Methods for Treating Autism Spectrum Disorders

Abstract

Described herein are methods for predicting treatment response to a glutamate modulating agent in a subject with an autism spectrum disorder (ASD), for selecting a treatment that includes a glutamate modulating agent, and for treating a subject with a glutamate modulating agent.

Description

[Technical field]

[0001] Claiming priority This application claims the benefit of U.S. Provisional Application No. 63 / 145,250, filed February 3, 2021, the entire contents of which are incorporated herein by reference.

[0002] Federally Funded Research and Development This invention was made with Government funding under Grant No. MH100450 awarded by the National Institutes of Health. The Government has certain rights in this invention.

[0003] Described herein are methods for predicting treatment response to a glutamate modulating agent in a subject with an autism spectrum disorder (ASD), for selecting a treatment that includes a glutamate modulating agent, and for treating a subject with a glutamate modulating agent. [Background technology]

[0004] Autism spectrum disorder (ASD) is a highly crippling neurodevelopmental disorder characterized by deficits in social communication and interaction along with restricted and repetitive behaviors, estimated to affect up to 2% of adolescents in the general population ( Blumberg et al., 2013 ).

[0005] Although there are psychopharmacological options available for the treatment of agitation and hyperactivity in ASD, currently no medication has been consistently shown to reliably improve social impairment in ASD (Hollander et al., 2005; Hollander et al., 2012; McCracken et al., 2002; McDougle et al., 1998; McDougle et al., 1996; "Risperidone treatment of autistic disorder: longer-term benefits and blinded discontinuation after 6 months," 2005). Early studies of fenfluramine, secretin, and naltrexone were generally disappointing (Campbell, 1988; Campbell et al., 1993; Willemsen-Swinkels et al., 1996; Williams et al., 2012). Summary of the Invention

[0006] The present invention is based at least in part on the discovery that subjects with autism spectrum disorder (ASD) have different levels of brain glutamate in certain brain regions, such as the pregenual anterior cingulate cortex (PgACC).As shown herein, non-invasive imaging methods can be used to determine these measurements, and these levels are then used to identify subpopulations of subjects with ASD that may benefit from treatment with glutamate modulating agents.The method can also be used to predict whether subjects with ASD will respond to glutamate modulating agents, to select treatments that include glutamate modulating agents for subjects with ASD, and to identify subjects with ASD and treat them with glutamate modulating agents.

[0007] Thus, provided herein is a method for predicting the response of a subject with an autism spectrum disorder (ASD) to treatment with a glutamate modulating (decreasing) agent. The method includes the steps of (i) identifying a subject with an ASD, (ii) determining the level of glutamate in one or more selected brain regions of interest (ROIs) in the subject's brain, (iii) comparing the level of glutamate in the ROIs with a reference level, and (iv) identifying a subject having a level of glutamate in the ROIs that is greater than the reference level based on step (iii) as likely to respond to treatment with a glutamate modulating agent.

[0008] Also provided herein is a method for selecting a treatment comprising administering a glutamate modulating (reducing) agent for a subject with autism spectrum disorder (ASD).The method includes the steps of (i) identifying a subject with ASD, (ii) determining the level of glutamate in one or more selected brain regions of interest (ROIs) in the subject's brain, (iii) comparing the level of glutamate in the ROIs with a reference level, and (iv) selecting a treatment with a glutamate modulating agent for a subject having a level of glutamate in the ROIs that exceeds the reference level based on step (iii).

[0009] Additionally, a method for treating a subject with autism spectrum disorder (ASD) is provided herein, which includes the steps of (i) identifying a subject with ASD, (ii) determining the level of glutamate in one or more selected brain regions of interest (ROIs) in the subject's brain, (iii) comparing the level of glutamate in the ROI with a reference level, and (iv) administering a treatment comprising a therapeutically effective amount of a glutamate modulating agent to the subject having a level of glutamate in the ROI that is greater than the reference level based on step (iii).

[0010] Further provided herein is a method for treating a subject having an autism spectrum disorder (ASD), comprising (i) providing a subject identified as having an ASD characterized by increased glutamate activity in one or more selected brain regions of interest (ROIs) in the subject's brain, and (ii) administering to the subject a therapeutically effective amount of a glutamate modulating agent.

[0011] Also provided herein is a method for monitoring the response of a subject with autism spectrum disorder (ASD) to treatment with a glutamate modulating (decreasing) agent.The method includes: (i) identifying a subject with ASD; (ii) determining the baseline level of glutamate in one or more selected brain regions of interest (ROIs) in the subject's brain; (iii) administering two or more doses of a glutamate modulating agent to the subject; (iv) determining the subsequent level of glutamate in the ROI; (v) comparing the baseline level of glutamate in the ROI with the subsequent level, and identifying a subject with a subsequent level of glutamate in the ROI that is below the baseline level as responding to treatment with a glutamate modulating agent.

[0012] In some embodiments, at least one ROI includes all or a portion of the pregenual anterior cingulate cortex (PgACC).

[0013] In some embodiments, determining the level of glutamate in one or more selected ROIs is performed using magnetic resonance imaging (MRI), positron emission tomography (PET) or magnetic resonance spectroscopy (MRS), preferably proton magnetic resonance spectroscopy ( 1 This involves the use of 1H MRS.

[0014] In some embodiments, determining the level of glutamate in the ROI comprises: 1In some embodiments, the proton spectrum is obtained and / or analyzed using H MRS. In some embodiments, the proton spectrum is obtained using two-dimensional J-resolved (2D-JPRESS) 1 H MRS is obtained at 3 or 4 Tesla (3T or 4T).

[0015] In some embodiments, determining the level of glutamate in the ROI comprises using Glutamate Chemical Exchange Saturation Transfer (GluCEST) imaging.

[0016] In some embodiments, the glutamate modulating agent is an NMDAR modulating (inhibitory) agent.

[0017] In some embodiments, the glutamate modulating agent is memantine, a nitro-aminoadamantane compound, lamotrigine, amantadine, D-cycloserine, N-acetylcysteine, an amino-adamantane derivative, or a pharma- ceutically acceptable salt thereof.

[0018] In some embodiments, the reference level represents a level in a cohort of subjects having levels of glutamate in the ROI that exceed the levels of glutamate in the ROI of a cohort of healthy control subjects.

[0019] In some embodiments, the reference level represents a level of glutamate that is at least one standard deviation above the level of glutamate in a cohort of healthy subjects.

[0020] In some embodiments, treatment involves administration of a glutamate modulating agent at least once daily for at least one week, one month, three months, six months, or one year.

[0021] In some embodiments, the therapeutically effective amount is sufficient to result in improvement in one or more functional impairments as measured by the Social Responsiveness Scale-2nd Edition (SRS-2) and / or the Clinical Global Impression (CGI) Severity Scale.

[0022] In some embodiments, the subject has high-functioning ASD (HF-ASD) and / or is intellectually capable.

[0023] In some embodiments, determining the level of glutamate in the ROI can be performed using, for example, 1 In some embodiments, the proton spectrum is obtained and / or analyzed using H MRS. In some embodiments, the proton spectrum is obtained using two-dimensional J-resolved (2D-JPRESS) 1 H MRS is obtained at 3 or 4 Tesla (3T or 4T).

[0024] In some embodiments, the subject is under 21, 18 or 15 years of age.

[0025] In some embodiments, the glutamate modulating agent is memantine or a pharma- ceutically acceptable salt thereof.

[0026] In some embodiments, the glutamate modulating agent is a nitro-amino adamantane compound or a pharma- ceutically acceptable salt thereof.

[0027] In some embodiments, the nitro-aminoadamantane compound is a compound of any one of Formulae (I)-(V).

[0028] In some embodiments, the nitro-amino adamantane compound is

[0029] [ka] and pharma- ceutically acceptable salts thereof.

[0030] Thus, described herein is a method for predicting response to treatment with a glutamate modulating (decreasing) agent in a subject with an autism spectrum disorder (ASD), the method comprising the steps of: (i) identifying a subject with ASD; (ii) determining levels of glutamate in one or more selected brain regions of interest (ROIs) in the subject's brain; (iii) comparing the levels of glutamate in the ROIs with a reference level; and (iv) based on step (iii), identifying subjects having levels of glutamate in the ROIs that exceed the reference level as likely to respond to treatment with a glutamate modulating agent.

[0031] In a related aspect, described herein is a method of selecting a treatment comprising administration of a glutamate modulating (decreasing) agent for a subject having an autism spectrum disorder (ASD), the method comprising: (i) identifying a subject having an ASD; (ii) determining a level of glutamate in one or more selected brain regions of interest (ROI) in the subject's brain; (iii) comparing the level of glutamate in the ROI to a reference level; and (iv) based on step (iii), selecting a treatment with a glutamate modulating agent for a subject having a level of glutamate in the ROI that exceeds the reference level.

[0032] In another related aspect, described herein is a method of treating a subject having an Autism Spectrum Disorder (ASD), comprising: (i) identifying a subject having an ASD; (ii) determining a level of glutamate in one or more selected brain regions of interest (ROI) in the subject's brain; (iii) comparing the level of glutamate in the ROI to a reference level; and (iv) based on step (iii), administering a treatment comprising a therapeutically effective amount of a glutamate modulating agent to subjects having a level of glutamate in the ROI that exceeds the reference level.

[0033] In a related aspect, described herein is a method of treating a subject having an autism spectrum disorder (ASD), the method comprising: (i) providing a subject identified as having an ASD characterized by increased glutamate activity in one or more selected brain regions of interest (ROIs) within the subject's brain; and (ii) administering to the subject a therapeutically effective amount of a glutamate modulating agent.

[0034] In one embodiment of any of the above methods, at least one ROI includes all or a portion of the pregenual anterior cingulate cortex (PgACC). In another embodiment of any of the above methods, determining the level of glutamate in one or more selected ROIs is performed using magnetic resonance imaging (MRI), positron emission tomography (PET) or magnetic resonance spectroscopy (MRS), preferably proton magnetic resonance spectroscopy (MRS). 1 For example, the step of determining the level of glutamate in the ROI can include using H MRS. 1 The method may include obtaining and / or analyzing a proton spectrum using H MRS. The proton spectrum may be obtained using two-dimensional J-resolved (2D-JPRESS) 1 H MRS can be obtained at 3 or 4 Tesla (3T or 4T). In another embodiment, determining the level of glutamate in the ROI can include using Glutamate Chemical Exchange Saturation Transfer (GluCEST) imaging.

[0035] In another embodiment of any of the above methods, the glutamate modulating agent is memantine, a nitro-amino adamantane compound, lamotrigine, amantadine, D-cycloserine or N-acetylcysteine, or a pharma- ceutically acceptable salt thereof.

[0036] In certain embodiments of any of the above methods, the reference level represents the level in the subject group that has the glutamate level in ROI that exceeds the glutamate level in the ROI of the healthy control subject group.For example, the reference level can represent the glutamate level that is at least 1 standard deviation higher than the glutamate level in the healthy subject group.

[0037] In certain embodiments of any of the above methods, the treatment comprises administration of the glutamate modulating agent at least once daily for at least one week, one month, three months, six months, or one year.

[0038] In one embodiment of any of the above methods, the subject has high-functioning ASD (HF-ASD) and / or is intellectually capable.

[0039] In a related aspect, a method for monitoring the response of a subject with an autism spectrum disorder (ASD) to treatment with a glutamate modulating (decreasing) agent is described herein, comprising: (i) identifying a subject with ASD; (ii) determining a baseline level of glutamate in one or more selected regions of interest (ROIs) in the subject's brain; (iii) administering two or more doses of a glutamate modulating agent to the subject; (iv) determining a subsequent level of glutamate in the ROI; (v) comparing the baseline level of glutamate in the ROI with a subsequent level; and identifying a subject with a subsequent level of glutamate in the ROI below the baseline level as responding to treatment with a glutamate modulating agent. At least one ROI can include all or a portion of the pregenual anterior cingulate cortex (PgACC). In certain embodiments, determining the level of glutamate in the one or more selected ROIs comprises using magnetic resonance imaging (MRI), positron emission tomography (PET) or magnetic resonance spectroscopy (MRS), preferably proton magnetic resonance spectroscopy (1H MRS). In another embodiment of any of the above methods, determining the level of glutamate in the one or more selected ROIs comprises using magnetic resonance imaging (MRI), positron emission tomography (PET) or magnetic resonance spectroscopy (MRS), preferably proton magnetic resonance spectroscopy (1H MRS). 1 For example, the step of determining the level of glutamate in the ROI can include using H MRS. 1 The method may include obtaining and / or analyzing a proton spectrum using H MRS. The proton spectrum may be obtained using two-dimensional J-resolved (2D-JPRESS) 1H MRS can be obtained at 3 or 4 Tesla (3T or 4T). In another embodiment, determining the level of glutamate in the ROI can include using glutamate chemical exchange saturation transfer (GluCEST) imaging. In another embodiment, the glutamate modulating agent is memantine, a nitro-aminoadamantane compound, lamotrigine, amantadine, D-cycloserine or N-acetylcysteine, or a pharma- ceutically acceptable salt thereof.

[0040] In another embodiment of any of the above methods, the subject is under the age of 21, 18, or 15. In other embodiments, the subject is 21 years of age or older.

[0041] In certain embodiments of any of the above methods, the glutamate modulating agent is memantine or a pharma- ceutically acceptable salt thereof.

[0042] In certain embodiments of any of the above methods, the glutamate modulating agent is a nitro-aminoadamantane compound or a pharma- ceutically acceptable salt thereof. For example, the nitro-aminoadamantane compound can be a compound of any one of formulas (I)-(V) (described herein). In some embodiments, the nitro-aminoadamantane compound is

[0043] [ka] and pharma- ceutically acceptable salts thereof.

[0044] As used herein, "therapeutically effective amount" refers to the amount of glutamate modulating agent required to ameliorate one or more symptoms of ASD.The effective amount of glutamate modulating agent used to practice the present method for treating ASD can vary depending on the glutamate modulating agent used, the mode of administration, the age, weight and general health of the subject.Finally, the attending physician decides the appropriate amount and dosage regimen.Such amount is referred to as "therapeutically effective amount".

[0045] By "pharmaceutical composition" is meant any composition containing a glutamate modulating agent in combination with a pharma- ceutical acceptable carrier suitable for co-administration to a subject. Pharmaceutical compositions useful in the present methods can take the form of tablets, gel caps, capsules, pills, powders, granules, suspensions, and / or emulsions.

[0046] As used herein, the term "pharmaceutical acceptable carrier" refers to an excipient or diluent in a pharmaceutical composition. For example, a pharmaceutical acceptable carrier may be a vehicle capable of suspending or dissolving an active ingredient (e.g., a glutamate modulating agent). A pharmaceutical acceptable carrier may be compatible with other ingredients of the formulation and not harmful to the recipient. For oral administration, a solid carrier may be preferred.

[0047] As used herein, the term "treat" or "treating" includes administration of a glutamate modulating agent to a subject by any route, e.g., orally. A subject, e.g., a patient, may be one who has an ASD. Treating includes alleviating, alleviating, altering, partially curing, ameliorating, improving, or affecting one or more symptoms of an ASD.

[0048] As used herein, the term "pharmaceutically acceptable salt" refers to a salt form (e.g., an acid addition salt or a metal salt) of a glutamate modulating agent that is suitable for therapeutic use according to the methods described herein.

[0049] As used herein, the term "nitro-aminoadamantane compound" refers to a compound that includes an adamantane moiety substituted with at least one amino group and at least one terminal nitrate group. The nitro-aminoadamantane compound used in the methods described herein is any nitro-aminoadamantane compound of formula (I)-(V), or a subgenus thereof.

[0050] The terms "halogen," "halide," and "halo" refer to fluorine / fluoride, chlorine / chloride, bromine / bromide, and iodine / iodide.

[0051] The term "alkyl" refers to a linear or branched, saturated monovalent hydrocarbon group that may be optionally substituted with one or more substituents as described herein. In certain embodiments, an alkyl group has 1 to 10 carbon atoms (C 1~10 ) or 1 to 6 (C 1~6 ) or a linear saturated monovalent hydrocarbon radical having 3 to 10 (C 3~10 ) or 3 to 6 (C 3~6 ) carbon atom. 1~6 The term "alkyl" refers to a linear saturated monovalent hydrocarbon radical of one to six carbon atoms or a branched saturated monovalent hydrocarbon radical of three to six carbon atoms. 1~6 and branched chain C 3~6 Alkyl groups are sometimes referred to as "lower alkyl" groups. Non-limiting examples of alkyl groups include methyl, ethyl, propyl (including n-propyl and isopropyl), butyl (including all isomers, e.g., n-butyl, isobutyl, sec-butyl and tert-butyl), pentyl (including all isomers, e.g., n-pentyl), and hexyl (including all isomers, e.g., n-hexyl).

[0052] The terms "alkylene" and "-alkyl-" refer to a divalent alkyl group optionally substituted with one or more substituents, as described herein.

[0053] The term "heteroalkyl" refers to a linear or branched, saturated monovalent hydrocarbon group containing one or more heteroatoms independently selected from O, N, and S. In some embodiments, the one or more heteroatoms are in the backbone of the linear or branched hydrocarbon group. The terms "heteroalkylene" and "-heteroalkyl-" refer to a divalent heteroalkyl group. Heteroalkyl and -heteroalkyl- groups may be optionally substituted with one or more substituents as described herein. Examples of heteroalkyl and -heteroalkyl- groups include, but are not limited to, -(CH2) m -(O or S)-(CH2) n CH3 and -(CH2) m -(O or S)-(CH2) p - (wherein m is 1, 2 or 3; n is 0, 1 or 2; and p is 1, 2 or 3).

[0054] The term "alkoxy" refers to an --O-alkyl group optionally substituted with one or more substituents as described herein.

[0055] Examples of -O-heteroalkyl and -O-heteroalkyl- groups include, but are not limited to, -(OCH2CH2) n -OR and -(OCH2CH2) n Examples of heteroalkyl groups include, but are not limited to, ethylene glycol and polyethylene glycol (PEG) groups, including -O-, where R is hydrogen or alkyl, and n is 1, 2, or 3. For -O-heteroalkyl-ONO2 groups, it is understood that when the -O-heteroalkyl group is an ethylene glycol or PEG group, the terminal oxygen atom of the ethylene glycol or PEG group is part of the nitrate (-ONO2) group. -O-heteroalkyl and -O-heteroalkyl- groups may be optionally substituted with one or more substituents as described herein.

[0056] The term "haloalkyl" refers to an alkyl group substituted with one or more halogen / halide atoms. Haloalkyl groups may be optionally substituted with one or more further substituents as described herein. Examples of haloalkyl groups include, but are not limited to, fluoroalkyl groups, such as -CHF, -CHF and -(CH) n CF3, and perfluoroalkyl groups such as -CF3 and -(CF2) n CF3 (wherein n is 1, 2, 3, 4 or 5).

[0057] The term "-alkylaryl" refers to an alkyl group that is substituted with one or more aryl groups. The -alkylaryl group may be optionally substituted with one or more further substituents as described herein.

[0058] The term "cycloalkyl" refers to a cyclic, saturated, bridged or unbridged, monovalent hydrocarbon group, optionally substituted with one or more substituents as described herein. In certain embodiments, a cycloalkyl group is an alkyl group having 3 to 10 carbon atoms (C 3~10 ) or 3 to 8 pieces (C 3~8 ) or 3 to 6 (C 3~6 ) carbon atoms. Non-limiting examples of cycloalkyl groups include cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, cyclooctyl, norbornyl, decalinyl, and adamantanyl. The term "-cycloalkyl-" refers to a divalent cycloalkyl group, optionally substituted with one or more substituents, as described herein.

[0059] The terms "heterocyclyl" and "heterocyclic" refer to a monocyclic non-aromatic group or a polycyclic group containing at least one non-aromatic ring, in which at least one non-aromatic ring contains one or more heteroatoms independently selected from O, N, and S. The non-aromatic ring containing one or more heteroatoms may be attached to or fused to one or more saturated, partially unsaturated, or aromatic rings. In certain embodiments, the heterocyclyl or heterocyclic group has 3 to 10, or 3 to 8, or 3 to 6 ring atoms. In some embodiments, the heterocyclyl or heterocyclic group may include fused or bridged ring systems, may have nitrogen or sulfur atoms optionally oxidized, may have nitrogen atoms optionally quaternized, and is a monocyclic, bicyclic, or tricyclic system in which one or more rings may be fully or partially saturated or aromatic. The heterocyclyl or heterocyclic group may be attached to the main structure at any heteroatom or carbon atom that results in a stable compound.Examples of heterocyclyl or heterocyclic groups include, but are not limited to, azepinyl, azetidinyl, aziridinyl, benzodioxanyl, benzodioxolyl, benzofuranonyl, benzopyranonyl, benzopyranyl, benzotetrahydrofuranyl, benzotetrahydrothienyl, benzothiopyranyl, β-carbolinyl, chromanyl, decahydroisoquinolinyl, dihydrobenzisothiazinyl, dihydrobenzisoxazinyl, dihydrofuryl, dihydropyranyl, dihydropyrazinyl, dihydropyridinyl, dihydropyrazolyl, dihydropyrimidinyl, dihydropyrrolyl, dioxolanyl, dithianyl, furanonyl, imidazolidinyl, imidazolinyl, indolinyl, indolizinyl, and the like. Examples of heterocyclyl include isobenzotetrahydrofuranyl, isobenzotetrahydrothienyl, isochromanyl, isoindolinyl, isothiazolidinyl, isoxazolidinyl, morpholinyl, octahydroindolyl, octahydroisoindolyl, oxazolidinonyl, oxazolidinyl, oxiranyl, piperazinyl, piperidinyl, 4-piperidonyl, pyrrolidinyl, pyrrolinyl, quinuclidinyl, tetrahydrofuryl, tetrahydrofuranyl (oxolanyl), tetrahydroisoquinolinyl, tetrahydropyranyl, tetrahydrothienyl (tetrahydrothiophenyl, thiolanyl), thiamorpholinyl (thiomorpholinyl), thiazolidinyl, and 1,3,5-trithianyl. The term "-heterocyclyl-" refers to a divalent heterocyclyl group. Heterocyclyl or heterocyclic groups, and -heterocyclyl- groups may be optionally substituted with one or more substituents as described herein.

[0060] The term "aryl" refers to a monocyclic aromatic hydrocarbon group or a polycyclic group containing at least one aromatic hydrocarbon ring. In certain embodiments, an aryl group has 6 to 10 ring atoms. Non-limiting examples of aryl groups include phenyl, naphthyl, fluorenyl, azulenyl, anthryl, phenanthryl, biphenyl, and terphenyl. The aromatic hydrocarbon ring of an aryl group may be bonded to or fused with one or more saturated, partially unsaturated, or aromatic rings, such as dihydronaphthyl, indenyl, indanyl, tetrahydronaphthyl (tetralinyl). The term "-aryl-" refers to a divalent aryl group. Aryl and -aryl- groups may be optionally substituted with one or more substituents as described herein.

[0061] The term "heteroaryl" refers to a monocyclic aromatic group or a polycyclic group containing at least one aromatic ring, where at least one aromatic ring contains one or more heteroatoms independently selected from O, N, and S. The heteroaromatic ring may be attached to or fused to one or more saturated, partially unsaturated, or aromatic rings, which may contain only carbon atoms or may contain one or more heteroatoms. The heteroaryl group may be attached to the main structure at any heteroatom or carbon atom to produce a stable compound. In certain embodiments, the heteroaryl group has 5 to 10 ring atoms. Examples of monocyclic heteroaryl groups include, but are not limited to, pyrrolyl, pyrazolyl, pyrazolinyl, imidazolyl, oxazolyl, isoxazolyl, thiazolyl, thiadiazolyl, isothiazolyl, furanyl, thienyl (thiophenyl), oxadiazolyl, triazolyl, tetrazolyl, pyridyl, pyridonyl, pyrazinyl, pyrimidinyl, pyridazinyl, pyridazinonyl, and triazinyl. Non-limiting examples of bicyclic heteroaryl groups include indolyl, benzothiazolyl, benzothiadiazolyl, benzoxazolyl, benzisoxazolyl, benzothienyl (benzothiophenyl), quinolinyl, tetrahydroisoquinolinyl, isoquinolinyl, benzimidazolyl, benzotriazolyl, indolizinyl, benzofuranyl, isobenzofuranyl, chromonyl, coumarinyl, cinnolinyl, quinazolinyl, quinoxalinyl, indazolyl, naphthyridinyl, phthalazinyl, quinazolinyl, purinyl, pyrrolopyridinyl, furopyridinyl, thienopyridinyl, dihydroisoindolyl, and tetrahydroquinolinyl. Examples of tricyclic heteroaryl groups include, but are not limited to, carbazolyl, benzindolyl, dibenzofuranyl, phenanthrolinyl, acridinyl, phenanthridinyl, xanthenyl, and phenothiazinyl. The term "-heteroaryl-" refers to a divalent heteroaryl group. Heteroaryl and -heteroaryl- groups can be optionally substituted with one or more substituents as described herein.

[0062] Each of the groups described herein (including, without limitation, monovalent and divalent alkyl, heteroalkyl, -O-alkyl, -O-heteroalkyl, alkylaryl, cycloalkyl, heterocyclyl, aryl, and heteroaryl) can be optionally substituted with one or more substituents, either as a primary group or as a substituent. In certain embodiments, each of the groups described herein can be substituted with any of a halide, cyano, nitro, nitrate, hydroxyl, sulfhydryl (-SH), -NH2, -OR, -N, -N- ... 11 , -SR 11 , -NR 12 R 13 , -C(=O)R 11 , -C(=O)OR 11 , -OC(=O)R 11 , -C(=O)NR 12 R 13 , -NR 12 C(=O)R 11 , -OC(=O)OR 11 , -OC(=O)NR 12 R 13 , -NR 12 C(=O)OR 11 , -NR 11 C(=O)NR 12 R 13 , optionally substituted with 1, 2, 3, 4, 5, or 6 substituents independently selected from alkyl, haloalkyl, alkoxy, cycloalkyl, heterocyclyl, aryl, and heteroaryl. (In the formula, R 11 is independently at each occurrence hydrogen, alkyl, cycloalkyl, heterocyclyl, aryl, or heteroaryl; R 12 and R 13 is independently at each occurrence hydrogen, alkyl, cycloalkyl, heterocyclyl, aryl, or heteroaryl, or R 12 and R 13 and the nitrogen atom to which they are attached form a heterocyclic or heteroaryl ring).

[0063] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by those skilled in the art to which this invention belongs.Methods and materials are described herein for use in the present invention, and other suitable methods and materials known in the art can also be used.Materials, methods, and examples are illustrative only and are not intended to be limiting.All publications, patent applications, patents, sequences, database entries, and other references mentioned herein are incorporated by reference in their entirety.In case of conflict, the present specification, including definitions, will control.

[0064] Other features and advantages of the present disclosure will become apparent from the following detailed description and drawings, and from the claims. [Brief description of the drawings]

[0065] [Figure 1] FIG. 1 is an exemplary RCT CONSORT flow diagram showing the study profile including eligibility, randomization, and participant follow-up throughout the trial of memantine for autism-related behaviors in youth. [Figure 2-1] 2A-D are tables of treatment response to baseline PgACC glutamate activity. A. Baseline PgACC glutamate activity in ASD. [Figure 2-2] B. Treatment response relative to baseline PgACC glutamatergic activity. [Figure 2-3] Same as above. [Figure 2-4] C. Three-way interaction between treatment group, wave, and baseline glutamatergic activity. [Figure 2-5] D. Comparison of AUC response to treatment between memantine and placebo relative to baseline glutamate activity. [Diagram 3] FIG. 3 is a schematic diagram showing an exemplary voxel arrangement in the anterior part of the anterior cingulate cortex (ACC). DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0066] Described herein is a method for identifying the subpopulation of subjects with ASD that can benefit from treatment with glutamate modulating agents.The methods described herein include treatment methods in which ASD subjects are first screened before starting treatment with glutamate modulating agents to improve patient outcomes.

[0067] The existing evidence for the role of glutamatergic agents for the treatment of social impairment in ASD is promising. Dysregulation of glutamatergic activity has been hypothesized to be related to the pathophysiology of ASD (Carlsson, 1998; McDougle, 2002). Glutamate is the major excitatory amino acid transmitter in the brain and is involved in neurodevelopment and synaptic plasticity through its activity at N-methyl-D-aspartate (NMDA) receptors (Cotman & Anderson, 1995). Overactivation of glutamatergic is associated with excitotoxicity and apoptosis. Serology, postmortem brain, genetic and proton magnetic resonance spectroscopy ( 1 Studies of the HMRS suggest increased glutamatergic activity in ASD (Blue et al., 1999; Fatemi et al., 2002; Jamain et al., 2002; Lappalainen & Riikonen, 1996; Purcell & Sham, 2002; Ramoz et al., 2004; Serajee et al., 2003; Shimmura et al., 2011; Shuang et al., 2004). 1The HMRS study reported significantly increased brain glutamatergic activity in the pregenual anterior cingulate cortex (PgACC) in adolescent males with high-functioning ASD (HF-ASD), without any such abnormalities in bilateral MTL regions (Joshi et al., 2012). The ACC is essential for social and emotional processing and is therefore a region of interest in autism. Evidence from various modes of investigation suggests abnormalities in the ACC region in individuals with ASD, including histopathological changes of increased cell population density and reduced cell size, volume, reduced regional cerebral blood flow, and decreased metabolic activity (Haznedar, Buchsbaum, Metyger, et al., 1997), along with abnormal functional activity (resting state associated with Theory of Mind tasks) (Bauman & Kemper, 1985; Di Martino et al., 2008; Di Martino et al., 2009; Haznedar, Buchsbaum, Metzger, et al., 1997; Kemper & Bauman, 1998; Ohnishi et al., 2000; Silk et al., 2006; Simms et al., 2009).

[0068] The glutamate modulators memantine, lamotrigine, amantadine, D-cycloserine, and N-acetylcysteine ​​are being investigated as potential treatments for the core symptoms of ASD, but the empirical evidence to date for their efficacy from a limited number of controlled trials conducted in populations of adolescents with ASD who also have intellectual disabilities is moderate at best (Belsito et al., 2001; D'Souza et al., 1995; Posey et al., 2004).

[0069] Lamotrigine is an antiepileptic drug of the phenyltriazine class that stabilizes neuronal membranes by blocking sodium channels and reduces glutamate release. Lamotrigine has been shown to be an effective mood stabilizer for bipolar disorder, but does not appear to have any effect on ASD symptoms. In an RCT, investigators found no significant differences in improvement between lamotrigine or placebo groups on the Autism Behavior Checklist, Aberrant Behavior Checklist, Vineland Adaptive Behavior Scale, PL-ADOS, or CARS (Belsito et al., 2001).

[0070] Like memantine, amantadine is a noncompetitive NMDA antagonist. Only one randomized controlled trial has been conducted on the effects of amantadine on ASD. The study showed improvement in ASD symptoms in 5-19 year olds after 4 weeks of amantadine hydrochloride vs. placebo. This improvement was reflected only in the clinical rating scale CGI, but not in the parent-rated behavioral scale ABC-CV (King et al., 2001).

[0071] D-cycloserine is a partial glycine agonist at N-methyl-D-aspartate (NMDA) receptors. It has been shown to improve stereotypic symptoms in older adolescents and young adults with ASD as measured by the Aberrant Behavior Checklist subscale 3 (Urbano et al., 2014). The same group of investigators also showed that application of D-cycloserine resulted in statistically and clinically significant improvements in the Interpersonal Responsiveness Scale and the Aberrant Behavior Checklist (Urbano et al., 2015).

[0072] NAC is an antioxidant commonly used to restore hepatic concentrations of cysteine ​​after liver injury. Cysteine ​​groups are also oxidized to cystine, which interacts with the glutamate-cystine antiporter and theoretically reduces glutamate neurotransmission. One RCT of NAC shows significant improvements in ABC excitability subscale scores compared to a placebo group in children with ASD (Hardan et al., 2012). However, another study suggests that NAC shows no significant effect on social impairment in adolescents with ASD (Wink et al., 2016).

[0073] Memantine is a medium affinity noncompetitive NMDA receptor antagonist approved by the United States Food and Drug Administration (FDA) for the treatment of moderate to severe Alzheimer's disease (USFDA, 2003). Preliminary evidence from limited trials of memantine in adolescents clearly suggests an acceptable safety and tolerability profile (Aman et al., 2017; Findling et al., 2007). Available data from retrospective and prospective treatment studies of memantine in individuals with ASD reported significant improvements in a variety of behavioral impairments, including attention, hyperactivity, language, eye contact, social interaction and social withdrawal, and repetitive behaviors (Aman et al., 2017; Findling et al., 2007). The only controlled trial of memantine in children with or without intellectual disability who received memantine for 12 weeks at a substantially lower dose (mean dose 5 mg / day) due to the study design reported no improvement in ASD behaviors versus the observed placebo response (Aman et al., 2017).Preliminary results from an uncontrolled trial of memantine reported significant improvements in social behaviors in adults with HF-ASD following 12 weeks of treatment with 20 mg / day of memantine (Joshi et al., 2016).

[0074] One common limitation of the above-mentioned trials of glutamate modulators in ASD is that many were conducted in intellectually disabled populations, which does not allow for testing of treatment responses to the higher order social impairments observed in intellectually able populations with ASD.

[0075] None of the above studies utilize biomarkers characteristic of subpopulations of ASD subjects that respond to treatment with glutamate modulators. The present invention arises from the discovery of such biomarkers and provides a strategy for the treatment of subpopulations as part of precision medicine therapeutic intervention. This study evaluated the short-term behavioral and neurological effects of memantine therapy in ASD. The clinical and neurological response to short-term memantine therapy was investigated in adolescents with ASD by conducting a 12-week randomized controlled trial (RCT). The study demonstrated the clinical efficacy and tolerability of glutamate modulators for the treatment of social impairment in adolescents with ASD who have elevated levels of glutamate in the ACC.

[0076] subject The methods described herein can be used to identify, select and treat subjects with ASD, for example, those diagnosed with ASD. These controls can include those who meet the DSM-IV-TR / 5 diagnostic criteria for autism, which is confirmed by clinical diagnostic evaluation. In some embodiments, the subject has at least moderate severity of ASD, as determined by informant-rated Social Responsiveness Scale, 2nd Edition (SRS-2; Constantino et al., 2003) score and / or clinician-rated National Institute of Mental Health (NIMH) Clinical Global Impression (CGI) Severity Scale (CGI-S; NIMH, 1985) score. In some embodiments, the subject does not have a formal diagnosis of ASD. In some embodiments, the subject is considered high-functioning or does not have intellectual disability (IQ>70).

[0077] Interpersonal Responsiveness Scale The Interpersonal Responsiveness Scale, Second Edition (SRS-2) school-age form assesses the severity of ASD symptoms in children aged 4–18 years. This handy, written questionnaire is completed by the child's caregiver and contains a total of 65 items. The rating scale measures the severity of ASD symptoms, including components of reciprocal social behavior (39 items), social use of language (6 items), and behaviors characteristic of children with ASD (20 items). Each item of the scale is rated on a Likert scale ranging from "0" (not at all true) to "3" (always true). There are five calculable treatment subscales, social awareness, social cognition, social communication, social motivation, and autistic stereotypies, which can provide further information to the clinician. The psychometric properties of the SRS are well established as a valid instrument for assessing autistic traits and can distinguish autism from other neuropsychiatric conditions (Constantino et al., 2003; Constantino & Todd, 2003). The assessment takes approximately 15-20 minutes to complete.

[0078] [Table 1]

[0079] [Table 2]

[0080] [Table 3]

[0081] Clinical overall impression The Clinical Global Impression is a clinician-rated scale measuring overall mental health, with scores ranging from 1 to 7. It includes subscales for Global Severity (CGI-S: 1, normal; 2, borderline mental illness; 3, mild mental illness; 4, moderate mental illness; 5, significant mental illness; 6, severe mental illness; and 7, very severe mental illness) and Global Improvement (CGI-I: 1, markedly improved; 2, much improved; 3, slightly improved; 4, unchanged; 5, slightly worse; 6, much worse; 7, severely worse). The CGI-I measures disease improvement and treatment effectiveness, and has an efficacy index that represents the extent of the treatment effect experienced along with the level of adverse events (AEs).

[0082] In some embodiments, the subject has no prior or has not recently (e.g., within the last 7, 14, 21, 28, 45, or 60 days or more) treatment with memantine or other glutamate modulating agents, such as lamotrigine, amantadine, and D-cycloserine.

[0083] In some embodiments, the subject is at least 6, 7, or 8 years old, and up to 12, 13, 14, 15, 16, 17, or 18 years old. In some embodiments, the subject is between 4, 5, 6, 7, 8 years old and up to 12, 13, 14, 15, 16, 17, 18, 19, 20, or 21 years old. Ranges of any of these specific ages as endpoints are also provided.

[0084] Selecting a target The method includes identifying and selecting subjects having increased levels of glutamate in a selected region of interest (ROI) in the brain, including the pregenual anterior cingulate cortex (PgACC). ... using magnetic resonance imaging (MRI 1 In some embodiments, the method may include obtaining and / or analyzing glutamate activity in the ROI, e.g., PgACC, using, for example, two-dimensional J-decomposition (2D-JPRESS). 1It is based on the acquisition and / or analysis of proton spectra obtained, for example, at 3 or 4 Tesla (3T or 4T) using a 1 H MRS protocol. For example, Ongur et al., Biol Psychiatry 2008; 64:718-726; Henry et al., Journal of Magnetic Resonance 208 (2011) 210-218; Jensen et al., NMR Biomed. 2009 Aug; 22(7):762-9; Prescot et al., J Magne Reson Imaging. 2013 Mar; 37(3):642-5; Dhamala et al., NMR in Biomedicine. 2019; 32:e4058; Ding et al., Magnetic Resonance in Medicine 73:921-928 (2015); Gottschalk et al., NMR Biomed. 2016; 29: 943-951; Wiebenga et al., NMR Biomed. 2014; 27: 304-311; and Bogner et al., NMR Biomed. 2012; 25: 873-882; Wozniak et al., Isr J Psychiatry Relat Sci. 2012; 49(1):62-9; Joshi et al., Eur Arch Psychiatry Clin Neurosci. 2013 Aug; 263(5):379-84. Alternatively, glutamate chemical exchange saturation transfer (CEST) imaging technology (GluCEST) can be used (Mao et al., Quant Imaging Med Surg. 2019 Oct; 9(10): 1652-1663). In some embodiments, glutamate concentration in combination with glutamine and gamma-aminobutyric acid (collectively referred to as Glx) is measured. In some embodiments, only glutamate concentrations are measured, and / or neither glutamine nor gamma-aminobutyric acid or both are measured.

[0085] In some embodiments, the method can include imaging a region of interest (ROI), for example, a ROI including a single voxel of 8cc (2cm x 2cm x 2cm) placed along the midline in the PgACC with the inferior edge of the voxel parallel to the descending plane of the corpus callosum, as determined by a longitudinal relaxation time (T1) image also used for tissue segmentation as shown in Figure 3. Other voxel sizes can be used, for example 1mm x 1mm x 1mm (van Elst et al., 2014), 20mm x 20mm x 20mm (Cochran et al., 2015), 3cm x 3cm x 3cm (Ito et al., 2017), or 2.5cm x 4cm x 2cm (Montag et al., 2008), or variations thereof.

[0086] These methods can be used to determine the level of glutamate in a ROI in a subject, which can then be compared to a reference level.

[0087] Suitable reference value can be determined by using methods known in the art, for example by using standard clinical test methods and statistical analysis.Reference value can have any relevant format.In some cases, the reference comprises a predetermined value for meaningful glutamate level, for example, the control reference level that represents normal or near-normal glutamate level, for example, the level in the control subject that has ASD but may not respond to treatment with glutamate modulating agent, and / or the responder criterion that shows elevated glutamate level, for example, the level in the subject that may respond to treatment with glutamate modulating agent.

[0088] The predetermined level can be a single cut-off (threshold) value, such as a median or mean value, or a level that defines the upper or lower quartile, tertile, or boundary of another segment of the clinical trial population that is determined to be statistically different from the other segment. It can be a range of cut-off (or threshold) values, such as a confidence interval. This can be established based on a comparison group, for example, when the relationship between the likelihood of response in one defined group is fold higher or lower (e.g., approximately 2-fold, 4-fold, 8-fold, 16-fold, or more) than the likelihood of response in another defined group. This can be, for example, a range where a population of subjects (e.g., control and ASD subjects) is divided evenly (or unequally) into groups, such as low glutamate, medium glutamate and high glutamate groups, where those in the high glutamate group are most likely to respond to treatment with a glutamate modulating agent; or into quartiles, where the lowest quartile is the subjects with the lowest glutamate and the highest quartile is the subjects with the highest glutamate, or into n quartiles (i.e., n evenly spaced intervals), where the lowest n quartile is the subjects with the lowest glutamate and the highest n quartile is the subjects with the highest glutamate, again where those in the high glutamate group are most likely to respond to treatment with a glutamate modulating agent. In some embodiments, the threshold is one standard deviation from the level of glutamate in healthy controls.

[0089] The subject (or a cohort of subjects) associated with a given value is typically referred to as a reference subject.For example, in some embodiments, the control or reference subject does not have a disorder (e.g., ASD) described herein.In some embodiments, the control or reference subject has ASD, but is not prone to respond or may respond to treatment with glutamate modulating agent.In some cases, it may be desirable for the control subject (or a cohort of subjects) to be age (e.g., age range) or gender matched.

[0090] Thus, in some cases, a glutamate level in a subject that is less than or equal to the baseline level of glutamate indicates a low likelihood of response to treatment with a glutamate modulating agent. In other cases, a glutamate level in a subject that is greater than or equal to the baseline level of glutamate indicates a high likelihood of response to treatment with a glutamate modulating agent. In some embodiments, the amount by which the glutamate level in a subject is lower than or exceeds the baseline level is sufficient to distinguish the subject from a control subject, and in some cases is statistically significantly lower than or higher than the level in the control subject. When the glutamate level in a subject is equal to the baseline level of glutamate, "equal" refers to approximately equal (e.g., not statistically different or within one standard deviation).

[0091] The predetermined value may depend on the particular population of the selected subject (e.g., human subject). For example, an apparently healthy population has a different "normal" level range of glutamate than a population of subjects with ASD. Thus, the selected predetermined value may take into account the classification (e.g., gender, age, health status, risk, presence of other diseases) that the subject (e.g., human subject) falls into. Appropriate ranges and classifications can be selected by those skilled in the art using only routine experimentation.

[0092] In some embodiments, glutamate levels are determined to be equal to or above a threshold or reference level in a cohort of subjects responsive to treatment with a glutamate modulating (lowering) agent, and the subjects are then identified and / or selected as a high glutamate group as likely to respond to treatment with the glutamate modulating agent, and optionally treated with the glutamate modulating agent.

[0093] Glutamate Modulators Glutamate modulating agents that can be used in the methods described herein include, but are not limited to, memantine, nitro-aminoadamantane compounds, lamotrigine, amantadine, D-cycloserine, N-acetylcysteine, other amino-adamantane derivatives, or pharma- ceutically acceptable salts thereof.

[0094] The nitro-aminoadamantane compound used in the methods described herein can be any compound of formula (I)-(V):

[0095] [ka] (In formulas (I)-(IV), Y is a nitrate-containing group, and R1, R2, R3, R4, R5, X, p, and m are as defined elsewhere herein). In formula (V), Y 1 , Y 2 and Y 3 each optionally being a nitrate-containing group, and Y 1 , Y 2 , Y 3 , X 1 , X 2 , X 3 , R 3 and R 4 m is as defined elsewhere herein.

[0096] Nitro-aminoadamantane compounds The nitro-aminoadamantane compounds used in the methods described herein can be synthesized using methods similar to those described in U.S. Pat. No. 7,326,730 and PCT Publication WO 2019104020, each of which is incorporated herein in its entirety.

[0097] The nitro-aminoadamantane compound used in the methods described herein is a compound of formula (I)

[0098] [ka] or a pharma- ceutically acceptable salt thereof. (In the formula, R 1 and R 2 is independently hydrogen, halide, straight or branched alkyl, straight or branched heteroalkyl, straight or branched alkoxy, straight or branched -O-heteroalkyl, cycloalkyl, heterocyclyl, aryl, or heteroaryl, each of which is optionally substituted; R 3 and R 4 are independently hydrogen or a straight or branched C1-C6 alkyl, or R 3 , R 4 and the nitrogen atom to which they are attached form a 3- to 8-membered heterocycle; R 5 is hydrogen or linear or branched C1-C6 alkyl, X is a bond, a linear or branched -alkyl-, a linear or branched -heteroalkyl-, a linear or branched -O-alkyl-, a linear or branched -O-heteroalkyl-, -(CH2) j -Cycloalkyl-(CH2) k -, -(CH2) j Heterocycle-(CH2) k -, -(CH2) j -aryl-(O) h -(CH2) k -or-(CH2) j -heteroaryl-(O) h -(CH2) k -, each of which is optionally substituted; Y is -ONO2 or

[0099] [ka] and m is 0, 1, 2, 3, 4 or 5; j is 0, 1, 2 or 3; k is 0, 1, 2 or 3; and h is 0 or 1.

[0100] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has the formula (Ia):

[0101] [ka] or a pharma- ceutically acceptable salt thereof, 1 , R 2 , X and Y are as defined for formula (I) and n is 1, 2, 3, 4, 5 or 6).

[0102] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has the formula (IA):

[0103] [ka] or a pharma- ceutically acceptable salt thereof, 1 , R 2 , R 3 , R 4 , R 5 , X and m are as defined for formula (I).

[0104] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has the formula (IA-a):

[0105] [ka] or a pharma- ceutically acceptable salt thereof, 1 , R 2 and X is as defined for formula (I) and n is 1, 2, 3, 4, 5 or 6).

[0106] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has the formula (IB):

[0107] [ka]

[0108] or a pharma- ceutically acceptable salt thereof, 1 , R 2 , R 3 , R 4 , R 5 , X and m are as defined for formula (I).

[0109] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has the formula (IB-a):

[0110] [ka] or a pharma- ceutically acceptable salt thereof, 1 , R 2 and X is as defined for formula (I) and n is 1, 2, 3, 4, 5 or 6).

[0111] In some embodiments, X and subgenera of compounds of formula (I) are a bond, a linear or branched C1-C6 or C1-C3-alkyl-, or a linear or branched C1-C6 or C1-C3-O-alkyl-. In certain embodiments, X and subgenera of compounds of formula I are a bond or a linear or branched C1-C3-alkyl-[e.g., -CH2-, -(CH2)2-, - C HCH3, -(CH2)3-, - C HCH2CH3, -CH2 C -HCH3 or -CH(CH3)CH2- C " In the original text, the bond positions are marked.)

[0112] The nitro-aminoadamantane compounds used in the methods described herein are compounds of formula (II) or (III)

[0113] [ka] or a pharma- ceutically acceptable salt thereof. (In the formula, R 1 and R 2 is independently hydrogen, halide, straight or branched chain alkyl, straight or branched chain heteroalkyl, straight or branched chain alkoxy, straight or branched chain -O-heteroalkyl, cycloalkyl, heterocyclyl, aryl, or heteroaryl, each of which is optionally substituted; R 3 and R 4 are independently hydrogen or a straight or branched C1-C6 alkyl, or R 3 , R 4 and the nitrogen atom to which they are attached form a 3- to 8-membered heterocycle; R 5 is hydrogen or linear or branched C1-C6 alkyl, X is a bond, a linear or branched -alkyl-, a linear or branched -heteroalkyl-, a linear or branched -O-alkyl-, a linear or branched -O-heteroalkyl-, -(CH2) j -Cycloalkyl-(CH2) k -, -(CH2) j Heterocycle-(CH2) k -, -(CH2) j -aryl-(O) h -(CH2) k -or-(CH2) j -heteroaryl-(O) h -(CH2) k -, each of which is optionally substituted; Y is -ONO2 or

[0114] [ka] and m is 0, 1, 2, 3, 4 or 5; j is 0, 1, 2 or 3; k is 0, 1, 2 or 3; and h is 0 or 1.

[0115] The nitro-aminoadamantane compound used in the methods described herein is a compound of formula (IV)

[0116] [ka] or a pharma- ceutically acceptable salt thereof, 1 , R 2 , X and Y are as defined for formulas (II) and (III), and p is 0, 1, 2, 3, 4, 5, or 6.

[0117] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has the formula (IV-a):

[0118] [ka] or a pharma- ceutically acceptable salt thereof, wherein X and Y are as defined for formulas (II) and (III) and p is 0, 1, 2, 3, 4, 5 or 6.

[0119] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein is represented by formula (II-a) or formula (III-a):

[0120] [ka] or a pharma- ceutically acceptable salt thereof, 1 , R 2 , R3 , R 4 , R 5 , X and m are as defined for formulas (II) and (III).

[0121] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has the formula (IVA):

[0122] [ka] or a pharma- ceutically acceptable salt thereof, 1 , R 2 and X is as defined for formulas (II) and (III) and p is 0, 1, 2, 3, 4, 5 or 6).

[0123] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has the formula (IVA-a):

[0124] [ka] or a pharma- ceutically acceptable salt thereof, wherein X is as defined for formulas (II) and (III) and p is 0, 1, 2, 3, 4, 5 or 6.

[0125] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has formula (IIB) or formula (IIIB):

[0126] [ka] or a pharma- ceutically acceptable salt thereof, 1 , R 2 , R 3 , R 4 , R 5, X and m are as defined for formulas (II) and (III).

[0127] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has the formula (IVB):

[0128] [ka] or a pharma- ceutically acceptable salt thereof, 1 , R 2 and X is as defined for formulas (II) and (III), and p is 0, 1, 2, 3, 4, 5 or 6.

[0129] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has the formula (IVB-a):

[0130] [ka] or a pharma- ceutically acceptable salt thereof, wherein X is as defined for formulas (II) and (III) and p is 0, 1, 2, 3, 4, 5 or 6.

[0131] For compounds of formula (II) and (III) and subgenera, compounds of formula III and subgenera, and compounds of formula IV and subgenera, the -XY, -X-ONO2 or -X-CH(ONO2)CH2-ONO2 moiety may be attached at the ortho, meta or para position of the phenyl ring. In certain embodiments, the -XY, -X-ONO2 or -X-CH(ONO2)CH2-ONO2 moiety is attached at the meta position of the phenyl ring.

[0132] For compounds of formula (II), (III), (IV) and subgenera, in some embodiments, X is a bond, a linear or branched C1-C6 or C1-C3-alkyl-, or a linear or branched C1-C6 or C1-C3-O-alkyl-. In certain embodiments, X is a bond or a linear or branched C1-C3-O-alkyl- [e.g., -O-CH2-, -O-(CH2)2-, -O- C HCH3, -O-(CH2)3-, -O- C HCH2CH3, -O-CH2 C -HCH3 or -O-CH(CH3)CH2- C " In the original text, the bond positions are marked.)

[0133] For compounds of formula (I), (II) and (III) and subgenera thereof, examples of 3-8 membered nitrogen-containing heterocycles include, but are not limited to, aziridinyl, azetidinyl, pyrrolidinyl, piperidinyl, morpholinyl, piperazinyl, azepanyl and azocanyl, where the second ring nitrogen atom of the piperazinyl group is optionally substituted with a straight chain C1-C3 alkyl group or a -(C=O)R group, where R is hydrogen or a straight chain C1-C3 alkyl group. In certain embodiments, R 3 , R 4 and the nitrogen atom to which they are attached form a 3- to 6-membered heterocycle.

[0134] For compounds of formula (I), (III) and (IV) and subgenera thereof, in certain embodiments, m is 0, 1 or 2; n is 1, 2 or 3; and p is 0, 1, 2 or 3.

[0135] For compounds of formula (I), (II) and (III) and subgenera thereof, in some embodiments, R 3 and R 4 are both hydrogen. In other embodiments, R 3 and R 4 One of R is hydrogen and the other is a straight or branched C1-C3 alkyl.3 and R 4 In yet other embodiments, one of R 3 and R 4 are independently straight chain C1-C3 alkyl (e.g., methyl or ethyl), optionally the same alkyl group.

[0136] For compounds of formula (I) and (III) and subgenera thereof, in some embodiments, R 5 is hydrogen. In other embodiments, R 5 is a straight or branched C1-C3 alkyl. In certain embodiments, R 5 is methyl or ethyl.

[0137] For compounds of formula (I), (II), (III) and (IV) and subgenera thereof, in some embodiments, R 1 and R 2 are independently hydrogen or straight or branched C1-C6 or C1-C3 alkyl. 1 and R 2 are both hydrogen. In other embodiments, R 1 is hydrogen, and R 2 is a straight or branched chain C1-C6 or C1-C3 alkyl, or R 2 is hydrogen, and R 1 is a straight or branched chain C1-C6 or C1-C3 alkyl. In certain embodiments, R 1 is hydrogen, and R 2 is methyl, ethyl or n-propyl, or R 2 is hydrogen, and R 1 is methyl, ethyl, or n-propyl. In still other embodiments, R 1 and R 2 are independently linear or branched C1-C6 or C1-C3 alkyl, optionally the same alkyl group. 1 and R 2are independently methyl, ethyl, or n-propyl, and optionally the same alkyl group. In some embodiments, R 1 is hydrogen, and R 2 is methyl or ethyl, or R 2 is hydrogen, and R 1 is methyl or ethyl. In another embodiment, R 1 and R 2 are both methyl or ethyl.

[0138] For compounds of formula (I), (II), (III) and (IV) and subgenera thereof, in some embodiments, R 1 Group, R 2 The X or X groups or any combination or all thereof are independently selected from linear or branched C1-C6 or C1-C3 alkyl, haloalkyl, -OR 6 , -NR 7 R 8 , -ONO2, -CN, -C(=O)R 6 , -C(=O)OR 6 , -OC(=O)R 6 , -C(=O)NR 7 R 8 , -NR 7 C(=O)R 6 , -OC(=O)OR 6 , -OC(=O)NR 7 R 8 , -NR 7 C(=O)OR 6 , -NR 6 C(=O)NR 7 R 8 , aryl and heteroaryl, and / or 1 to 6 halogens (e.g., fluorine) or all available hydrogen atoms are replaced with halogens (e.g., fluorine); R 6 is independently in each occurrence hydrogen or straight or branched chain C1-C6 or C1-C3 alkyl; R 7 and R 8is independently in each occurrence hydrogen or a straight or branched chain C1-C6 or C1-C3 alkyl, or R 7 , R 8 and the nitrogen atom to which they are attached form a 3- to 6-membered ring. 1 Group, R 2 The groups or X groups or any combination or all thereof are independently mono- or divalent fluoroalkyl or alkyl-ONO2.

[0139] For compounds of formula (I), (II), (III) and (IV) and subgenera thereof, non-limiting examples of linear or branched C1-C6 alkyl groups include methyl, ethyl, n-propyl, isopropyl, n-butyl, isobutyl, sec-butyl, tert-butyl, n-pentyl and n-hexyl. Examples of linear or branched C1-C3 alkyl groups include methyl, ethyl, n-propyl and isopropyl.

[0140] For compounds of formula (I), (II), (III) and (IV) and subgenera thereof, in some embodiments, X has 0, 1, 2, 3, 4, 5 or 6 carbon atoms. In certain embodiments, X has 0, 1, 2 or 3 carbon atoms.

[0141] Table A1 shows representative compounds of formulae (IA-ai) to (IA-a-xx).

[0142] [ka]

[0143] [Table 4-1]

[0144] [Table 4-2]

[0145] In certain embodiments, the nitro-aminoadamantane compounds used in the methods described herein are further described by the subgenus of formula (IA-ai) to (IA-a-xx), or a pharma- ceutically acceptable salt thereof.

[0146] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein is

[0147] [ka]

[0148] [ka] and pharma- ceutically acceptable salts thereof.

[0149] Table A2 shows representative compounds of formulas (IB-ai) to (IB-a-vii).

[0150] [ka]

[0151] [Table 5-1]

[0152] [Table 5-2]

[0153] In certain embodiments, the nitro-amino adamantane compounds used in the methods described herein are further described by the subgenus of formulas (IB-ai) to (IB-a-vii) or a pharma- ceutically acceptable salt thereof.

[0154] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein is

[0155] [ka]

[0156] [ka]

[0157] [ka] and pharma- ceutically acceptable salts thereof.

[0158] Table A3 shows representative compounds of formulae (IVA-i) to (IVA-vii).

[0159] [ka]

[0160] [Table 6-1]

[0161] [Table 6-2]

[0162] In certain embodiments, the nitro-aminoadamantane compounds used in the methods described herein are further described by the subgenus of formulas (IVA-i) to (IVA-vii) or a pharma-ceutically acceptable salt thereof.

[0163] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein is

[0164] [ka] and pharma- ceutically acceptable salts thereof.

[0165] Table A4 shows representative compounds of formulae (IVB-i) to (IVB-vi).

[0166] [ka]

[0167] [Table 7-1]

[0168] [Table 7-2]

[0169] In certain embodiments, the nitro-aminoadamantane compounds used in the methods described herein are further described by the subgenus of formulas (IVB-i) to (IVB-vi) or a pharma-ceutically acceptable salt thereof.

[0170] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein is

[0171] [ka] and pharma- ceutically acceptable salts thereof.

[0172] In certain embodiments, instead of an amine group, the amine group indirectly or directly bonded to the C-1 or C-2 position of the nitro-amino adamantane compounds described herein can be an amide, carbamate, or urea (e.g., -NH(C=O)R amide, -NH(C=O)OR carbamate, or -NHC(=O)NR a Rb urea group). In some embodiments, the -NR 3 R 4 The moiety is -NH(C=O)R 6 , -NH(C=O)OR 6 or -NHC(=O)NR 7 R 8 (wherein R 6 is hydrogen (for formamide) or linear or branched C1-C6 alkyl, R 7 and R 8 are independently hydrogen or a straight or branched C1-C6 alkyl, or R 7 , R 8 and the nitrogen atom to which they are attached form a 3- to 6-membered ring. 6 is hydrogen (for formamide) or linear or branched C1-C3 alkyl (e.g., methyl or ethyl), R 7 and R 8 are independently hydrogen or straight or branched C1-C3 alkyl (e.g., methyl or ethyl).

[0173] The nitro-aminoadamantane compound used in the methods described herein is a compound of formula (V)

[0174] [ka] or a pharma- ceutically acceptable salt thereof. (In the formula, R 3 and R 4 are independently hydrogen or a straight or branched C1-C6 alkyl, or R 3 , R 4 and the nitrogen atom to which they are attached form a 3- to 8-membered heterocycle; R 5 is hydrogen or linear or branched C1-C6 alkyl, X 1 , X 2 and X 3each of which is a bond, a straight or branched chain -alkyl-, a straight or branched chain -heteroalkyl-, a straight or branched chain -O-alkyl-, a straight or branched chain -O-heteroalkyl-, -(CH) j -Cycloalkyl-(CH2) k -, -(CH2) j -Heterocycle-(CH2) k -, -(CH2) j -aryl-(O) h -(CH2) k -or-(CH2) j -heteroaryl-(O) h -(CH2) k -, each of which is optionally substituted;

[0175] Y 1 , Y 2 and Y 3 Each of the above is -ONO2,

[0176] [ka] , hydroxy or a hydrogen atom, where Y 1 , Y 2 , and Y 3 At least one of the following is -ONO2 or

[0177] [ka] Provided that, j is 0, 1, 2 or 3; k is 0, 1, 2 or 3; and h is 0 or 1).

[0178] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein has the formula (VA):

[0179] [ka] or a pharma- ceutically acceptable salt thereof, 1 , Y 2 and Y 3 each is independently selected from -ONO2, hydroxy, or a hydrogen atom; p is 0, 1, 2, 3, 4, 5, or 6; q is 0, 1, 2, 3, 4, 5, or 6; and r is 0, 1, 2, 3, 4, 5, or 6; with the proviso that Y 1 , Y 2 , and Y 3 (Provided that at least one of the is -ONO2).

[0180] In certain embodiments, the nitro-amino adamantane compound used in the methods described herein is

[0181] [ka] and pharma- ceutically acceptable salts thereof.

[0182] Pharmaceutical Compositions The methods described herein utilize pharmaceutical compositions comprising the glutamate modulators described herein, or pharma- ceutically acceptable salts thereof, and one or more pharma- ceutically acceptable excipients or carriers. Pharmaceutical compositions / formulations can be prepared in sterile form. For example, pharmaceutical compositions / formulations for parenteral administration by injection or infusion are generally sterile. Sterile pharmaceutical compositions / formulations are formulated or prepared according to pharmaceutical grade sterility standards known to those skilled in the art, such as those described or required by the United States Pharmacopeia Chapters 797, 1072, and 1211 and 21 Code of Federal Regulations 211. Pharmaceutically acceptable excipients and carriers can include pharma- ceutically acceptable substances, materials, and vehicles. Non-limiting examples of excipient types include liquid and solid fillers, diluents, binders, lubricants, glidants, surfactants, dispersants, disintegrants, emulsifiers, wetting agents, suspending agents, thickening agents, solvents, isotonicity agents, buffers, pH adjusters, absorption retarders, stabilizers, antioxidants, preservatives, antibacterial agents, antibacterial agents, antifungal agents, chelating agents, adjuvants, sweeteners, flavorings, coloring agents, encapsulating materials and coating materials.The use of such excipients in pharmaceutical preparations is known in the art.For example, conventional vehicles and carriers include, but are not limited to, oils (e.g., vegetable oils, e.g., olive oil and sesame oil), aqueous solvents (e.g., saline, buffered saline (e.g., phosphate buffered saline [PBS]) and isotonic solutions (e.g., Ringer's solution)), and organic solvents (e.g., dimethyl sulfoxide [DMSO] and alcohols (e.g., ethanol, glycerol and propylene glycol).See, for example, Remington: The Science and Practice of Pharmacy, 21st Edition, Lippincott Williams and Wilkins (Philadelphia, Pennsylvania) (2005); Handbook of Pharmaceutical Excipients, 5th Edition, Rowe et al., eds., The Pharmaceutical Press and the American Pharmaceutical Association (2005); Handbook of Pharmaceutical Additives, 3rd Edition, Ash and Ash, eds., Gower Publishing Co. (2007); and Pharmaceutical Pre-formulation and Formulation, Gibson, ed., CRC Press LLC (Boca Raton, Florida) (2004). Appropriate formulations can depend on a variety of factors, such as the route of administration selected. Potential routes of administration of pharmaceutical compositions comprising glutamate modulating agents include, but are not limited to, oral, parenteral (including intradermal, subcutaneous, intramuscular, intravascular, intravenous, intraarterial, intraperitoneal, intracavity, intramedullary, intrathecal and topical), and topical (including dermal / epidermal, transdermal, mucosal, transmucosal, intranasal (e.g., by nose drops or drops), ocular / intracranial (e.g., eye drops), pulmonary (e.g., by oral or nasal inhalation), buccal, sublingual, rectal (e.g., by suppository) and vaginal (e.g., by suppository). Topical formulations can be designed to provide a local or systemic therapeutic effect. By way of example, formulations of glutamate modulating agents suitable for oral administration can be present, for example, in capsules (including push-fit capsules and soft capsules), tablets, pills, cachets or lozenges; as powders or granules; as semi-solids, lozenges, pastes or gels; as solutions or suspensions in aqueous and / or non-aqueous liquids; or as oil-in-water or water-in-oil liquid emulsions.Tablets can contain the glutamate modulating agent in admixture with, for example, a filler or inert diluent (e.g., calcium carbonate, calcium phosphate, lactose, mannitol, or microcrystalline cellulose), a binder (e.g., starch, gelatin, acacia, alginic acid or a salt thereof, or microcrystalline cellulose), a lubricant (e.g., stearic acid, magnesium stearate, talc, or silicon dioxide), and a disintegrant (e.g., crospovidone, croscarmellose sodium, or colloidal silica), and optionally a surfactant (e.g., sodium lauryl sulfate). Compositions for oral administration can also be formulated as solutions or suspensions in aqueous liquids or / and non-aqueous liquids, or as oil-in-water liquid emulsions or water-in-oil liquid emulsions. Dispersible powders or granules of the glutamate modulating agent can be mixed with any suitable combination of aqueous liquids, organic solvents, or / and oils, and any suitable excipients (e.g., any combination of dispersing agents, wetting agents, suspending agents, emulsifying agents, or / and preservatives) to form solutions, suspensions, or emulsions.

[0183] Treatment Method Described herein are methods for the treatment of a subject with an ASD to ameliorate one or more impairments associated with the ASD.

[0184] The method comprises administering a glutamate regulating (reducing) agent, such as but not limited to memantine, lamotrigine, amantadine, D-cycloserine, N-acetylcysteine ​​or other nitro-aminoadamantane derivatives, or its pharmaceutically acceptable salt, including the agent described herein.Generally, the method comprises administering a therapeutically effective amount of a glutamate regulating agent as described herein to the subject identified by the method described herein as likely to respond to such treatment, i.e., the subject has a glutamate level above baseline level.In some embodiments, the glutamate regulating agent is an NMDAR regulating (inhibiting) agent.

[0185] In some embodiments, treatment involves administration of a glutamate modulating agent at least once daily, twice daily, every other day, once weekly, or once monthly, and administration can continue for at least one week, one month, three months, six months, or more than one year.

[0186] In some embodiments, administration follows FDA guidelines for dosage and administration of other glutamate modulating agents.

[0187] For example, if memantine is used, doses ranging from 20 to 40 mg / day can be used.

[0188] If lamotrigine (approved for the treatment of bipolar disorder in adults 18 years of age and older) is used, a titration regimen as shown in the table below can be used (lower doses can be used for younger subjects as needed):

[0189] [Table 8]

[0190] If amantadine (approved for the treatment of Parkinsonism) is used, a dose of 100 mg twice daily (total 200 mg) can be used, or 2.5 mg / kg per day for one week, then increased to 5.0 mg / kg per day (King et al., 2001), or 100-150 mg / day (administered in combination with risperidone) can be used in patients weighing less than or more than 30 kg, respectively (Mohammadi et al., 2013).

[0191] When D-cycloserine (approved for the treatment of renal disease) is used, the initial dosage is up to 250 mg twice daily and can be increased to 500 mg and up to 1 g daily in divided doses as monitored by blood levels. In some embodiments, the dose is 50 mg daily or 50 mg weekly (Urbano et al., 2015), 50 mg / week (Minshawi et al., 2016).

[0192] If N-acetylcysteine ​​(approved for the treatment of acetaminophen toxicity and liver injury) is used, an exemplary loading dose of 140 mg / kg can be used, other alternative regimens include 900 mg daily for 4 weeks, followed by 900 mg two or three times daily for 4 weeks (Hardan et al., 2012), or 60 mg / kg / day in three divided doses (Wink et al., 2016).

[0193] As used in this context, "treat" means ameliorating at least one symptom of ASD. In some embodiments, the improvement is one or more impairments in function as measured by, for example, scores on the Social Responsiveness Scale-2nd Edition (SRS-2; Constantino et al., 2003) and / or the Clinician-Rated National Institute of Mental Health (NIMH) Clinical Global Impression (CGI) Severity Scale as shown in the tables or figures herein.

[0194] The therapeutically effective amount and frequency of administration of the glutamate modulating agent for treating ASD may depend on various factors, including the type of disorder, the severity of the condition, the potency of the glutamate modulating agent, the mode of administration, the age, weight, general health, sex and diet of the subject, and the response of the subject to treatment, and can be determined by the treating physician. In some embodiments, the effective daily dose of the glutamate modulating agent is about 1, 5 or 10 mg to about 100 mg, or as deemed appropriate by the treating physician, which can be administered in a single dose or in divided doses. The glutamate modulating agent can be administered at any suitable frequency for treating ASD, which can be determined by the treating physician, including once a day, twice a day, three or more times a day, once every two days, once every three days, twice a week or once a week, or as deemed appropriate by the treating physician. In certain embodiments, the glutamate modulating agent is administered once a day. The glutamate modulating agent can be administered by any suitable route for the treatment of ASD (e.g., the method can be performed by oral or parenteral routes of administration). In certain embodiments, the glutamate modulating agent is administered orally (e.g., as a tablet or capsule). In other embodiments, the glutamate modulating agent is administered parenterally (e.g., intravenously, intramuscularly, or subcutaneously by injection or infusion).

[0195] In some embodiments, the subject is not administered an agent that affects memantine plasma levels, such as triamterene, hydrochlorothiazide, metformin, cimetidine, ranitidine, quinidine, nicotine, carbonic anhydrase inhibitors, or sodium bicarbonate. EXAMPLES

[0196] The invention is further described in the following examples, which do not limit the scope of the invention described in the claims.

[0197] method In the examples set forth below, the following methods were used.

[0198] subject Subjects were recruited from outpatient referrals to a general child and adolescent psychiatry clinic and a specialized ASD clinic at a university hospital between January 2015 and July 2018. The study adhered to the principles of Good Clinical Practice guidelines and was approved by the Partners HealthCare Institutional Review Board, which oversees human subjects research conducted by Massachusetts General Hospital (MGH) and McLean Hospital. Each subject's parent or legal guardian provided written informed consent prior to participation. Subjects <14 years of age provided written informed consent, and subjects ≥14 years of age provided written informed consent.

[0199] Study Design The study was a 12-week randomized, double-blind, placebo-controlled, parallel-group clinical trial of memantine in adolescents with ASD. Adolescents with ASD who met the eligibility criteria were randomized to receive either memantine or placebo for the 12-week study. Subjects underwent multimodal MRI scans prior to and at completion of the 12-week study. Subjects were assessed weekly during the dose titration phase (baseline-week 4) and at midpoint (week 6), week 9, and completion (week 12) during the maintenance phase. Safety and efficacy were assessed at each study visit by measuring efficacy (CGI, GAF), tolerability (assessment of treatment-emergent AEs), and safety (vital signs, including weight). Autism severity was assessed at baseline, midpoint and end point (completion / early termination) by administering measures of autism severity (SRS-2, ABC-SW, CY-BOCS-PDD) and relevant psychopathology measures (ADHD-RS, CDRS-R, CASI-ANX).

[0200] Eligibility criteria for subjects Eligible subjects were of both genders, aged 8–17 years, and intellectually intact as determined by a full-scale intelligence quotient of 85 or greater on the Verbal and Matrix Reasoning subtests of the Wechsler Abbreviated Intelligence Scale, Second Edition (WASI-II (Wechsler, 2011)). Subjects were required to meet DSM-IV-TR / 5 diagnostic criteria for autism as determined by a clinical diagnostic assessment and to have at least moderate severity of ASD as determined by a total raw score of 85 or greater on the informant-rated Interpersonal Responsiveness Scale, Second Edition (SRS-2; Constantino et al., 2003) and a score of 4 or greater on the clinician-rated National Institute of Mental Health (NIMH) Clinical Global Impression (CGI) Severity Scale (CGI-S; (National Institute of Mental Health, 1985)).

[0201] Youth will be excluded from participation if they report a history of treatment with memantine or current treatment with glutamate modulating agents, such as lamotrigine, amantadine, N-acetylcysteine ​​and D-cycloserine, or medications that affect memantine plasma levels, such as triamterene, hydrochlorothiazide, metformin, cimetidine, ranitidine, quinidine, nicotine, carbonic anhydrase inhibitors, or sodium bicarbonate.

[0202] Screening evaluation Eligible subjects underwent a comprehensive assessment battery consisting of diagnostic, neuropsychological and physical assessment measures. In addition to the clinical diagnostic assessment, a systematic evaluation for autism was performed by administering the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Scale-Second Edition (ADOS-2). Relevant psychopathology was assessed using the Children's Schedule for Affective Disorders and Schizophrenia-Epidemiology Edition (K-SADS-E). Full-scale intelligence was assessed with the WASI-II and a battery of selected tasks from the Wechsler Intelligence Scale for Children (WISC-IV; Wechsler, 2003) or the Wechsler Adult Intelligence Scale (WAIS-IV; Wechsler, 2008). Physical examination included height, weight, waist circumference and Tanner stage on the Petersen Pubertal Development Scale to establish the stage of sexual maturation. The physical evaluation included a standard battery of blood tests, electrocardiogram, urine drug screen, and, for women of childbearing potential, a urine pregnancy test.

[0203] Study intervention and randomization In this 12-week, randomized, double-blind, placebo-controlled, parallel-group clinical trial, ASD subjects were randomized in a 1:1 ratio to receive memantine or placebo. An independent statistician created a computer-generated randomization schedule using stratified randomization by sex (male vs. female) and race (white vs. non-white). MGH's clinical trials pharmacy dispensed the study medications (memantine and placebo) according to the randomization schedule. The randomization schedule remained confidential throughout the study.

[0204] Study medication was titrated to a maximum daily dose during the first 4 weeks of the study (titration phase), from which subjects remained at the maximum achieved dose until the end of the study (maintenance phase). Study medication titration proceeded with a flexible titration schedule that allowed for slower titration or maintenance at a lower dose, guided by the study clinician's judgment of tolerability. Study medication was administered in divided doses. Study medication was initiated at 2.5 mg / day (raised to 5 mg / day on day 4) and titrated upward by 5 mg / week to a maximum dose of 20 mg / day.

[0205] Adherence was assessed by caregiver report at each study visit. The number of study medications returned was checked against caregiver reports, and those who did not take their medication regularly were counseled to improve their adherence.

[0206] Primary outcome measure The efficacy of memantine for the treatment of autism-related impairment was assessed by the informant-rated Interpersonal Responsiveness Scale, 2nd Edition (SRS-2) as a continuous outcome measure, and by clinician-rated CGI-I subscales as categorical outcome measures. Treatment response criteria for this study were defined as a ≥ 25% improvement on the SRS-2 and a score of 2 or 1 on the CGI-I subscales, i.e., "much improved" or "markedly improved."

[0207] Secondary outcome measures Additional treatment response of autistic dysfunction was examined for ASD subdomains by assessing treatment-related change in severity of SRS-2 subscales and the Children's Yale Brown Obsessions-Compulsions Scale Modified for PDD (CY-BOCS-PDD) (Goodman et al., 1986 (Rev 89); Scahill et al., 2006), and evaluating treatment-related change in ritualistic behaviors associated with ASD. Treatment response of psychopathology frequently associated with ASD was assessed by administering the clinician-rated Attention Deficit Hyperactivity Disorder Rating Scale (ADHD-RS) (DuPaul, Power, Anastopoulos, & Reed, 1998), the Children's Depression Rating Scale-Revised (CDR-R) (Poznanski et al., 1985) and the CASI-4 ASD Anxiety Scale (CASI-Anx) (Gadow et al., 2002). Changes in level of global functioning with treatment were assessed by the clinician-rated GAF.

[0208] The glutamate response to memantine therapy in PgACC was assessed by obtaining spectroscopic MRI before and after treatment.

[0209] Safety and tolerability evaluation The safety and tolerability of memantine was monitored by performing a complete physical examination, blood tests (complete blood count, electrolytes, liver function tests, thyroid function tests, and random glucose testing), urinalysis (drug screen and pregnancy screen [for women of childbearing potential only]), and an EKG battery at baseline and study endpoints, as well as by recording treatment-emergent AEs and obtaining vital signs (pulse, blood pressure, weight) at each study visit.

[0210] Neuroimaging methods Healthy control subjects were enrolled for spectroscopic neuroimaging data acquisition and formed the control group. Healthy subjects (HC) were age-, sex-, and IQ-matched to the enrolled ASD subjects. HC subjects had no significant autistic traits as screened by an SRS-2 raw score of <60 and no significant psychopathology as determined by the K-SADS-E and confirmed by clinical diagnostic interview.

[0211] Data acquisition - Proton spectra, two-dimensional J-resolved (2D-JPRESS) 1 HMRS protocols were used to acquire data at 4T. 2D-JPRESS sequences were selected to improve certainty about the spectral fitting of metabolites (Gonenc et al., 2010; Moore et al., 2007), to allow analysis of glutamate alone or combined criteria (e.g., Glx), and to ensure that measured metabolic differences truly arise from differences in metabolic levels and not from differences in T2 relaxation times. A single voxel of 8cc (2cm x 2cm x 2cm) was placed along the midline in the PgACC such that the inferior edge of the voxel was parallel to the descending plane of the corpus callosum, as determined by the longitudinal relaxation time (T1) image, which was also used for tissue segmentation. Data were collected at TR=2s, average=16, scan duration=7min, during 12 TE-stepped spectra with echo times ranging from 30 to 250ms in 20ms increments.

[0212] Data processing: Spectral analysis was performed in a fully automated manner using the commercially available LCModel package (version 6.2-1F). The 2D-JPRESS data set was decomposed into a series of one-dimensional spectra, each of which was modeled and simulated using GAMMA. 96 Glutamate activity levels were derived from the integral over the J series after fitting with a J-resolved basis set. Glutamate transverse relaxation times (T2) were determined from raw peaks versus TE decay curves fitted with the Levenberg-Marquardt algorithm using an exponential decay function (for glutamate T2) convolved with a polynomial function (for glutamate J coupling) obtained from GAMMA simulations performed with previously measured spectral parameters (Govindaraju, Young, & Maudsley, 2000). Data quality was assessed by full width at half maximum (FWHM), signal-to-noise ratio (SNR) and Cramer-Rao lower limit (CRLB) calculated with LCModel.

[0213] Determining sample size Based on our pilot study (Joshi et al., 2016), in which 4 of 7 subjects were responders to memantine at 15-20 mg daily, we estimated that 57% of subjects receiving memantine would respond to treatment. In the RUPP Autism Network study of risperidone (RUPP, 2002), response rates were 69.4% and 11.5% in the treatment (memantine) and placebo groups, respectively. Therefore, we based our sample size calculations on response rates of 57% in the memantine group and 11.5% in the placebo group. We a priori determined that a total sample size of 40 subjects (20 subjects per group) would be required to detect this difference in response rates at a two-sided significance level of .05 with 80% power. The final sample consisted of 16 subjects in the memantine group and 19 subjects in the placebo group with response data. With this sample size, we had 84% power to detect the above-mentioned difference in response rates.

[0214] statistical methods Primary outcomes were analyzed using Pearson's chi-square test with an a priori defined significance level of 0.05. Secondary efficacy measures were analyzed using mixed-effects regression models with robust standard errors, taking into account repeated measurements for each subject. Primary and secondary outcomes were compared between memantine vs. placebo and between high vs. normal baseline glutamate activity levels. Subjects were classified as having high vs. normal glutamate activity levels at baseline using z-scores. Population means and SDs for z-score calculations were derived from healthy control glutamate activity levels (baseline and endpoint). Glutamate activity levels with a z-score ≥ 1 were classified as high glutamate activity levels, those with z-scores < 1 and > -1 were classified as normal glutamate activity levels, and those with z-scores ≤ -1 were classified as low glutamate activity levels. Changes in PgACC glutamate activity levels within groups were tested using paired t-tests, and changes between groups were tested using two-sample t-tests. ROC curve analyses were also performed to determine the predictive utility of baseline PgACC glutamate activity levels in identifying treatment responders within the memantine and placebo groups. All other analyses of the primary outcome were considered exploratory. Analyses were performed using a modified intent-to-treat analysis set that included all randomized patients who were considered exposed to study drug (completed at least 2 weeks of treatment) and had at least one follow-up assessment.

[0215] Mixed-effects regression models used to analyze secondary efficacy outcomes predicted outcome measures from treatment group (memantine vs. placebo), study visit (continuous), and treatment group x study visit interactions, which were efficacy tests. To examine the effect of baseline PgACC glutamate activity levels on response to treatment, outcome measures were predicted from treatment group, study visit (continuous), PgACC glutamate activity level (continuous), interaction between treatment group and study visit, interaction between glutamate activity level and study visit, interaction between treatment group and glutamate activity level, and interaction between treatment group, glutamate activity level, and study visit. All mixed-effects regression models had random intercepts by subject ID, used robust standard errors to account for repeated measurements for each subject, and used independent covariance structures for random effects. Analytical methods did not impute data, but instead used all available time series data for subjects in the analysis set, provided they had data at baseline and at least one follow-up visit. All missing data were assumed to be missing at random.

[0216] Receiver operating characteristic (ROC) curve analysis was performed to examine the ability of baseline PgACC glutamate activity levels to identify treatment responders and non-responders. Separate ROC curve analyses were performed in the memantine and placebo groups, and their area under the curve (AUC) statistics were compared. The ROC analysis uses each value across the entire range of baseline PgACC glutamate activity levels as cutoffs to define treatment responders, and compares this classification to a "true" response classification defined by a ≥20% reduction in SRS total raw score and CGI-I ≤2. The ROC analysis then plots the false positive rate (1-specificity) and true positive rate (sensitivity) for each PgACC glutamate activity level on the x-axis and y-axis, respectively, to generate the ROC curve. The ROC analysis summarizes predictive utility using the area under the curve (AUC) statistic. An AUC of 0.5 means that baseline PgACC glutamate activity levels never predict treatment response, and an AUC of 1.0 means that baseline PgACC glutamate activity levels perfectly predict treatment response. Based on information from the ROC curve analysis, the Liu method was used to calculate optimal cut points for identifying subjects who responded to treatment and those who did not respond in both the memantine and placebo groups (Liu, Stat Med. 2012 Oct 15; 31(23):2676-86). This method defines the optimal cut point as the point where the product of sensitivity and specificity is maximized. Conditional probability was used to examine the predictive utility of these cut-off points. For each cut-off, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and percentage correctly classified were calculated.

[0217] Effect sizes are presented as standardized mean differences (SMD) for continuous outcomes and odds ratios (OR) for dichotomous outcomes. SMDs for the difference in score change over time between memantine and placebo, and between high glutamate and normal glutamate, were calculated as Cohen's d using the following calculation: the difference in score change between the two groups divided by the pooled standard deviation. SMDs for the change in score within groups were calculated as Cohen's d using the following calculation: the difference in score from baseline to endpoint divided by the pooled standard deviation. For memantine vs. placebo and high glutamate vs. normal glutamate comparisons, a positive SMD and OR>1 indicates better improvement in the memantine and high glutamate groups, respectively. For ASD vs. healthy controls comparisons, a positive SMD indicates lower glutamate activity levels in the ASD group. As defined by Cohen (Statistical Power Analysis for the Behavioral Sciences. 2nd ed., Hillsdale, NJ: Erlbaum. 1988), an effect size of SMD = 0.2 was interpreted as small, an effect size of SMD = 0.5 as moderate, and an effect size of SMD = 0.8 as large. ORs > 2 were considered clinically significant.

[0218] Safety outcomes were summarized descriptively by treatment group and baseline glutamate activity levels (high vs. normal) and compared at the end of the study using Fisher's exact test or Pearson's chi-square test. All analyses were performed using Stata (Version 16) (StataCorp, Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC. 2019).

[0219] [Example 1] Study population As shown in Figure 1, 58 subjects were assessed for eligibility, and 45 were randomized to treatment with either memantine (23 subjects) or placebo (22 subjects). The main reasons for exclusion before randomization were ineligibility (7 subjects [12.1%]) and refusal to participate (4 subjects [6.9%]). 22 subjects received memantine and 21 subjects received placebo, with 1 each lost to follow-up and 1 having compliance problems. One subject in the memantine treatment group was removed from the study during the first week of the study due to a protocol violation (starting an excluded medication). Thus, 21 subjects per group were included in the analysis. Of those receiving treatment, 16 memantine subjects and 17 placebo subjects completed the study.

[0220] Subject characterization Subject characteristics are shown in Table B. Subjects receiving memantine and placebo showed similar age distribution (mean [SD] 13.1 [2.8] vs. 13.3 [2.5] years), sex distribution (16 [76%] vs. 16 [76%] men; 5 [24%] vs. 5 [24%] women), race / ethnicity (19 [90%] vs. 20 [95%] white), and other characteristics related to neurocognitive, autism, psychological, functional, and psychopharmacological profiles.

[0221] [Table 9-1]

[0222] [Table 9-2]

[0223] Treatment fidelity Excluding subjects lost to follow-up (N=1), fidelity to study visits for ASD subjects was excellent, with a mean (SD) rating of 100.0 (0.0). Compliance with study medication treatment for subjects who reached the midpoint was excellent, with a mean (SD) rating of 98.5 (4.9). Compliance with study medication treatment was calculated based on return of study medication.

[0224] [Example 2] Effectiveness Primary outcomes: Analysis of the primary outcome, the percentage of subjects who responded to treatment as defined by a ≥25% reduction in SRS total score and a CGI-I score ≤2, included 16 memantine and 19 placebo subjects. Seven subjects were excluded because they only had baseline SRS data. The proportion of treatment responders was significantly higher in the memantine group compared with the placebo group (9 [56%] vs. 4 [21%]; OR = 4.82, 95% CI 1.10 to 21.19; P = .03) (Table 1).

[0225] Secondary outcomes: As with the primary outcomes, secondary outcomes were analyzed for 16 memantine and 19 placebo subjects because seven subjects only had baseline data available. Of the seven SRS scales, the ABC social withdrawal scale, and the four scalar measures of psychopathology, the only significant differences between memantine and placebo were in the SRS social cognition and SRS social awareness scales (Table 1). Those in the memantine group showed greater improvements from baseline to endpoint on the SRS social cognition (SMD = 0.83; 95% CI 0.13 to 1.52; P = .02) and SRS social awareness (SMD = 0.74 95% CI 0.05 to 1.42; P = .04) subscales compared with the placebo group.

[0226] [Table 10]

[0227] [Example 3] Safety and Tolerability As shown in Table 2, the memantine and placebo groups had similar dose distributions (mean [SD] 19.7 [1.1] vs. 19.0 [3.0], P = .35), with the majority of subjects reaching 20 mg / day (18 [95%] vs. 19 [90%], P > .99). There were no significant differences between memantine and placebo in the number of reported adverse events (AEs) (2.2 [1.2] vs. 2.1 [1.5], P = .87) or the percentage of subjects reporting AEs (14 [67%] vs. 9 [43%], P = .12). The most commonly reported AEs were headache (5 [24%] vs. 2 [10%], P = .41) and insomnia (3 [14%] vs. 2 [10%], P > .99) (Table 2). Two subjects in the memantine group reported severe AEs (headache [5%] and worsening irritability and agitation [5%]). There was no difference between memantine and placebo in the percentage of subjects requiring rescue medication (4 [19%] vs. 4 [19%], P>0.99). Four subjects terminated memantine treatment due to an AE of worsening anxiety (2 in week 1 and 2 in week 4), and one subject terminated placebo treatment in week 2 due to an AE of worsening irritability.

[0228] [Table 11-1]

[0229] [Table 11-2]

[0230] [Example 4] MR spectroscopic PgACC glutamatergic activity-based response Baseline spectroscopic PgACC glutamate data were collected for 37 ASD and 16 HC subjects, of whom endpoint spectroscopic data were collected for 31 ASD and 13 HC subjects.

[0231] Baseline PgACC glutamatergic activity in ASD: Baseline PgACC glutamatergic activity was significantly higher in ASD compared to HC (95.5±14.6 vs. 76.6±17.7; MD=-18.8±33.9; SMD=-1.21, 95% CI -1.84 to -0.57; P<.001). In addition, there was a significantly stronger positive correlation between the level of PgACC Glu activity and autism severity in ASD subjects. See Figures 2A-2B.

[0232] Glutamate dysregulation subtypes of ASD: For calculation of z-scores, a mean SD value of 76.5 ± 18.0 was derived from baseline (N = 16) and endpoint (N = 13) glutamatergic activity levels in HCs. Based on z-scores, high PgACC glutamatergic activity was observed in 54% of ASD subjects, and no ASD subjects had low PgACC glutamatergic activity.

[0233] Stability of PgACC glutamatergic activity: Mean glutamatergic activity levels in HCs remained relatively unchanged over the 12-week period (baseline = 75.7 ± 18.3, endpoint = 76.2 ± 19.2; MD = 0.5 ± 1.7; SMD = 0.02, 95% CI -0.71 to 0.75; P = .28).

[0234] PgACC glutamate response to Tx: Table 3A shows within-group changes in PgACC glutamate activity levels from baseline to endpoint in the ASD group overall and stratified by treatment group (memantine vs. placebo), treatment response (responders vs. non-responders), and baseline PgACC glutamate activity (high vs. normal). In unselected samples of ASD, significant decreases in PgACC glutamate activity with treatment were observed in the memantine and placebo treatment groups, treatment responders, and memantine responders. In high glutamate samples, there was a significant decrease in PgACC glutamate activity with treatment in both the memantine and placebo treatment groups, but the magnitude of glutamate decrease was significantly higher in the memantine group versus the placebo treatment group. In normal glutamate samples, PgACC glutamate activity did not change significantly with treatment (memantine, placebo, memantine and placebo non-responders). See Figure 2B. Table 3A further compares baseline PgACC glutamate activity levels at baseline and endpoint between HC and different ASD groups. In unselected ASD samples, baseline PgACC glutamate activity was significantly higher than HC in all ASD groups or responder status by treatment exposure, except that the memantine non-responder group did not have higher glutamate activity than HC. However, PgACC glutamate activity after treatment in unselected ASD samples was not significantly different from HC, except that the non-responder group had significantly higher glutamate activity than HC. In high glutamate samples, PgACC glutamate activity with treatment was not significantly different from HC for memantine and memantine responder groups, but glutamate activity in placebo and placebo non-responder groups was significantly higher than HC. In normal glutamate samples, no significant differences in glutamate activity were found between different ASD groups and HC.

[0235] Glutamate dysregulation-based Tx. response in ASD: Moderating effect of PgACC glutamatergic activity levels: As shown in Figure 2C, there was a significant three-way interaction between PgACC glutamatergic activity levels and treatment group and study visit when predicting SRS total (P = .02), SRS-SCI (P = .007), and ABC-Social Withdrawal (P < .001) scores, but not SRS-Autistic Stereotypy scores (P = .19) (Figure 2C, Table 3B). Higher PgACC glutamatergic activity levels were associated with greater score changes in the memantine group, but not in the placebo group.

[0236] [Example 5] Predictive utility of PgACC glutamate activity levels As shown in Figure 2D, there was a significant difference in area under the curve when comparing the predictive utility of baseline glutamate between the memantine and placebo groups (AUC statistic [95% CI]: 0.93 [0.80, 1.00] vs. 0.34 [0.02, 0.66], P < .001). Baseline PgACC glutamate activity levels had excellent predictive utility in the memantine group and very poor predictive utility in the placebo group. This striking difference suggests that it predicts treatment response but not placebo response. The study identified optimal baseline PgACC glutamate cut points of 99 in the memantine group and 97 in the placebo group (Figure 2D).

[0237] [Table 12]

[0238] [Table 13]

[0239] [Table 14]

[0240]

Table 15

[0241] References

[0242]

Table 16-1

[0243]

Table 16-2

[0244]

Table 16-3

[0245]

Table 16-4

[0246]

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[0247]

Table 16-6

[0248]

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[0249]

Table 16-8

[0250] Other embodiments While the present invention has been described in conjunction with the detailed description thereof, it should be understood that the foregoing description is intended to be illustrative and not limiting of the scope of the invention as defined by the appended claims. Other aspects, advantages, and modifications are within the scope of the appended claims.

Claims

1. 1. A method for predicting response to treatment with a glutamate modulating (decreasing) agent in a subject with an autism spectrum disorder (ASD), comprising: (i) identifying a subject with ASD; (ii) determining the level of glutamate in one or more selected brain regions of interest (ROIs) in the subject's brain; (iii) comparing the level of glutamate in the ROI to a reference level; and (iv) identifying subjects having a level of glutamate in said ROI that exceeds said reference level based on step (iii) as likely to respond to treatment with a glutamate modulating agent. A method comprising:

2. 1. A method for selecting a treatment for a subject with autism spectrum disorder (ASD) comprising administering a glutamate modulating (decreasing) agent, comprising: (i) identifying a subject with ASD; (ii) determining the level of glutamate in one or more selected brain regions of interest (ROIs) in the subject's brain; (iii) comparing the level of glutamate in the ROI to a reference level; and (iv) selecting a treatment with a glutamate modulating agent for subjects having a level of glutamate in said ROI that exceeds said reference level based on step (iii). A method comprising:

3. 1. A pharmaceutical composition for use in a method of treating a subject having an autism spectrum disorder (ASD), the pharmaceutical composition comprising a glutamate modulating agent, the method comprising: (i) identifying a subject with ASD; (ii) determining the level of glutamate in one or more selected brain regions of interest (ROIs) in the subject's brain; (iii) comparing the level of glutamate in the ROI to a reference level; and (iv) administering to a subject having a level of glutamate in the ROI that exceeds a reference level based on step (iii), a treatment comprising a therapeutically effective amount of a glutamate modulating agent; Pharmaceutical compositions.

4. 1. A pharmaceutical composition for use in a method of treating a subject having an autism spectrum disorder (ASD), the pharmaceutical composition comprising a glutamate modulating agent, the method comprising: (i) providing a subject identified as having an ASD characterized by increased glutamate activity in one or more selected brain regions of interest (ROIs) in the subject's brain; and (ii) administering to the subject a therapeutically effective amount of a glutamate modulating agent; Pharmaceutical compositions.

5. 5. The pharmaceutical composition of claim 3, wherein at least one ROI comprises all or a portion of the pregeniculate anterior cingulate cortex (PgACC).

6. The step of determining the level of glutamate in one or more selected ROIs may be performed using magnetic resonance imaging (MRI), positron emission tomography (PET) or magnetic resonance spectroscopy (MRS), preferably proton magnetic resonance spectroscopy ( １ 5. The pharmaceutical composition according to claim 3, comprising the use of 1H MRS.

7. Determining the level of glutamate in the ROI comprises: １ 7. The pharmaceutical composition of claim 6, comprising obtaining and / or analyzing a proton spectrum using H MRS.

8. The proton spectrum is two-dimensional J-resolved (2D-JPRESS) １ 8. The pharmaceutical composition of claim 7, obtained using H MRS at 3 or 4 Tesla (3T or 4T).

9. 7. The pharmaceutical composition of claim 6, wherein the step of determining the level of glutamate in the ROI comprises using Glutamate Chemical Exchange Saturation Transfer (GluCEST) imaging.

10. 10. The pharmaceutical composition of any one of claims 3 to 9, wherein the glutamate modulating agent is memantine, a nitro-aminoadamantane compound, lamotrigine, amantadine, D-cycloserine, N-acetylcysteine, an amino-adamantane derivative, or a pharma- ceutically acceptable salt thereof.

11. The pharmaceutical composition of claim 3, wherein the reference level represents a level in a cohort of subjects having levels of glutamate in the ROI that exceed the level of glutamate in the ROI of a cohort of healthy control subjects.

12. The pharmaceutical composition of claim 10, wherein the reference level represents a level of glutamate at least one standard deviation above the level of glutamate in the cohort of healthy subjects.

13. 13. The pharmaceutical composition of any one of claims 3 to 12, wherein the treatment comprises administration of the glutamate modulating agent at least once daily for at least one week, one month, three months, six months or one year.

14. 14. The pharmaceutical composition of any one of claims 3 to 13, wherein the therapeutically effective amount is sufficient to result in improvement of one or more impairments as measured by the Social Responsiveness Scale, Second Edition (SRS-2) and / or the Clinical Global Impression (CGI) Severity Scale.

15. 15. The pharmaceutical composition of any one of claims 3 to 14, wherein the subject has high-functioning ASD (HF-ASD) and / or is intellectually capable.

16. 1. A pharmaceutical composition for use in a method for monitoring response to treatment with a glutamate modulating (decreasing) agent in a subject having an autism spectrum disorder (ASD), said pharmaceutical composition comprising a glutamate modulating (decreasing) agent, said method comprising: (i) identifying a subject with ASD; (ii) determining a baseline level of glutamate in one or more selected brain regions of interest (ROIs) in the subject's brain; (iii) administering to the subject two or more doses of the glutamate modulating agent; (iv) determining the subsequent level of glutamate in said ROI; (v) comparing the baseline level of glutamate in the ROI with the subsequent level; and (vi) identifying subjects having subsequent levels of glutamate in said ROI that are below said baseline level as responsive to treatment with a glutamate modulating agent.

17. 17. The pharmaceutical composition of claim 16, wherein at least one ROI comprises all or a portion of the pregenual anterior cingulate cortex (PgACC).

18. The step of determining the level of glutamate in one or more selected ROIs may be performed using magnetic resonance imaging (MRI), positron emission tomography (PET) or magnetic resonance spectroscopy (MRS), preferably proton magnetic resonance spectroscopy ( １ 17. The pharmaceutical composition of claim 16, comprising using 1H MRS.

19. Determining the level of glutamate in the ROI comprises: １ 20. The pharmaceutical composition of claim 18, comprising obtaining and / or analyzing a proton spectrum using H MRS.

20. The proton spectrum is two-dimensional J-resolved (2D-JPRESS) １ 20. The pharmaceutical composition of claim 19, obtained using H MRS at 3 or 4 Tesla (3T or 4T).

21. 20. The pharmaceutical composition of claim 18, wherein the step of determining the level of glutamate in the ROI comprises using Glutamate Chemical Exchange Saturation Transfer (GluCEST) imaging.

22. 21. The pharmaceutical composition of claims 15-20, wherein the glutamate modulating agent is memantine, a nitro-aminoadamantane compound, lamotrigine, amantadine, D-cycloserine, N-acetylcysteine, or a pharma- ceutically acceptable salt thereof.

23. 23. The pharmaceutical composition of any one of claims 3 to 22, wherein the subject is under the age of 21, 18 or 15.

24. 24. The pharmaceutical composition of any one of claims 3 to 23, wherein the glutamate modulating agent is memantine or a pharma- ceutically acceptable salt thereof.

25. 24. The pharmaceutical composition of any one of claims 3 to 23, wherein the glutamate modulating agent is a nitro-amino adamantane compound or a pharma- ceutically acceptable salt thereof.

26. 26. The pharmaceutical composition of claim 25, wherein the nitro-aminoadamantane compound is a compound of any one of formulas (I) to (V).

27. The nitro-aminoadamantane compound is 【Chemistry 1】 and pharma- ceutically acceptable salts thereof.

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