Background
Rett syndrome (RTT) caused mostly by disruptions in the
MECP2 gene is a neurodevelopmental disorder occurring in 1/10,000 live female births [
1]. One of the major consequences of the
MECP2 disruption is brainstem dysfunction. [
2‐
5]. In
MECP2-null mice, several groups of brainstem neurons including those in the locus coeruleus (LC) show increased membrane excitability. As a result of the excessive neuronal excitability, the balance of excitation and inhibition in local neuronal networks is impaired, affecting normal brainstem functions for breathing control, cardiovascular regulation, gastrointestinal activity, arousal, and locomotion, consistent with RTT manifestations in humans [
3,
6].
The increased neuronal excitability in the brainstem is attributable to abnormal intrinsic membrane properties and deficiency in GABAergic synaptic inhibitions [
7‐
11]. In
MECP2-null mice, both GABA
A and GABA
B synaptic currents are reduced in LC neurons [
9]. In contrast, our recent studies indicate that extrasynaptic GABA
A currents are well retained in LC neurons of
MECP2-null mice [
12], which is encouraging as the extrasynaptic GABA receptors (GABA
ARs) may provide an alternative pharmaceutical target to relieve the excessive neuronal excitability and its associated RTT symptoms. Indeed, we have found that the extrasynaptic GABA
AR agonist 4,5,6,7-tetrahydroisoxazolo[5,4-c]pyridin-3-ol hydrochloride (THIP) is beneficial to RTT-like symptom relief in
MECP2
−/Y mice.
THIP or gaboxadol is an investigational drug, originally developed for insomnia. Clinical trials suggest that THIP (10 mg/day) has no significant effects on sleep onset and total sleep time [
13]. It does have effects on these measures in a higher dose (15 mg) where the effects are inconsistent between genders, and side effects emerge including sedation and disorientation [
13,
14]. Therefore, Merck and Lundbeck canceled further development of the drug. It is not unusual, however, that a preclinical drug fails in one application but succeeds in another. The low efficacy of THIP on insomnia indeed may be beneficial for its applications to RTT, as the unnecessary sedation can be avoided. We have found that intraperitoneal injection of THIP alleviates the breathing abnormalities and extends lifespans of
MECP2-null mice [
12]. However, intraperitoneal injection may introduce stress and subject the animals to infection. To overcome this potential problem, oral administration was given to mice in this study. Also, we chose to use a low and non-sedative dose of THIP to avoid potential side effects. RTT symptoms start 6–18 months after birth, causing a loss of certain acquired motor and language skills in humans. To intervene in this early period of development, we exposed neonatal mice to THIP 1 day after birth before the RTT-like symptoms manifest themselves. Therefore, this study was conducted in a way that was close to therapeutic condition and very much different from our previous study [
12].
Methods
Animals
All experimental procedures were conducted in accordance with the National Institutes of Health (NIH) Guide for the Care and Use of Laboratory Animals and were approved by the Georgia State University Institutional Animal Care and Use Committee. Female heterozygous mice (genotype: MECP2
−/+
; strain name: B6.129P2(C)-MECP2
tm1.1Bird/J; stock number 003890) from Jackson Lab were crossbred with male C57BL/6 mice (wild type (WT)) to produce the MECP2-null mice with the genotype MECP2
−/Y. The PCR protocol from Jackson Lab was used to identify the genotype. All experiments were done in male mice because the MECP2
−/Y males offer a completely MECP2-null condition that is not always available in MECP2
−/+ females owing to uncontrolled X-chromosome inactivation.
THIP administration
THIP was given to the mother in her drinking water (200 mg/L) and then passed to pups of WT and
MECP2
−/Y male mice via lactation [
15]. This will last till weaning at P18. After that, THIP was given through the pup’s drinking water (20 mg/L) for another 5 weeks.
Brain slice preparation
Experiments were performed as we described previously [
7]. In brief, mice were decapitated after deep anesthesia with inhalation of saturated isoflurane. The brain stem was obtained and immediately placed in ice-cold and sucrose-rich artificial cerebrospinal fluid (aCSF) containing (in mM) 220 sucrose, 1.9 KCl, 0.5 CaCl
2, 6 MgCl
2, 33 NaHCO
3, 1.2 NaH
2PO
4, and 10 D-glucose. The solution was bubbled with 95 % O
2 balanced with 5 % CO
2 (pH 7. 40). The transverse pontine sections (150–250 μm) containing the LC area were obtained using a vibratome sectioning system and then recovered at 33 °C for 60 min in normal aCSF containing (in mM) 124 NaCl, 3 KCl, 2 CaCl
2, 2 MgCl
2, 26 NaHCO
3, 1.3 NaH
2PO
4, and 10 D-glucose. The brain slices were kept at room temperature before use. During recording, the slices were perfused with oxygenated aCSF at a rate of 2 ml/min and maintained at 34 °C in a recording chamber by a dual automatic temperature control (Warner Instruments).
Electrophysiology
Whole-cell current clamp was performed on LC neurons in brain slices. Patch pipettes with resistance as 3–5 MΩ were pulled with a Sutter pipette puller (Model P-97, Novato, CA). Only the neurons with membrane potential less than −40 mV (LC neurons) and action potential larger than 65 mV were accepted for further experiments. The pipette solution contained (in mM) 130 K gluconate, 10 KCl, 10 HEPES, 2 Mg-ATP, 0.3 Na-GTP, and 0.4 EGTA (pH 7. 3). The bath solution was normal aCSF bubbled with 95 % O2 and 5 % CO2 (pH 7. 40). Recorded signals were amplified with an Axopatch 200B amplifier (Molecular Devices, Union City, CA), digitized at 10 kHz, filtered at 2 kHz, and collected with the Clampex 8.2 data acquisition software (Molecular Devices). Paired experiments were done by three people double-blindly.
Membrane potentials were measured without any current injection. The input resistance was calculated as the slope of the linear portion in the I-V curve in response to a series of injected pulse hyperpolarized currents (typically from 0.15 to 0 nA). The action potential overshoot was measured as the amplitude from 0 mV to the peak of more than 20 events. The threshold was determined at the initiation point of at least 20 spontaneous action potentials.
Quantitative PCR
Mice 5–7 weeks old were used in the experiments. Transcripts were obtained from the pontine slices containing the LC. Using complementary DNAs (cDNAs) synthesized with the high-capacity cDNA reverse transcription kit (Life Technologies, Grand Island, NY), quantitative PCR (qPCR) was performed with Fast SYBR® Green Master Mix (Applied Biosystems, Life Technologies, New York, NY) in a fast real-time PCR system (Applied Biosystems 7500) for 40 cycles. GAPDH was used as the internal control for the quantification of tyrosine hydroxylase (TH) and dopamine β hydroxylase (DBH) expression. The following are PCR primers for the experiments: GAPDH (forward: CCAGCCTCGTCCCGTAGA; reverse: TGCCGTGAGTGGAGTCATACTG), TH (forward: TGGCTGACCGCACATTTG; reverse: CCTGCACCGTAAGCCTTCA), DBH (forward: TACCACAACCCACGGAAGATA; reverse: CGGTCAACACAAAGGCAGTCT), δ subunit (forward: GGCTTCTTGGGCTTTACC; reverse: CACCCCCACTGTTTTTCTC), α6 subunit (forward: GACTTTGCCCATCGTTCC; reverse: TGCAAAAGCTACTGGAAGAG), β1 subunit (forward: TGGTTTTCGATCTTGTGTGTCAG; reverse: AGCCACCTCTCTCTTTGTGTTTG), and β2 subunit (forward: TTCCCACTGCTGTTTCTCACATAC; reverse: ATCCTAACCACTTCTCCTTTTTTCC).
Western blot
Pontine tissues containing the LC were obtained from 5- to 7-week-old mice and processed in RIPA buffer (Sigma-Aldrich, St. Louis, MO) with 1 % protease inhibitor. BCA protein assay reagent (Pierce, Rockford, IL) was used to estimate the protein concentrations using 30 μg proteins to detect TH and DBH signals in 10 % SDS-PAGE gels and electrophoretically transferred to nitrocellulose membranes. The membranes were then blocked for 2 h in 5 % non-fat milk and incubated overnight at 4 °C with rabbit GAPDH primary antibodies (1:10,000, Sigma-Aldrich, St. Louis, MO), rabbit TH (1:1000, Sigma-Aldrich, St. Louis, MO), and DBH primary antibodies (1:1000, Sigma-Aldrich, St. Louis, MO). After being washed in PBS twice, the membranes were incubated by horseradish peroxidase (HRP) conjugate goat anti-rabbit secondary antibodies (1:5000, Life Technologies, Frederick, MD) for 1 h in room temperature. The chemiluminescent detection system (Pierce) was used to expose the membrane to films (Hy Blot CL; Denville, Metuchen, NJ), and the photographs were scanned. The immunoblotting signals were quantified using the ImageJ software (NIH). TH and DBH signals were normalized to the internal GAPDH controls.
Plethysmograph recording
Breathing activity of conscious mice was recorded with the plethysmograph system consisting of a ~40 ml test chamber, a reference chamber, and a force-electricity transducer. The individual animal was kept in the test chamber flowed by air at a rate of 60 ml/min. The mouse was allowed to adapt to the chamber for at least 20 min followed by a 20-min recording. The breathing activity was recorded continuously as the barometrical changes between the test chamber and the reference chamber with the force-electricity transducer. The signal was amplified and then collected with a Pclamp 9 software. The animals were monitored via a video camera to ensure the wake status during tests. The data analysis was done double-blindly to the treatment. Apnea was considered only if the breathing cycle lasts twice longer than the previous one. Breathing frequency variation was calculated as the ratio of standard deviation (SD) over the arithmetic mean of breathing frequency. The SD and arithmetic mean were measured from 200~300 successive breathing events, which were randomly sampled from three or four stretches with at least 50 breaths in each.
Grip strength
When lifted by the tail, the forelimbs of a mouse (age 5–6 weeks) were allowed to grasp the sensor lever of a force-electricity transducer. The mouse was then gently pulled upward by the tail until it released the grip. Forces were continuously recorded with the Clampex 9 software. The grip strength of each mouse was measured as the maximum force before lever release, and averaged from three consecutive trails.
Grid walking
A mouse (age 5–6 weeks) was placed on the metal rigid floor of a trial box (32 cm × 20 cm × 20 cm). The box was elevated by 50 cm with the floor made of 11 × 11 mm metal mesh. Mouse walking on the metal mesh floor was videotaped for 5 min. In the video record, the limb placement error was counted. A footfault was counted only when a limb missed the metal floor bar (0.5 mm in diameter) completely and went through the grid opening. The footfault ratio was calculated by the overall number of footfaults divided by the total steps including both forelimbs and hindlimbs.
Open field test
The experiment was performed as we described previously [
16]. Mice aged 5–6 weeks were tested in an open field chamber made of white plexiglass boards (50 cm L × 50 cm W × 30 cm H) with 10 cm × 10 cm square lines. Test animals were kept in their home cages and habituated for 30 min in the test room before testing. When tested, each animal was placed in the center square and allowed to move freely in the chamber. Spontaneous locomotion activity was monitored by a video camera for 5 min. With the video record, square crosses (all four paws cross) were measured in each mouse. To eliminate potential residual odors and potential contaminants, 70 % ethanol was used to clean the apparatus followed by dd H
2O rinse after each test.
Social interaction
Mice, age 6–7 weeks, were tested in a box (60 cm L × 30 cm W × 40 cm H), in which there were three chambers (20 cm L × 30 cm W × 40 cm H) separated with transparent walls. A door was arranged diagonally in each wall allowing the tested mouse to travel freely in the chambers. Before test, mice were placed in the test room for 30 min habituation. Then sequential tests were performed in each mouse. Firstly, the tested mouse was placed in the center chamber and allowed to move freely over all three chambers for 10 min. Its chamber preference was analyzed by the time spent in each chamber. Secondly, the social behavior test was performed by introducing a random littermate in one of the side chambers for 10 min, while times that the tested mice spent with the mice were measured. The littermate was randomly assigned in either side of the chamber to avoid the side bias. Lastly, social novelty test was performed by introducing a new stranger mouse in the chamber and switching the familiar littermate to the other chamber. The time spent in both side the chambers were analyzed subsequently [
17].
Lifespan
MECP2
−/Y mice used in the experiment were randomly selected and divided into two groups. One group was treated with THIP containing water and the other treated with regular water as vehicle control. Their lifespan were monitored under identical living conditions. Their daily activity and general physical conditions, including feeding, movement, body weight, and interaction with other mice, were observed. Death date of each mouse was recorded when it occurred naturally or reached the humane end point that was determined by staff members in the animal facility at Georgia State University without any consultation with the investigators. One outlier, which was 1.5 interquartile range (IQR) above the third quantile and below the first quantile, was removed from each group to minimize data variations.
Randomization/double blind
The animals used in the study were randomly separated into a vehicle group and THIP group. The patch experiments were done double-blindly by two to three people without information of mouse genotype and treatment. All the data analysis of behavior experiments, including breathing activity, motor function, and social behavior, were done with no information of the genotype and treatment.
Data analysis
The sample sizes in the experiments were examined with G-Power Analysis to yield sufficient statistical power. Data are presented as means ± SE or median ± IQR. Mantel-Cox test was used in the lifespan experiment. Kruskal-Wallis test, Pearson correlation, and Spearman’s correlation were used in the breathing experiments. ANOVA and Tukey’s post hoc were applied in the behavior tests and electrophysiology experiments. Student’s t test was performed to analyze the data in the molecular experiments. Difference was considered significant when P < 0.05.
Discussion
In these studies, we have shown that early-life exposure of the MECP2-null mice to a non-sedative dose of the extrasynaptic GABAARs agonist THIP has several beneficial effects on lifespan, breathing activity, motor function, and social behaviors. Such alleviation of RTT-like symptoms by THIP treatment is associated with the stabilization of neuronal excitability and enhancement of NE biosynthetic enzymes in LC neurons.
The extrasynaptic GABA
ARs have several properties different from the synaptic GABA
ARs, which may be unique in interventions to neuronal excitability. They are located outside the synaptic area, produce tonic or long-lasting Cl
− currents, show very little desensitization upon activation, and are sensitive to some synaptic GABA
AR agonists and extrasynaptic GABA
AR-specific agonists [
37‐
39]. They have the capability to change dynamically their expression levels under different physiological and pathophysiological conditions [
12,
40,
41]. Manipulations of these receptors with selective agents do not interrupt GABAergic synaptic transmission mediated by the synaptic GABA
ARs. Thus, therapeutic activation of these extrasynaptic GABA
ARs may avoid several side effects of the synaptic GABA
AR activators including sedation, tolerance, and addiction.
People with RTT and the mouse models show the delayed onset and progressive symptoms. Although the mechanism for the delayed symptom onset remains unclear, some factors may contribute to it, such as dynamic spatiotemporal relationship between
MECP2 and methylated DNA [
42] and the altered allopregananallone modulation of the GABA system during perinatal period [
8]. Thus, intervention to neuronal hyperexcitability before the symptom onset may be a potential way to prevent or delay the development of the disease. The δ subunit containing extrasynaptic GABA
ARs are expressed dynamically with growth [
41]. Since severe defects in the synaptic GABA
AR system have been demonstrated in mature
MECP2-null mice, treatment with THIP in early lives may be beneficial with respect to enforcement of the inhibitory system in the neurodevelopment of
MECP2-null mice.
The reduced expression of α6 subunits suggests that early treatment of THIP may lower the GABAR expression and the consequent GABAergic inhibition. The α6 subunit is known to contribute to both the extrasynaptic receptors together with the δ subunit and the synaptic GABA
ARs with β and γ subunits [
43,
44]. The reduction in these GABA
ARs might possibly lead to rebound excitation after THIP withdrawal. The stabilization of neuronal excitability, however, might affect cellular mechanisms reducing abnormalities, which could result in a long-term reduction in neuronal hyperexcitabiltiy after THIP withdrawal, contributing to the outcome of THIP in breathing, motor function, social behaviors, and lifespan.
To minimize potential side effects of THIP, we chose to use THIP chronically in low dosage. Although pharmacokinetic studies were not performed in this report, such information has been collected in previous studies on mice, rats, dogs, and humans [
27‐
30]. With a daily dose of 10 mg in humans, THIP reaches the maximum plasma concentration ~140 ng/ml in 2.0 h, and the terminal plasma half-life time is 1.7 h [
27]. Another preclinical study in humans, rats, and mice shows a rapid and complete absorption of THIP with the peak concentration reached within 0.5 h in several organs include the brain [
29]. A clinical report indicates that therapeutic dosages of THIP by long-term oral administration range from 20 to 120 mg daily in human patients [
45]. Higher doses of THIP may cause adverse side effects, including sedation, confusion, and dizziness [
14]. In our present study, the oral dose of THIP was calculated to be ~6 mg, which appears effective for alleviating multiple RTT-like symptoms in
MECP2-null mice. Our test of spontaneous locomotion supports the non-sedative effects of the dosage. The dosage given to the mother during lactation was 61.0 ± 2.2 mg/kg/day, which was also reported to have no sedative effects neither behavioral alterations [
15].
Similar to the dosages that we used in the study, several previous studies have reported to use THIP for treatment of mouse models of Fragile X syndrome and Angelman syndrome. Since these diseases share multiple similarities to RTT, such as impaired GABA system, neuronal hyperexcitability, and autism-like symptoms [
24,
26,
46], the information shown in the present study is likely to benefit to moving the drug for further clinical trials in all these diseases.
LC neurons, the major NE source in the CNS, project broadly to the other brain regions, including the medulla where the respiratory center is located and the prefrontal cortex where the NE system affects cognitive functions, seizure, and social behaviors [
47,
48]. In
MECP2-null mice with THIP treatment, the target regions of LC-NE projection may benefit from the enhanced NE synthesis, leading to the alleviation of the associated abnormal behaviors. On the other hand, impaired neuron networks were widely seen in
MECP2-null mice [
40,
49]. The social defects of autism spectrum disorders were believed to be correlated to the weak connections in the default networks including the medial prefrontal cortex and posterior cingulate cortex [
50]. With the beneficial effects found in this study, we speculate that THIP might contribute to reinforcement of these connections as well as amelioration of the phenotypes.
In comparison to the
MECP2-null mice, the most widely used RTT mouse model, the
MECP2
−/+ mice tend to display large variations in RTT-like symptoms due to the random X-chromosome inactivation. According to our previous study, only 15–20 %
MECP2
−/+ mice in age 1-6 months showed the RTT-like symptom of breathing abnormalities, suggesting that the wild-type allele is not randomly inactivated [
2]. Generally, ~50 % the neurons in the CNS of
MECP2
−/+ mice retained
MECP2 expression [
51,
52], which may allow the
MECP2
−/+ mice to recapitulate the normal behaviors to some degree, compared to the
MECP2-null mice. However, the
MECP2 mosaic expression pattern is not uniform in the CNS and it varies between individuals, ages, and brain regions [
51,
52]. Regional expression levels of
MECP2 was reported be correlated to the specific symptoms in the
MECP2
−/+ mice. Hippocampus
MECP2 expression is related to the exploratory activity behaviors and anxiety-like behaviors. Cortical
MECP2 expression affects the general symptomatic severity [
53]. The age-dependent mosaic pattern suggests that even the X-chromosome inactivation ratio may also be affected by
MECP2 deficiency in the RTT mice brain and the consequent variation of postnatal brain functions in RTT [
51]. Thus, the age-dependent and region-specific expression pattern of
MECP2 in the CNS contributes to the large variation of the phenotypic outcome in
MECP2
−/+ mice, which all need to be considered in studies of female RTT models. Furthermore,
MECP2
−/+ mice usually develop the diagnostic symptoms when they become sexually mature. The periodical hormone alternations in
MECP2
−/+ mice may affect mouse performance in the behavioral tests complicating the interpretation of the THIP effects. A previous study reports significant variations in the open field, tail flick, and suspension tests in female mice during their estrous cycle [
54]. With all these complications in the female models, therefore, studies under
MECP2-null condition in the male model seems beneficial as the first step of investigation before sophisticated preclinical trials are conducted, which can be based on
MECP2
−/+ female mice and may benefit from the experimental evidence obtained from the male RTT models.
Selective restoration of
MECP2 in GABAergic neurons rescues multiple phenotypes in both
MECP2
−/Y and
MECP2
−/+ mice [
55], which suggests that the GABA system is a feasible target to manipulate in RTT female mouse model and RTT patients. Although the sexual difference of LC neurons might be a concern of the potential effects of THIP, a morphological study suggested female LC neurons showed a higher frequency of communication with peri-LC neurons in comparison to the male [
56,
57], indicating that THIP may have a greater effect in female RTT mouse model or patients. A previous study reports that for some unknown reasons, THIP tends to have a greater efficacy in women than in men [
13], further suggesting the potential beneficial effects of THIP in RTT female mouse model and patients. Nevertheless, further studies on
MECP2
−/+ mice are needed, which may be conducted as deliberate, thorough, and systematic investigations that might benefit from our findings in the male model.