Transcript Pronio A, et al. Probiotic in Pts with IPA for UC is

Literature Review
Peter R. McNally, DO, FACP, FACG
University Colorado School of Medicine
Center for Human Simulation
Aurora, Colorado 80045
1
Pronio A, Montesani C, Butteroni C,
Vecchione S, Mumolo G, Vestri A,
Vitolo D, Boirivant M.
Probiotic Administration in Patients with Ileal
Pouch-Anal Anastomosis for Ulcerative
Colitis Is Associated with Expansion of
Mucosal Regulatory Cells.
Inflamm Bowel Dis. 2008;14:1-7
Departments of Surgery, Internal Medicine &
Experimental Medicine, Rome, Italy
2
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Introduction
• Pouchitis is the #1 long term complication after Ileal Pouch
Anal Anastomosis (IPAA) for ulcerative colitis (20% at 1 yr &
50% at 10 yr).1
• Pouchitis is believed to be a result of an unstable microflora:
– ↓ lactobacilli & bifidobacteria
– ↑ anaerobes/aerobes ratio
– ↑ Clostridia perfringens
• Antibiotics (Ciprofloxicin, Metronidazole, Rifaximin) are an
effective acute therapy for pouchitis, but relapse is high.1,2
1.
2.
Shen B. Managing Pouchitis. AM J Gastroenterol. 2007;102:S60-64.
Kiehne K, et al. Defensin expression in chronic pouchitis in pts with UC or FAP. World J Surg. 2006;21:1065-1062.
3
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Introduction
• The probiotic, VSL#3, has been shown to regulate mucosal
response, by reductions in mucosal levels of interleukin (IL-8), and
cytokines IL-1β & INF-γ. 3,4,5
• 4 Mechanisms of Inflammation in IBD & Pouchitis:
– Regulatory T cells (Tregs = CD4+CD25+ T lymphocytes) are
important in down regulation of inflammation, but are relatively ↓
in the inflammatory states of IBD and pouchitis -- inverse
relationship.
– Lamina Propria Mononuclear Lymphocytes (LPML) & Peripheral
Blood Mononuclear Cells (PBMC) directly correlate with
inflammation.
– IL-1β cytokine directly correlates with inflammation.
– Foxp3 is a specific functional marker of Treg (↑ in inflammation).
3.
4.
5.
Ruseler-van Embden JG et al. Gut. 1994;35:658–664.
Gionchetti et al. Gastroenterology 2000;119:305-309.
Mimura T, et al. Gut. 2004;53:108-14.
4
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Aim
• To determine if the probiotic, VSL#3, would suppress
clinical pouchitis (pouchitis disease activity index)
among patients with IPAA for Ulcerative colitis when
compared to untreated controls.
• Compare the effect of the probiotic, VSL#3, on
mucosal markers of inflammation among patients with
IPAA for Ulcerative Colitis when compared to
untreated controls.
5
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Study Design:
Pts with IPAA for UC from 1984
to 2005
Evaluations: T 3, 6,12 mo
PDAI (>7 = pouchitis)
None had active pouchitis at
enrollment
Open-label randomization to
VSL#3 or No Rx
Study Medication VSL#3 (450
billion cfu/pkg) 2 packet/d
Cohort
VSL#3 n=16
Control n=12
Endoscopy
Biopsy of Lamina Propria:
mononuclear cells (LPMC’s),
IL-1β, CD25high T cell,
LAP(+)T cells, & Foxp3
mRNA
Blood: peripheral
mononuclear cells (PBMC)
6
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Study Design: VSL#3 450 billion CFU/dose
Lactobacilus (4 sp), Bifidobacteium (3 sp),
Streptoccus (1 sp)
Lactobacillus (20185A), Bifidobacteria (24704B), and Streptoccus (26702B)
Images copyright Dennis Kunkel Microscopy, Inc.
Reproduced with permission.
7
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Clinical Inflammatory Marker
Pouchitis Disease Activity Index (PDAI)
Clinical Parameter
Stool#
Rectal Bleeding
Fecal urgency/Cramps
Fever (>100F)
Score
usual
0
1-2/d
1
>3/d
2
None
0
Daily
1
none
0
occasional
1
usual
2
absent
0
present
1
Sandborn WJ, et al: Pouchitis after ileal pouch-anal anastomosis: PDAI. Mayo Clin Proc.
1994;69:409-415.
Pouchitis is defined as a total score of ≥7.
8
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Biological Inflammatory Markers
• Immune staining for PBMC and LPMC
– Conjugated mouse antihuman CD3
– Conjugated mouse antihuman CD4
– Conjugated mouse antihuman CD25
– Goat anti-LAP (specific CD3/CD4
populations)
9
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Biological Inflammatory Markers
• FOX3p m-RNA and IL-1β
• Expression of each gene transcript
in biopsies was analyzed by real
time reverse-transcription PCR
using primer sequences and
antisense
10
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Baseline Demographic & Clinical
Characteristics
VSL#3
N=16
Control
N=12
∆ time from
IPAA (mo)
97+/-66
88+/-58
Age (yr)
37
35
Sex (M/F)
8/8
8/4
Previous
Pouchitis
5
5
PDAI at T0
1.5+/-0.9
1.6+/- 1.6
11
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Baseline Demographic & Clinical
Characteristics
VSL#3
Control
No Pts
12
7
PDAI
1.5+/-0.90
1.4+/-1.4
CD25+
7.08+/-3.6
4.83+/-1.8
CD25high
1.39+/-0.78
0.84+/-0.68
LAP+
1.17+/-0.70
1.22+/-1.44
CD25+
5.72+/-4.9
7.7+/-1.4
CD25high
1.39+/-1.19
1.5+/-0.3
LAP+
0.99+/-0.3
1.1+/-0.3
PBMC
LPMC
12
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Results: significant ↓ PDAI in VSL#3 pts
2.5
PDAI
2
1.5
Control
VSL#3
1
*
0.5
**
†
0
0
3 Mo
6 Mo
12 Mo
Mean PDAI at T 0,3,6,12 mo for ulcerative colitis IPAA randomized to VSL#3
or no treatment (control). T3mo *P 0.014; T6mo **P 0.006 & T12mo †P 0.001
13
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Results: Significant ↓ IL-1β in VSL#3 pts
4
3.5
Change in interleukin (IL–1β)
mRNA content isolated from
mucosal biopsies for IAPP-UC
pts randomized to VSL#3 or no
treatment (control) *P0.03 versus
control.
P=0.03
IL-1beta
3
2.5
2
1.5
1
0.5
0
VSL#3
control
14
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Results: Significant ↑ in CD25high in VSL#3 pts
3.5
3
**P 0.012
CD25high
2.5
2
Control
VSL#3
*P 0.04
1.5
1
0.5
0
0
3 Mo
6 Mo
Percentage of CD25high T lymphocytes in the CD3/ CD4 gated cell
population of lamina propria mononuclear cells in patients with
IPAA for ulcerative colitis randomized to (A) VSL#3 (*P 0.04 versus
baseline and at 3 months; **P 0.012 versus baseline and at 6
months) or (B) no treatment (control).
15
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Results: Foxp3 ↑ VSL#3 pts
14
Change in Foxp3 mRNA isolated
from mucosal biopsies
of consecutive observations in
patients with IPAA for ulcerative
colitis randomized to
VSL#3 or no treatment (control)
quantified by real time-PCR (*P
0.008 versus control).
P=0.08
12
Foxp3
10
8
6
4
2
0
VSL#3
control
16
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Conclusions
• VSL#3 450 billion CFU bid
decreased PDAI in patients with
IPaA for UC p < 0.005
• VSL#3 decreased peripheral and
mucosal immune response seen in
pts wit IPAA for UC.
17
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Reviewer Comments
• Pronio, et al, have demonstrated several immunologic
mechanisms by which VSL#3 suppresses pouchitis.
– ↑ Regulatory T cells (Tregs = CD4+CD25+ T
lymphocytes)
– ↑ Foxp3 a specific and functional marker of Treg.
– ↓ Concentrations of Lamina Propria Mononuclear
Lymphocytes (LPML) & Peripheral Blood
Mononuclear Cells (PBMC)
– ↓ IL-1β an inflammatory cytokine that directly
correlates with inflammation.
18
Pronio A, et al . Inflamm Bowel Dis. 2008:14:1-7.
Reviewer Comments
• Pronio, et al, have demonstrated VSL#3 is more
effective than no treatment (control) in suppressing
pouchitis as measured by PDAI score.
• The findings of Pronio, et al, emphasize the need to
support further research of the immunologic
mechanisms responsible for probiotics to influence
gut microbiotica, immunity and gastrointestinal
disorders.
19