Fragile X syndrome is the leading monogenic cause of ASD. Trinucleotide repeats in the FMR1 gene abolish FMRP protein expression, leading to hyperactivation of ERK and mTOR signaling, upstream of mRNA translation. Here we show that metformin, the most widely used anti-type 2 diabetes drug, rescues core phenotypes in Fmr1-/y mice and selectively normalizes Erk signaling, Eif4e phosphorylation and the expression of Mmp9. Thus, metformin is a potential FXS therapeutic. Dysregulated mRNA translation is linked to core pathologies diagnosed in the Fragile X neurodevelopmental Syndrome (FXS), such as social and behavior problems, developmental delays and learning disabilities 1,2. In the brains of FXS patients and knockout mice (Fmr1-/y ; X-linked Fmr1 deletion in male mice), loss of Fragile X mental retardation protein (FMRP) results in hyperactivation of the mammalian/mechanistic target of rapamycin complex 1 (mTORC1) and the extracellular signal-regulated kinase (ERK) signaling pathways 1,2. Consistent with increased ERK activity, eukaryotic initiation factor 4E (eIF4E) phosphorylation is elevated in the brain of FXS patients and Fmr1-/y mice, thereby promoting translation of the mRNA encoding for matrix metalloproteinase 9 (MMP-9), which is elevated in the brains of both FXS patients and the Fmr1-/y mice 1-5. In accordance with these findings, knockout of Mmp9 rescues the majority of phenotypes in Fmr1-/y mice. MMP-9 degrades components of the extracellular matrix, including proteins important for synaptic function and maturation, which are implicated in FXS and autism spectrum disorders (ASD). Recent observations indicate that metformin, a first-line therapy for type 2 diabetes, imparts numerous health benefits beyond its original therapeutic use, such as decreased cancer risk and improved cancer prognosis 6. Metformin inhibits the mitochondrial respiratory chain complex 1, leading to a decrease in cellular energy state and thus activation of the energy sensor AMP-activated protein kinase (AMPK) 6. Several AMPK-independent activities of metformin have also been reported 7,8. Since metformin suppresses translation by inhibiting

Most patients hospitalized at tertiary care pediatric institutions receive at least 1 medication outside the terms of the Food and Drug Administration product license. Substantial variation in the frequency of off-label use was observed across diagnostic categories and drug classes. Despite the frequent off-label use of drugs, using an administrative database, we cannot determine which of these treatments are unsafe or ineffective and which treatments result in substantial benefit to the patient.

Background-Children with complex chronic conditions depend upon both their families and systems of pediatric health care, social services, and financing. Investigations into the workings of this ecology of care would be advanced by more accurate methods of population-level predictions of the likelihood for future hospitalization.