Fig. 1 The CONSORT flow diagram for the phase 2 clinical trial. The CONSORT flow diagram details the progress, from screening through to study completion, of participants in the double-blind randomized placebo-controlled trial testing a 4-week intranasal vasopressin treatment versus placebo in children with ASD. A total of 149 prospective participants were screened. Thirty-eight of the 68 individuals enrolled in the study were not randomized owing to either not meeting eligibility criteria or declining to participate. All 30 participants who were randomized to a treatment condition or placebo completed the study, independent of whether they were in the vasopressin or placebo group.
Fig. 2 Improvement scores for participants receiving 4-week intranasal arginine vasopressin (AVP) treatment versus placebo. Participants’ improvement scores for the clinical trial’s key primary and secondary outcome measures are provided for each treatment condition. (A) Primary outcome measure: the Social Responsiveness Scale, 2nd Edition (SRS-2) T score. (B to F) Secondary outcome measures: Clinical Global Impression (CGI)-Improvement score (B), Reading the Mind in the Eyes Test (RMET) score (C), Facial Emotion Recognition Test (FERT) score (D), Spence Children’s Anxiety Scale (SCAS) score (E), and Repetitive Behaviors Scale-Revised (RBS-R) total score (F). General linear model F tests were used to evaluate whether participants treated with AVP (orange circles) versus placebo (blue circles) differed as a main effect of treatment (i.e., at the mean pretreatment blood AVP concentration). Data are presented as least-squares means (LSM) ± SEM, with individual data points plotted as residuals from their LSM adjacent to the respective error bar. Thus, all data are plotted corrected for other variables in the analysis. Data depicted in (A) and (C) to (F) are presented as absolute difference scores (between posttreatment and baseline pretreatment) such that positive numbers on the y axis indicate improvement. Data depicted in (B) are presented as clinician improvement ratings where 1 = very much improved since the initiation of treatment, 2 = much improved, 3 = minimally improved, and 4 = no change since the initiation of treatment. AVP-treated participants differed significantly from placebo-treated participants in their improvement scores on nearly all measures except for the RBS-R, in which there was no overall group difference. n = 30 for the SRS, CGI, and SCAS; n = 29 for the RBS-R; n = 17 for the FERT; and n = 16 for the RMET.
- Table 1 Characteristics of participants in the study.
Fisher’s exact test was used to test whether the distribution of individuals randomized to the treatment conditions differed by sex and by ethnicity; no significant effects were found. For age, IQ, pretreatment SRS-2 T score, pretreatment CGI-S score, pretreatment blood AVP concentration (in picograms per milliliter), and pretreatment blood AVPR1A:OXTR gene expression, differences between treatment conditions were tested with a simple one-way general linear model; no significant effects were discerned. The values are reported as means ± SE. F, female; M, male; IQ, Intelligence Quotient; SRS-2, Social Responsiveness Scale, 2nd Edition; CGI-S, Clinical Global Impression-Severity; AVP, arginine vasopressin AVPR1A:OXTR, relative gene expression as the ΔΔCt of AVPR1A and OXTR gene expression.
Treatment n Sex Ethnicity Age (years) Full-scale
IQ scoreSRS-2 T score CGI-S score Blood AVP
concentrationBlood
AVPR1A:
OXTRF M Caucasian Other AVP 17 3 14 8 9 9.14 ± 0.57 77.65 ± 5.03 78.12 ± 1.66 4.82 ± 0.15 1.32 ± 0.25 2.25 ± 0.31 Placebo 13 2 11 11 2 9.86 ± 0.65 91.85 ± 5.76 83.00 ± 1.90 4.77 ± 0.17 1.28 ± 0.29 2.21 ± 0.35 - Table 2 Change from baseline in the behavioral outcome measures for the 4-week arginine vasopressin (AVP) treatment trial.
Data were analyzed using the same model throughout (which controlled for ethnicity, IQ, pretreatment blood differential receptor gene expression, and baseline behavioral severity for each measure). All analyses tested for a main effect of treatment condition at the mean pretreatment blood AVP concentration. This LSM response takes into account any predictive effect of pretreatment blood AVP concentration on treatment response and gives an overall measure of efficacy in the population of participants as a whole. The ability of pretreatment blood AVP concentration to predict treatment response differentially in the drug-treated group is tested by the treatment condition–by–pretreatment blood AVP concentration interaction. Clinical Global Impression-Improvement (CGI-I) is a single score taken after a 4-week treatment. Otherwise, all other scores are given as a change from baseline, normalized for the direction of the scale, so that symptomatic improvement is reported as a positive change. For all measures, significant overall effects of treatment condition are in the predicted direction (i.e., AVP-treated participants improve more than placebo-treated participants). When a treatment condition–by–pretreatment blood AVP concentration interaction is significant, post hoc tests are reported for AVP-treated and placebo-treated participants: “Greater” indicates that symptomatic improvement increased with higher pretreatment blood concentrations of AVP; “Lesser” indicates that less improvement was observed at higher pretreatment blood concentrations of AVP; “ns” indicates that the scale was not significantly affected by pretreatment blood AVP concentrations. Subscales of an instrument are only tested if the overall score is significant at P < 0.05 and are tested at appropriate Bonferroni-corrected critical α to minimize the risk of false discovery. (Social Behavior Scale, 2nd Edition (SRS-2), critical α < 0.025; Repetitive Behaviors Scale-Revised (RBS-R), critical α < 0.0083). Any post hoc tests of treatment condition–by–pretreatment blood AVP concentration interactions are further Bonferroni-corrected to a critical α half that of the original critical α for the interaction. Effect sizes are given as ηp2. SCI, Social Communication and Interaction; RRB, Restricted Interests and Repetitive Behavior; CGI-S, Clinical Global Impression-Severity; FERT, Facial Emotion Recognition Test; RMET, Reading the Mind in the Eyes Test; NEPSY, Developmental NEuroPSYchological Assessment.
Measure Treatment condition
main effectImprovement in
score LSM ± SE*Significant
after
correction
for multiple
comparisonsTreatment condition–
by–pretreatment blood
AVP concentration
interaction*Significant
after
correction
for multiple
comparisonsImprovement in score
becomes greater or
lesser with higher
pretreatment blood
AVP concentrationsAVP Placebo AVP Placebo Primary outcome measure SRS-2 T score F1,20 = 9.853; P = 0.0052;
ηp2 = 33.0%17.6 ± 1.37 10.8 ± 2.11 * F1,20 = 50.49; P < 0.0001;
ηp2 = 71.6%* Greater Lesser SCI F1,20 = 12.74; P = 0.0019;
ηp2 = 38.9%17.5 ± 1.37 9.75 ± 2.11 * F1,20 = 58.38; P < 0.0001;
ηp2 = 74.5%* Greater Lesser RRB F1,20 = 1.045; P = 0.3188;
ηp2 = 5.0%15.6 ± 1.73 12.7 ± 2.70 ns F1,20 = 7.601; P = 0.0122;
ηp2 = 27.5%* Greater ns Secondary outcome measures (clinician-evaluated) CGI-S, social and
communicationF1,20 = 0.549; P = 0.4674;
ηp2 = 2.7%0.873 ± 0.126 0.712 ± 0.202 ns F1,20 = 1.519; P = 0.2320;
ηp2 = 7.1%ns CGI-I, social and
communicationF1,21 = 7.098; P = 0.0145;
ηp2 = 25.3%2.23 ± 0.149 2.93 ± 0.244 * F1,21 = 9.520; P = 0.0056;
ηp2 = 31.2%* Greater ns Secondary outcome measures (parent-rated) Spence Children’s
Anxiety ScaleF1,20 = 9.014; P = 0.0070;
ηp2 = 31.1%17.9 ± 1.66 9.14 ± 2.68 * F1,20 = 19.48; P = 0.0003;
ηp2 = 49.3%* Greater Lesser RBS-R—total F1,19 = 1.600; P = 0.2213;
ηp2 = 7.8%17.2 ± 1.83 21.3 ± 3.18 ns F1,19 = 18.57; P = 0.0004;
ηp2 = 49.4%* Greater ns Stereotypic F1,19 = 0.001; P = 0.9783;
ηp2 = 0.0%2.24 ± 0.313 2.23 ± 0.486 ns F1,19 = 4.932; P = 0.0381;
ηp2 = 20.6%ns Self-injurious F1,19 = 0.552; P = 0.4666;
ηp2 = 2.8%0.594 ± 0.467 1.18 ± 0.828 ns F1,19 = 27.54; P < 0.0001;
ηp2 = 59.2%* Greater Lesser Compulsive F1,19 = 2.028; P = 0.1707;
ηp2 = 9.6%3.35 ± 0.511 4.59 ± 0.819 ns F1,19 = 22.49 ; P = 0.0001;
ηp2 = 54.2%* Greater ns Ritualistic F1,19 = 3.133; P = 0.0920;
ηp2 = 14.2%3.08 ± 0.504 4.63 ± 0.818 ns F1,19 = 3.643; P = 0.0708;
ηp2 = 16.1%ns Sameness F1,19 = 0.043; P = 0.8375;
ηp2 = 0.2%5.61 ± 0.661 5.85 ± 1.03 ns F1,19 = 3.071; P = 0.0950;
ηp2 = 13.9%ns Restricted F1,19 = 0.623; P = 0.4392;
ηp2 = 3.2%2.58 ± 0.54 3.4 ± 1.01 ns F1,19 = 4.261; P = 0.0522;
ηp2 = 18.3%ns Secondary outcome measures (child performance) FERT F1,7 = 10.85; P = 0.0132;
ηp2 = 60.8%3.10 ± 2.42 −7.19 ± 1.81 * F1,7 = 0.971; P = 0.3573;
ηp2 = 12.2%ns RMET F1,6 = 6.2341; P = 0.0467;
ηp2 = 51.0%4.04 ± 1.63 −1.28 ± 1.24 * F1,6 = 0.068; P = 0.8031;
ηp2 = 1.1%ns NEPSY—Theory of
MindF1,12 = 0.647; P =0.4367;
ηp2= 5.1%2.1 ± 1.41 0.677 ± 1.20 ns F1,12 = 1.162; P =0.3022;
ηp2= 8.8%ns NEPSY—Affect
RecognitionF1,12 = 0.946; P = 0.3500;
ηp2 = 7.3%0.094 ± 2.20 −2.58 ± 1.90 ns F1,12 = 0.251; P = 0.6254;
ηp2 = 2.0%ns - Table 3 Reported adverse events during the 4-week arginine vasopressin (AVP) treatment trial assessed by the DOTES and OAS scales.
Adverse events are reported as counts and percentages. Fisher’s exact test was used to test for differences in adverse events between the AVP and placebo treatment conditions. No significant effects were discerned. DOTES, Dosage Record Treatment Emergent Symptom Scale; OAS, Overt Aggression Scale; HEENT, head, ears, eyes, nose, and throat.
Adverse event AVP (n = 17) Placebo (n = 13) General Fever 2 (12%) 1 (8%) Cough 1 (6%) 0 (0%) Body ache 1 (6%) 0 (0%) Neurological/
psychiatricExcitement/agitation 4 (24%) 1 (8%) Insomnia 4 (24%) 1 (8%) Increased motor
activity4 (24%) 0 (0%) Depressive affect 2 (12%) 1 (8%) Headache 2 (12%) 0 (0%) Drowsiness 1 (6%) 3 (23%) Decreased motor
activity1 (6%) 2 (15%) Aggression 1 (6%) 1 (8%) Akathisia 1 (6%) 0 (0%) Head banging 1 (6%) 0 (0%) Dizziness 0 (0%) 1 (8%) Lethargy/tiredness 0 (0%) 1 (8%) HEENT Nasal congestion 3 (18%) 4 (31%) Dry mouth 1 (6%) 3 (23%) Blurred vision 1 (6%) 1 (8%) Ear infection 0 (0%) 1 (8%) Runny nose 0 (0%) 1 (8%) Sore throat 0 (0%) 1 (8%) Cold sore 0 (0%) 1 (8%) Gastrointestinal Decreased appetite 4 (24%) 5 (38%) Nausea/vomiting 2 (12%) 2 (15%) Constipation 1 (6%) 0 (0%) Diarrhea 0 (0%) 1 (8%) Renal Increased urination 1 (6%) 1 (8%) Bed-wetting 1 (6%) 0 (0%) Dermatological Skin rash 1 (6%) 1 (8%) Bug bite 1 (6%) 0 (0%) Skin burn 0 (0%) 1 (8%)
Supplementary Materials
stm.sciencemag.org/cgi/content/full/scitranslmed.aau7356/DC1
Table S1. Raw data and SAS code for the data and analyses shown in Table 1.
Table S2. Participants’ stable concomitant medications during the 4-week AVP treatment trial.
Table S3. Raw data and SAS code testing whether parents could ascertain treatment condition.
Table S4. Raw data and SAS code testing whether bottle weights differed between treatment conditions.
Table S5. Raw data and SAS code for Fig. 2A and associated analyses.
Table S6. Raw data and SAS code testing treatment effects for the SRS-2 using an unweighted analysis.
Table S7. Raw data and SAS code testing treatment effects for the SCI subscale of the SRS-2.
Table S8. Raw data and SAS code correlating parent SRS-2 ratings with clinician CGI evaluations.
Table S9. Raw data and SAS code for Fig. 2B and associated analyses.
Table S10. Raw data and SAS code for Fig. 2C and associated analyses.
Table S11. Raw data and SAS code for Fig. 2D and associated analyses.
Table S12. Raw data and SAS code for Fig. 2E and associated analyses.
Table S13. Raw data and SAS code for Fig. 2F and associated analyses.
Table S14. Raw data and SAS code testing treatment effects for the RRB subscale of the SRS-2.
Table S15. Change from baseline in the safety assessments for the 4-week AVP treatment trial.
Table S16. Raw data and SAS code for the data and analyses shown in table S15.
Additional Files
This PDF file includes:
- Table S1. Raw data and SAS code for the data and analyses shown in Table 1.
- Table S2. Participants’ stable concomitant medications during the 4-week AVP treatment trial.
- Table S3. Raw data and SAS code testing whether parents could ascertain treatment condition.
- Table S4. Raw data and SAS code testing whether bottle weights differed between treatment conditions.
- Table S5. Raw data and SAS code for Fig. 2A and associated analyses.
- Table S6. Raw data and SAS code testing treatment effects for the SRS-2 using an unweighted analysis.
- Table S7. Raw data and SAS code testing treatment effects for the SCI subscale of the SRS-2.
- Table S8. Raw data and SAS code correlating parent SRS-2 ratings with clinician CGI evaluations.
- Table S9. Raw data and SAS code for Fig. 2B and associated analyses.
- Table S10. Raw data and SAS code for Fig. 2C and associated analyses.
- Table S11. Raw data and SAS code for Fig. 2D and associated analyses.
- Table S12. Raw data and SAS code for Fig. 2E and associated analyses.
- Table S13. Raw data and SAS code for Fig. 2F and associated analyses.
- Table S14. Raw data and SAS code testing treatment effects for the RRB subscale of the SRS-2.
- Table S15. Change from baseline in the safety assessments for the 4-week AVP treatment trial.
- Table S16. Raw data and SAS code for the data and analyses shown in table S15.
