

Dr Wang-Tso Lee For PS128, not all patients will benefit from PS128 because some patients when they take PS128 the constipation becomes more severe. PS128 we can say it will effect the brain function, but may be not good to the GI function, and so some patients after taking PS128 in fact, constipation gets worse. That's the real problem. You can take some other medication to solve that problem because constipation is much easier to treat. But for the brain function if we can combine some drug medication for constipation and PS128 maybe we can solve the problem of constipation and also the problem of the brain.

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Julie So would it be beneficial then for diarrhoea in some AADC patients?

Dr Wang-Tso Lee No one complained about diarrhoea after treatment with PS128. In Rett Syndrome patients I remember that no one told me that they had diarrhoea after treatment but constipation we really met.

Lisa With children that already have diarrhoea do you think that PS128 could improve their diarrhoea because it can cause a more constipating effect?

Dr Wang-Tso Lee I am not sure. Theoretically, for some patients after taking PS128, they may become constipated but not all the patients did so I am not sure but you can try because you want to use the side effect of PS128.

Lisa We have some gene therapy families that have suffered diarrhoea following gene therapy treatment so PS128, as a side effect, could potentially treat that.

Dr Wang-Tso Lee Yes constipation is a side effect so if diarrhoea is your major concern you can try PS128 to see if there is a side effect of PS128 leading to constipation in the patient.

Julie What was the dose used in the AADC study and how many children were in the study?

Dr Wang-Tso Lee I enrolled around fourteen patients.

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Julie I have two types of PS128 there is Nuva 128 from Malaysia and PS128 from Inseed Taiwan. May I know what the difference is and how many should be taken by my son who is eighteen months old?

Dr Wang-Tso Lee I am not sure because I am not from the company. The company we collaborated for the clinical trial used a capsule filled with PS128 and also some fibre for the placebo so I am not sure of the difference between two kinds of PS128 but theoretically they should be the same.

Julie What would you advise the best dosage to be?

Dr Wang-Tso Lee The dosage should be the recommended dosage. For the clinical trial we use two capsules each time. Two capsules may be equal to one or two packs of PS128.

Julie Is PS128 available in Europe and if not will it be at some point?

Dr Wang-Tso Lee I am not sure but I can try to export it to you. If you give me your email address I can contact the company. I am not sure, because I just conducted the clinical trial. I know it is available in China and Taiwan. I'm not sure about USA. It is conducting clinical trials in USA for autism using PS128.

Lisa So if families email you, you could see whether you could send them some PS128 from there? Can you enrol anybody else onto your trial? Could you follow more patients than you have already?

Dr Wang-Tso Lee The clinical trial was conducted in China with only some Taiwanese patients.

Maybe if I get the chance I can do more clinical trials to see the efficacy of Page 13

PS128 on AADCd.

Lisa So if they email you heir situation maybe you can have a discussion with the family.

Dr Wang-Tso Lee Yes I am glad to.

Julie One of our parents says that their son has taken PS128 for about two weeks and he has become quite emotional, is that possibly related?

Dr Wang-Tso Lee Very emotional? It is impossible. In my study in China I found that after treatment with PS128, most patients emotions became more stabilised after treatment so it is impossible that it would get worse.

Julie Enterococcus faecium can convert L-Dopa to dopamine - do you agree?

Dr Wang-Tso Lee I am not sure. I am sorry. For the gut microbiota the true mechanism, is unknown; for example, even if enterococcus can change L-Dopa into dopamine in the intestine, it doesn't mean that it will increase the level of dopamine in the brain.

PS128 does not just change L-Dopa to dopamine. The mechanism leading to the increase of dopamine and serotonin in the brain is unknown. I am not sure what is the true mechanism.

Julie My son will sleep all day and night sometimes when we give him PS128 - is that related?

Dr Wang-Tso Lee PS128, I remember that some families mention to me that after treatment with Page 14

PS128, in fact the sleep condition improved. Some patients improve after treatment, but some don't so. If it gets worse I am not sure if it is related to PS128.

You have to consider PS128 is not effective for this condition in this patient.

Lisa Is the keto diet better for AADC children?

Dr Wang-Tso Lee I am not sure if ketogenic diet is effective for the patients with AADCd but theoretically, from my understanding of ketogenic, it is impossible to be effective for patients with AADCd because it will not increase the level of the dopamine in the brain. But it will have some epigenic function in the brain. Sometimes patients using the ketogenic diet diarrhea will become very severe and that is a major concern for some patients with AADCd.

Julie Can we just make sure that PS128 is ok with other medications that AADC patients are on, there are no contra indications?

Dr Wang-Tso Lee Yes, it is just one kind of probiotic. Micro bacteria is good to the patients, so is not harmful to the patients. All patients with AADCd can use it but not all may be effected. You have to consider I only conducted a clinical trial in fourteen patients. Not all the patients responded very well to the treatment. I mention to you that a major change was the sleep condition, also sweating and cognition.

Many families mention to me the improvement in cognition but motor function not so well. Only in one of my AADC patients treated with PS128 the motor function improved a lot. Her mother told me that after treatment with PS128, her motor function has become much better after treatment.

Julie How long did it take for you to see improvements?

Dr Wang-Tso Lee I have to say it depends because some patients really described to me the improvements were very fast. One of my patients after treatment with PS128, after just one month, she told me there was very much improvement after Page 15

treatment so sometimes it’s very fast after treatment, just one month. But I have to say that not all patients respond equally to the treatment. Some patients respond not very well, but this is very similar to the use of dopamine agonist or MAOi. Not all patients treated with those respond very well. Even if you are treated with gene therapy it can take a very long time to see improvements, so I suppose PS128 can only be the supplementary treatment, not the major treatment. Gene therapy is still the treatment of choice, but after gene therapy ,maybe you can try PS128 as a supplement as there is not much side effect.

Julie Earlier you said that from two years old it's the same dose for everyone, so for under two years would you recommend using PS128 or not?

Dr Wang-Tso Lee I have to say not two years old, you should be over 10 kilograms. Over 10 kilograms you can use the same dose, but below 10 kilograms I am not sure whether you can use the same dose of PS128. In my clinical trial I just used one capsule of PS128 in those below 10 Kilogram.

Lisa My daughter sees improvement in terms of sleeping better and dystonia duration is shorter which is good but there is also a question about which make did you use for the trial. What was the manufacturer of the PS128 for the trial? Which brand of PS128 did you use for the trial?

Dr Wang-Tso Lee There is only one company that synthesises the PS128. Only one company has this product. For a clinical trial it is impossible to use the PS128 on the market because there are some supplements added into the PS128. But for clinical trial we had to make sure that the effects came from the PS128 per se, so we had to use the purer PS128, so it was pure in the capsule. So in the clinical trial we just used the capsules for patients. PS128 on the market has some other components in it. PS128 is the major component for the probiotics available on the market but there are still some other components, but for clinical trial we have to use the purer PS128.

Lisa Some people have reported that sleep has improved. Is there a time of day best Page 16

to give PS128, say with melatonin in the evening or is it an improvement with sleep that just happens because of the cycle in the system or is it better to give at night?

Dr Wang-Tso Lee There is no difference because the melatonin you should give at night but PS128 it just changes the population of bacteria in the gut. So once the population of bacteria in the gut has been changed it should stay the same, there is no difference. So you can give PS128 in the morning or at night. There is no difference.

Lisa Bened Biomedical is that supplier? Is that the supplier that you use for the trial?

Dr Wang-Tso Lee Yes that is correct.

Lisa Is it only one dose per day?

Dr Wang-Tso Lee Yes one time a day. Sometimes they will suggest one pack in the morning and one pack at night but I think it makes no difference because once the bacteria stay in your intestine for a very long time, there is no difference. Even if you did not take the probiotic for one or two days, it should be ok, you don't need to worry about it because once the bacteria stay in your intestine it stays for a very long time, many days. So even if you did not take the probiotic for one or two days there is no change in the bacteria population in your intestine.

Lisa Could families give your email to their doctors so they can communicate with you about PS128?

Dr Wang-Tso Lee Yes sure but I apologise in advance, if I do not answer emails very fast, because there is an outbreak of Covid 19 in Taiwan. You can just mention to me again or Page 17

email me again I will eventually respond to you.

Lisa We may have some questions where we haven't fully understood the answers so I may send you an email once I chat with families in case they missed anything.

Julie If I give PS128 to my son and afterwards test urine for catecholamine metabolites will it give me an idea if it worked for him?

Dr Wang-Tso Lee I think it is minimal in urine. Even in a patient with AADC the level of catecholamine in urine is varied. So some patients may have very high level of catecholamine and some patients may have a low level. If you just measure the content in the urine, it means nothing. If you want to measure the content you should do a CSF; Cerebral Spinal Fluid neurotransmitter.

Lisa Which is invasive. So you want to look at clinical improvements like sleep, digestion, mood, behaviour, etc in the physical sense.

Thank you Dr Lee and thank you everybody for joining us today.

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AADCd Family Workshop 2 : Transcript Produced by Julie Ramsay Verified by Lisa Flint & Dr Wang-Tso Lee The AADC Research Trust would like to thank all involved.

#CureAADC #CureAADCd

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