urrent estimates of ASD prevalence reach one in 54 children born in the United States 1 , and recent clinical failures [2][3][4][5][6][7][8][9] highlight the need to expand drug development efforts. Behavioral features and severity are measured by validated observational assessment tools, as there are no imaging-based or molecular biomarkers that reliably and objectively diagnose ASD. Furthermore, autism manifests across a broad spectrum, from minimally affected individuals to those who require intense support, and there are no approved drugs for core symptoms. The etiology of ASD is poorly understood and likely multifactorial but is known to involve complex genetic risks 10 , with over 100 genes implicated to date, each with a small effect size 11 . A role for environmental risks in ASD has also been proposed, encompassing diet 12 , maternal infection 13 , exposure to toxins 14 and changes in the gut microbiome 15 . The notion that fixed genetic predispositions coupled with variable environmental risks together manifest symptom severity is intriguing from a therapeutic perspective, because correcting mutations in the genome remains challenging, and reducing potential environmental contributors is likely more tractable. Recent studies suggest that molecules produced in the GI tract can enter systemic circulation and affect immunity 16 , metabolism 17 and behavior 18 . Altered immune and metabolic profiles have been associated with various neuropsychiatric disorders, such as ASD [19][20][21] , and the microbiome and metabolome are altered in individuals with ASD 19,22 , anxiety 23 , depression 24 and schizophrenia 25 . Notably, over a dozen studies have shown changes in the fecal microbiome in several ASD cohorts compared to controls 26 , although these associations do not resolve cause or effect. Dietary habits likely contribute to the ASD microbiome 27 . Several studies have also revealed changes in the metabolome of individuals with ASD from diverse geographies 19,[28][29][30] , with reports showing dysregulation of the fecal metabolome 19,[31][32][33] . We previously identified several gut microbial metabolites that correlate with ASD-like symptoms in mice, and administration of one of these metabolites, 4-ethylphenyl sulfate (4EPS), to naive animals Safety and target engagement of an oral small-molecule sequestrant in adolescents with autism spectrum disorder: an open-label phase 1b/2a trial