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 ?