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Probiotics in IBD
Philippe Marteau, MD, PhDGastroenterologyHôpital Européen Georges Pompidou, Paris
Pathogenesis of IBD
immunologiques
Geneticbackground
Environment
Immune response
Intestinal Intestinal floraflora
Microbes IBD
??
Which micro-organism ?Or microbial component ?
??
Toll like receptors recognise microbial molecular pattern and influence the cellular response
Polysaccharide
Wall teichoicacid (WTA)
S-layer
Lipoteichoic acid(LTA) Protein
Peptidoglycan
Membrane
Signal for NOD2 = bacterial peptidoglycan (muramyl dipeptide)
Microbes IBD
?? ??
Which micro-organism ?Or microbial component ?
??
ProbioticsProbiotics
Probiotic Health
Immune cells
Microflora
PharmacologicalPharmacological approachapproach ofof probioticsprobiotics
Micro-organismActive components
TargetsSpecific effects
•Positive•Negative
Pharmacokinetics•Survival•Adhesion / colonisation•Fate of active components
EffectsEffects pfpf probioticsprobiotics
Idea, Research For clinical practice
Randomised controlled trials
Probiotics and IBD : RCTs in HumansVSL#3
• chronic pouchitis• prevention of pouchitis• prevention of post-operative relapse of CD
Escherichia coli sNissle 1917• prevention of relapse of UC • prevention of relapse of CD
Others• Saccharomyces boulardii• Lactobacillus rhamnosus GG• Lactobacillus johnsonii LA1• Lactobacillus salivarius UCC118 ?• Genetically modified Lactococcus lactis
MixtureMixture
300 billion lyophilized bacteria per gram
4 strains of lactobacilli (casei, plantarum, acidophilus, bulgaricus)
3 strains of bifidobacteria (longum, breve, infantis)
1 strain of Streptococcus thermophilusSurvival of some strains till faeces
4 positive RCTs in IBD
VSL #3 and IBD
Gionchetti P et al. Gastroenterology 2000;119:305-9
n=40 VSL#3 (3g x 2/d) vs placebo 9 n=40 VSL#3 (3g x 2/d) vs placebo 9 monthsmonths
Maintenance Maintenance ofof remissionremission ofof relapsingrelapsingpouchitispouchitis withwith VSL#3VSL#3
VSL#3VSL#3
PlaceboPlacebo
Mimura T et al. Gut 2004;53:108
P<0.0001
RCT, DB, n=36, RCT, DB, n=36, AB 4 AB 4 weeksweeks, , thenthen VSL#3 6g/d vs placebo for 12 VSL#3 6g/d vs placebo for 12 monthsmonths
% r
em
issi
on
M1
2PreventionPrevention ofof recurrencerecurrence ofof pouchitispouchitis withwith VSL#3VSL#3
90%
6%0%
20%
40%
60%
80%
100%
VSL#3 placebo
90%
60%
0%
20%
40%
60%
80%
100%
VSL#3 placebo
PreventionPrevention ofof 1st 1st episodeepisode ofof pouchitispouchitis withwith VSL#3VSL#3
P<0.0001
RCT, DB, n=40, RCT, DB, n=40, VSL#3 3g/d vs placebo 12 VSL#3 3g/d vs placebo 12 monthsmonths
% r
emis
sion
M12
Gionchetti P et al. Gastroenterology 2003;124:1202-9
20%
40%
0%
20%
40%
VSL#3 placebo
VSL#3 VSL#3 afterafter surgerysurgery for Crohn’s for Crohn’s diseasedisease
P<0.05
RCT, DB, n=28, RCT, DB, n=28, VSL#3 3g/d vs placebo 12 VSL#3 3g/d vs placebo 12 monthsmonths
% r
elap
se 1
2 m
onth
s
Campieri et al. Gastroenterology 2000 abstract
Prantera C et al. Gut 2002;51:405
LactobacillusLactobacillus GGGG doesdoes notnot preventprevent postoperativepostoperativerecurrencerecurrence ofof Crohn’s Crohn’s diseasedisease
RCT, DB, n=45, Lactobacillus GG (2 capsules/d) vs placebo 12 months
22%13%
83%89%
40%
65%
0%
20%
40%
60%
80%
100%
Sortie Rémisionclinique
Rémissionendoscopique
Lacto GG n= 23 Placebo n=22
% r
emis
sion
12 m
onth
s
Prevention of postoperative recurrence of Crohn’s D.
Double blind placebo controlled trial
98 subjects operated for CD
Lactobacillus johnsonii LA1 (4 109 cfu/d) or placebo 6 months
Marteau and the GETAID. 2005
% endosc. relapse grade > 1
PLACEBOLA1
Prevention of postoperative recurrence of Crohn’s D.
Double blind placebo controlled trial
98 subjects operated for CD
Lactobacillus johnsonii LA1 (4 109 cfu/d) or placebo 6 months
Marteau and the GETAID. 2005
49% 64%
05
1015202530354045
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4
%
LA1
Placebo
Escherichia coli serotype O6,K5,H1 (non pathogenic)
Mutaflor, Germany
Survive in the GIT
can inhibit the growth of other E. coli or enteric bacteria
E. coli Nissle 1917
E. E. colicoli NissleNissle 1917 to 1917 to preventprevent relapse of UC : 3RCTrelapse of UC : 3RCT
010203040506070
Kru
is (3
m)
Rem
back
en
Kru
is
E. coli5-ASA
Equivalent to 5-ASANo placebo controlled trial
Competitive exclusion ?
Immunomodulation ? ….…. Production of anti-inflammatory molecules ?
Probiotics and IBD : how could they work ?
Competitive exclusion ?
Immunomodulation ? ….…. Production of anti-inflammatory molecules ?
What is reaching the targets in the intestine ?
Probiotics and IBD : how could they work ?
PharmacologicalPharmacological approachapproach ofof probioticsprobiotics
Micro-organismActive components
TargetsSpecific effects
•Positive•Negative
Pharmacokinetics•Survival•Adhesion / colonisation•Fate of active components
SurvivalSurvival of of alimentaryalimentary LactobacillusLactobacillus acidophilusacidophilus and and BifidobacteriumBifidobacterium spsp in in thethe humanhuman smallsmall bowelbowelMarteau et al. Gastroenterol Clin Biol 1992,16:25-8
99
88
77
66
55
44
00 22 44 66 88
log CFU/hlog CFU/h
Time (h)Time (h)
Fermented product with living bacteria
Fermented product with heat killed bacteria
SurvivalSurvival of of alimentaryalimentary BifidobacteriumBifidobacterium spsp till till faecesfaeces in in healthyhealthy humanshumans
Bouhnik Y, Pochart P, Marteau P et al. Gastroenterology 1992,102:875-8
1010
88
66
44
22
00
loglog1010 CFU/g of CFU/g of faecesfaeces
44 88 1212 1616 daysdays
Ingested Bifidobacteria
Total Bifidobacteria
Transit marker (spores)Ingestion period
PharmacologyPharmacology of of probioticsprobiotics
Ingested micro-organismwith active constituents
TargetsSpecific effects
•Beneficial•Negative
Pharmacokinetics•Survival•Adhesion / colonisation•Fate of active constituents
Strain specificity
Active Active ingredientsingredients in in probioticsprobiotics ??
CPG DNA ?Bacterial DNA contains immunostimulatory sequences Interact with Toll like receptor-9 of epithelial cellActivators of innate immunity and antiapoptotic properties in the mucosa
Rachmilewitz D Gastroenterology 2004Beneficial effect of VSL#3 in mice with chemically induced colitis ... effect was derived from the CPG DNA as
• VSL genomic unmethylated DNA : effective • VSL-methylated DNA and calf thymus DNA : ineffective • No effect in TLR9 KO mice
ProbioticsProbiotics andand gastroenteritisgastroenteritis
LactococcusLactococcus lactislactis to to deliverdeliver active active moleculesmolecules in in thethegastrointestinalgastrointestinal tract tract duringduring ((experimentalexperimental) IBD) IBD
Genetically modified L. lactis secreting IL-10 or trefoil peptides
--> reduction of experimental colitidies in mice
Steidler L Science 2000Vandenbroucke et al. Gastroenterology 2004
Human trial ongoing
PharmacokineticsPharmacokinetics of of probioticsprobioticsin in thethe smallsmall bowelbowelVesa T, Marteau P. Alim Pharmacol Ther 2000;14:823-8
0,0E+0
1,0E+4
2,0E+4
3,0E+4
4,0E+4
5,0E+4
6,0E+4
7,0E+4
0 1 2 3 4 5 6 7 8 10 24
Time (h)
cfu/
ml
L. fermentum KLD
Marker
Pharmacokinetics ofL. lactis : a bile sensitive strain
L. lactisMarker (spores of bacillus)
PharmacologicalPharmacological approachapproach ofof probioticsprobiotics
Micro-organismActive components
TargetsSpecific effects
•Positive•Negative
Pharmacokinetics•Survival•Adhesion / colonisation•Fate of active components
SafetySafety ofof probioticsprobiotics
Theoretical risks ?– Infections– Excessive immuno-stimulation– Gene transfer
Reports :IBD : no case Rare cases of infections with related endogenous bacteria
Patients with central catheters : cases of fungemia with S. boulardii andlactobacillemia with L. rhamnosus GGOne case of liver abscessRisk linked to immunosuppression ?
SafetySafety ofof probioticsprobiotics
Theoretical risks ?– Infections– Excessive immuno-stimulation– Gene transfer
Reports :IBD : no case Rare cases of infections with related endogenous bacteria
Patients with central catheters : cases of fungemia with S. boulardii andlactobacillemia with L. rhamnosus GGOne case of liver abscessRisk linked to immunosuppression ?
CONCLUSIONS
... concept = using ingested living micro-organisms to produce and transport molecules of potential therapeutic interest to targets in the intestine Original pharmacological approach : potential for in vivo production of active molecules, targeting immune cells, presenting immunogenic molecules in a microbial context...
Proven therapeutic effects in specific situations
Extrapolation of effects between products is not possible and one should avoid excessive enthusiasm or scepticism
UnansweredUnanswered QuestionsQuestions
How does it work… and how canwe select new strains ?
Do probiotics work better afterantibiotics ?
Do combinations of strains workbetter ?