Effects of theophylline on ADCY5 activation-From cellular studies to improved therapeutic options for ADCY5-related dyskinesia patients

Pearls & Oy-sters: ADCY5-Related Dyskinesia: From a Longstanding Misdiagnosis of Drug-Resistant Epilepsy

ADCY5-related dyskinesia (ADCY5-RD) is a hyperkinetic movement disorder of childhood onset, resulting from pathogenic variants in the ADCY5 gene. Paroxysmal worsening of the movements and movements that occur in relation to sleep and/or awakenings are hallmarks of ADCY5-RD. ADCY5-RD is therefore often misdiagnosed as sleep-related hypermotor epilepsy, sleep disorders, paroxysmal hyperkinesias, childhood onset chorea, or psychogenic events. In this case, a 59 year-old woman with a longstanding misdiagnosis of drug-resistant epilepsy was ultimately diagnosed with ADCY5-RD following video EEG. She had been followed for paroxysmal episodes of nonvoluntary movements mostly occurring during sleep since 2 years of age. She also exhibited continuous progressive dysarthria and axial hypotonia. Episodic orofacial dystonia was present as well. For 57 years, these symptoms had been treated with various combinations of antiseizure medications. However, the diagnosis was reconsidered when prolonged video-EEG monitoring recorded sleep-onset nonepileptic events, starting during N1 and N2 stages of NREM sleep. Genetic testing of ADCY5 confirmed the diagnosis. Caffeine and progressive withdrawal of antiseizure medications except clonazepam resulted in clinical improvement in paroxysms, which became less intense and less frequent. Given that ADCY5-RD was first described in 2012, there may be more adult patients misdiagnosed in childhood. Thus, we recommend considering alternative diagnosis for adult patients with paroxysmal sleep-related events to detect ADCY5-RD in adults. Although there are still no treatment guidelines for ADCY5-RD, adenosine-2A receptor antagonists have emerged as a promising therapeutic option.

Treatment Efficacy of Theophylline in ADCY5-Related Dyskinesia: A Retrospective Case Series Study

BACKGROUND

ADCY5-related dyskinesia is a rare disorder caused by mutations in the ADCY5 gene resulting in abnormal involuntary movements. Currently, there are no standardized guidelines to treat this condition.

OBJECTIVE

The aim of this study was to evaluate the efficacy of theophylline administration in improving symptoms and quality of life in patients with ADCY5-related dyskinesia.

METHODS

A retrospective study was conducted involving 12 patients (aged 2-41 years) with ADCY5-related dyskinesia. Participants completed a questionnaire about theophylline administration, including dosage, improvement of symptoms, adverse effects, and changes in quality of life. Data were analyzed for reported efficacy and side effects.

RESULTS

Theophylline administration demonstrated substantial efficacy, with 92% (11 of 12) of patients reporting significant improvements in their movement disorders. The average improvement score was 7.0 ± 1.9 (mean ± SD) on a 10-point scale. Notable improvements included reductions in severity and frequency of episodes, improved gait, more independent mobility, psychosocial well-being, and quality of sleep. Adverse effects were reported by 6 patients, including dystonia, worsening of speech, headaches, nausea, impaired sleep, and agitation.

CONCLUSIONS

Theophylline shows substantial promise as a treatment option for ADCY5-related dyskinesia, improving various aspects of patients' quality of life and movement disorder symptoms. Further research is needed to optimize dosing, to understand long-term effects, and to explore combinational drug therapies. Despite the small cohort size and the retrospective nature of this study, the results support theophylline administration to decrease dyskinetic movements and enhance overall quality of life in patients. © 2025 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Emerging therapies for childhood-onset movement disorders

PURPOSE OF REVIEW

We highlight novel and emerging therapies in the treatment of childhood-onset movement disorders. We structured this review by therapeutic entity (small molecule drugs, RNA-targeted therapeutics, gene replacement therapy, and neuromodulation), recognizing that there are two main approaches to treatment: symptomatic (based on phenomenology) and molecular mechanism-based therapy or 'precision medicine' (which is disease-modifying).

RECENT FINDINGS

We highlight reports of new small molecule drugs for Tourette syndrome, Friedreich's ataxia and Rett syndrome. We also discuss developments in gene therapy for aromatic l-amino acid decarboxylase deficiency and hereditary spastic paraplegia, as well as current work exploring optimization of deep brain stimulation and lesioning with focused ultrasound.

SUMMARY

Childhood-onset movement disorders have traditionally been treated symptomatically based on phenomenology, but focus has recently shifted toward targeted molecular mechanism-based therapeutics. The development of precision therapies is driven by increasing capabilities for genetic testing and a better delineation of the underlying disease mechanisms. We highlight novel and exciting approaches to the treatment of genetic childhood-onset movement disorders while also discussing general challenges in therapy development for rare diseases. We provide a framework for molecular mechanism-based treatment approaches, a summary of specific treatments for various movement disorders, and a clinical trial readiness framework.

Scoping Review on ADCY5-Related Movement Disorders

Background

Adenylyl cyclase 5 (ADCY5)-related movement disorder (ADCY5-RMD) is a rare, childhood-onset disease resulting from pathogenic variants in the ADCY5 gene. The clinical features, diagnostic options, natural history, and treatments for this disease are poorly characterized and have never been established through a structured approach.

Objective

This scoping review attempts to summarize all available clinical literature on ADCY5-RMD.

Methods

Eighty-seven articles were selected for inclusion in this scoping review. The majority of articles identified were case reports or case series.

Results

These articles demonstrate that patients with ADCY5-RMD suffer from permanent and/ or paroxysmal hyperkinetic movements. The paroxysmal episodes can be worsened by environmental triggers, in particular the sleep-wake transition phase in the early morning. Occurrence of nocturnal paroxysmal dyskinesias and perioral twitches are highly suggestive of the diagnosis when present. In the majority of patients intellectual capacity is preserved. ADCY5-RMD is considered a non-progressive disorder, with inter-individual variations in evolution with aging. Somatic mosaicism, mode of inheritance and the location of the mutation within the protein can influence phenotype.

Conclusions

The current evidence for therapeutic options for ADCY5-RMD is limited: caffeine, benzodiazepines and deep brain stimulation have been consistently reported to be useful in case reports and case series.