Effect of a Novel Nasal Oxytocin Spray With Enhanced Bioavailability on Autism: A Randomized Trial

A Randomized Trial

Hidenori Yamasue; Masaki Kojima; Hitoshi Kuwabara; Miho Kuroda; Kaori Matsumoto; Chieko Kanai; Naoko Inada; Keiho Owada; Keiko Ochi; Nobutaka Ono; Seico Benner; Tomoyasu Wakuda; Yosuke Kameno; Jun Inoue; Taeko Harada; Kenji Tsuchiya; Kazuo Umemura; Aya Yamauchi; Nanayo Ogawa; Itaru Kushima; Norio Ozaki; Satoshi Suyama; Takuya Saito; Yukari Uemura; Junko Hamada; Yukiko Kano; Nami Honda; Saya Kikuchi; Moe Seto; Hiroaki Tomita; Noriko Miyoshi; Megumi Matsumoto; Yuko Kawaguchi; Koji Kanai; Manabu Ikeda; Itta Nakamura; Shuichi Isomura; Yoji Hirano; Toshiaki Onitsuka; Hirotaka Kosaka; Takashi Okada


Brain. 2022;145(2):490-499. 

In This Article

Abstract and Introduction


Although intranasal oxytocin is expected to be a novel therapy for the core symptoms of autism spectrum disorder, which has currently no approved medication, the efficacy of repeated administrations was inconsistent, suggesting that the optimal dose for a single administration of oxytocin is not optimal for repeated administration.

The current double-blind, placebo-controlled, multicentre, crossover trial (ClinicalTrials.gov Identifier: NCT03466671) was aimed to test the effect of TTA-121, a new formulation of intranasal oxytocin spray with an enhanced bioavailability (3.6 times higher than Syntocinon® spray, as assessed by area under the concentration–time curve in rabbit brains), which enabled us to test a wide range of multiple doses, on autism spectrum disorder core symptoms and to determine the dose–response relationship. Four-week administrations of TTA-121, at low dose once per day (3 U/day), low dose twice per day (6 U/day), high dose once per day (10 U/day), or high dose twice per day (20 U/day), and 4-week placebo were administered in a crossover manner. The primary outcome was the mean difference in the reciprocity score (range: 0–14, higher values represent worse outcomes) on the Autism Diagnostic Observation Schedule between the baseline and end point of each administration period. This trial with two administration periods and eight groups was conducted at seven university hospitals in Japan, enrolling adult males with high-functioning autism spectrum disorder. Enrolment began from June 2018 and ended December 2019. Follow-up ended March 2020.

Of 109 males with high-functioning autism spectrum disorder who were randomized, 103 completed the trial. The smallest P-value, judged as the dose–response relationship, was the contrast with the peak at TTA-121 6 U/day, with inverted U-shape for both the full analysis set (P = 0.182) and per protocol set (P = 0.073). The Autism Diagnostic Observation Schedule reciprocity score, the primary outcome, was reduced in the TTA-121 6 U/day administration period compared with the placebo (full analysis set: P = 0.118, mean difference = −0.5; 95% CI: −1.1 to 0.1; per protocol set: P = 0.012, mean difference = −0.8; 95% CI: −1.3 to −0.2). The per protocol set was the analysis target population, consisting of all full analysis set participants except those who deviated from the protocol. Most dropouts from the full analysis set to the per protocol set occurred because of poor adherence to the test drug (9 of 12 in the first period and 8 of 15 in the second period). None of the secondary clinical and behavioural outcomes were significantly improved with the TTA-121 compared with the placebo in the full analysis set.

A novel intranasal spray of oxytocin with enhanced bioavailability enabled us to test a wide range of multiple doses, revealing an inverted U-shape dose–response curve, with the peak at a dose that was lower than expected from previous studies. The efficacy of TTA-121 shown in the current exploratory study should be verified in a future large-scale, parallel-group trial.


Oxytocin is expected to be a novel therapy for the core symptoms of autism spectrum disorder (ASD),[1,2] such as deficits in social interaction and communication, which are currently untreatable using any established medication.[3] Although previous studies have consistently shown the positive effects of a single oxytocin administration on neurobehavioural measures associated with ASD,[4–8] discrepancies regarding the efficacy of repeated oxytocin administrations on clinical measures of ASD core symptoms[9–15] impede its clinical application.

These discrepancies suggest that the optimal dose for a single administration of oxytocin is not optimal for repeated administration.[16] A potential deterioration in the efficacy of oxytocin by repeated administration, suggested by previous human[17–19] and animal studies,[20–22] supports this possibility. An inverted U-shape dose–response relationship of oxytocin has been suggested by previous human single-dose[23–25] and animal studies,[26] and both too-high and too-low dose settings can lead to a failure to detect the efficacy of oxytocin. To identify the optimal dose for repeated administrations of oxytocin, a wide range of multiple doses should therefore be used in trials. However, the low bioavailability of administered oxytocin, which is a critical issue for its clinical application,[27] limits the possible range of doses.

Although intranasal administration improves central bioavailability compared with oral or intravenous administrations, doses are difficult to regulate or replicate via this route.[16] TTA-121 is a novel oxytocin nasal spray with a high bioavailability (3.6 times the area under the concentration–time curve (AUCt) of the existing Syntocinon® spray in rabbit brains) that allows increased oxytocin delivery to the brain by adjusting the osmolality and viscosity of the formulation (WO 2017/073798 A1).[28] TTA-121 has been developed to obtain the optimal dose with just one puff because in our preliminary study, participants with ASD complained about the difficulty of administering 24 units (U) intranasal oxytocin in Syntocinon® with six puffs, and difficulty was associated with efficacy. Toxicity studies in animals[29,30] and the phase I trial of TTA-121 have been completed.[31]

The current study aimed, by testing the effect of TTA-121 on ASD social core symptoms and determining the dose–response relationship, to explore the optimal dose for repeated administrations of oxytocin to improve the core social symptoms of ASD. Taking advantage of the enhanced bioavailability of TTA-121, the current trial involved a wide range of oxytocin doses. Additionally, to suppress the placebo effect as much as possible,[10,15,32–34] a crossover design[17,35] and outcome measures with high objectivity[9,16,17,19,34] were used.