- Email: [email protected]
Use of lactobacillus-GG in paediatric Crohn's disease
DIGEST LIVER DIS 2002;341SUPPL.21:S63-5
Use of Lactobacillus-GG S. Guandalini
in paediatric
Liver
Key words:
tivm
Prof. S. Guandalini Department of Paedi0tric.9, MC 4065, UniverSieyof Chicago, 5841 6. Maryland Ave, Chicago, IL tV637s USA. Fax: + I-773-7L32Ll666. E-mail: .sguandel@pt?ds.bsd. uchicago.edu
disease
The potential role of luminal bacteria in initiating the abnormal immune response seen in inflammatory bowel disease is stressed by many observations. A defect in mucosal barrier function could allow luminal bacterial antigens to initiate the chronic relapsing inflammation in Crohn’s disease. The potential role of luminal bacteria in initiating the abnormal immune response seen in inflammatory bowel disease is stressed by many observations. A pilot study to investigate the possible effect of Lactobacillus GG in children with active Crohn’s disease was conducted. Four male patients were enrolled, median age 14.5 years [range 1018]. In terms of clinical outcome, the patients showed significant improvement. In three patients on Lactobacillus GG, it was possible to taper the dose of steroids. Thus, although our data are obviously very preliminary Lactobacillus GG appears to be effective in improving the clinical status of children with Crohnk disease. A multicentre study is currently being carried out in 7 US University centres in a randomized, double-blind, placebo-controlled fashion to establish the efficacy of this probiotic in children with Crohn’s disease.
Digest
Department of Peediatrics, University of Chicago#IL, USA.
Crohn’s
Dis 2002;34ISuppl.21:S63-5 Crohn’s
disease;
inflammatory
bowel
disease;
Lactobacillus GG; lumlnal
bacteria
There is increasing evidence suggesting that endogenous bacterial flora plays an important role in the initiation and perpetuation of inflammatory bowel disease (IBD) ’ 2. It has been hypothesized that the intestinal inflammatory response is the result of an exaggerated intestinal host immune response to commensal enteric bacteria or their components in genetically predisposed individuals. A defect in mucosal barrier function could allow luminal bacterial antigens to initiate a chronic relapsing inflammation. The intestinal mucus layer from patients with IBD has a high number of bacteria compared to controls 3, and it was thus hypothesized that the intestinal mucus layer in this condition is less protective against the endogenous microflora than in controls. The potential role of luminal bacteria in initiating the abnormal immune response seen in IBDs is stressed by the observation that mice deficient in interleukin 2 (IL-2) 4, IL-10 5 and T cell receptors 6 develop spontaneous colitis only in the presence of luminal bacteria while they do not if raised in germ-free conditions. Finally, metronidazole and ciprofloxacin are useful in the treatment of Crohn’s disease 7 *. Do probiotics have any protective role in this scenario? Recently, Madsen et al. 9 reported that IL- 10 deficient mice, that develop a patchy, chronic colitis similar to human Crohn’s disease ‘” have, during the neonatal period, decreased levels of Lactobacillus specie; and increased colonic mucosa adherent as well as translocated bacteria when compared to normal controls. Normalising the levels of Luctobacihs sp. by daily rectal delivery of Lactobacillus reuteri or oral lactulose intake reduced the numbers of colonic mucosa adherent and translocated bacteria and markedly and significantly prevented the development of colonic inflammation. Very few data are, so far, available in humans, and then only in adults 11-‘4.They will not be reviewed here, as they are the subjects of another presentation.
S63
Use of L-GG in paediatric
CD
As a pilot study to investigate the possible effect of Lactobacillus-GG (L-GG) in IBD in children, we conducted I5 an open-label small-sized trial to assess the clinical efficacy of L-GG oral supplementation in children with Crohn’s disease. Children under 18 years old with Crohn’s disease, diagnosed by established clinical, radiographic and endoscopic criteria, were included in the study. Patients with mildly to moderately active disease, despite concomitant therapy with prednisone and immunomodulatory drugs like 6-mercaptopurine (6-MP), azathioprine (AZA) or methotrexate were included in the study. Active disease was defined as Pediatric Crohn’s Disease Activity Index (PCDAI) of >lO 16.All patients were on stable doses of immunomodulatory drugs and of prednisone for at least four weeks before enrolment. Subjects were screened one week before starting of L-GG therapy. Clinical features and disease activity (PCDAI) were assessed at baseline and at 1,4, 12 and 24 weeks on L-GG. Stools were cultured at each follow-up visit to assess colonization by L-GG. We also assessed intestinal permeability by the cellobiose/mannitol (C/M) sugar permeability test, at each visit. In fact, intestinal permeability is thought to reflect disease activity I7 and we hypothesized that L-GG might have been effective in improving its alteration. Four patients were enrolled. All were male with a median age of 14.5 years (range 1O-18). Two patients had ileo-colonic disease and the other two had gastro-colonic disease. None had fistulas. Median duration of Crohn’s disease was 3 years (range l-5). All patients were on prednisone at entry with a median dose of 22.5 mg and on immunomodulatory drugs, either 6-MP or imuran. Two patients were also on flagyl. Median PCDAI score at entry was 19 (range 12-35). Cellobiose/mannitol ratio was also high at baseline reflecting increased intestinal permeability (median 0.12, range 0.023-o. 17). There was successful intestinal colonization with L-GG in all patients: the probiotic was recovered in stool samples of all the patients at follow-up visits at a faecal concentration ranging from 10’ to 10” CFU/gm. Interestingly, concomitant treatment with metronidazole did not inhibit intestinal colonization with L-GG. We found that L-GG intake improved the intestinal permeability, as measured by the double sugar permeability test. Such decrease was evident already at 1 week, and peaked at 12-week follow-up (median 0.02 1, range 0.009-0.046, ~~0.05). However, intestinal permeability appeared to drift back at 24-week follow-up. In terms of clinical outcome, the patients showed significant improvement, as documented by repeated PCDAI assessments (p=O.O2, see Figure 1). Median PCDAI score at 4-week visit was 5 (range O-12.5). PCDAI score at 12 weeks was also significantly lower than baseline (median 7.5, range O-10). The median PCDAI at the 24-week fol-
I
I
I
Baseline
1 week
4 week
I 12 week
I 24 week
Fig. 1. PCDAI during LGG therapy. Box shows the 2EYhpercentile, mejian and 75th percentile. Whiskers show the range of the data. AbDreviations: see list.
low-up (a time when intestinal permeability seemed to return to increased values, as shown in Figure 2) was still lower than baseline, but not significantly so. In three patients on L-GG, we were able to taper the dose of steroids: average reduction in steroid dose in these patients was 50% at 12 weeks. Finally, no patient reported any adverse effects during the study period. Thus, although our data are obviously very preliminary, L-GG appears to be effective in improving the clinical status of children with Crohn’s disease. The intriguing improvement in intestinal permeability suggests that L-GG may act by enhancing the gut mucosal barrier directly or by offering resistance to colonization by bacteria that modulate tight junction permeability. A multicentre study is currently being carried out in 7 US University centres in a randomized, double-blind,
0
.$j 0.15 L 5 .E 5
0.10
s m 0
a 0 i 0
*
0.05
d 0.00
I Baseline
I 1-k
1 4week
I 12week
I 24-k
Fii. Z. Cellobios&lannitoI ratio during LGG therapy. Box shows the 2!F lercentile, median and 75* percentile. Whiskat% show range of data.
S. Guandalini
placebo-controlled fashion to establish the efficacy of this probiotic in children with Crohn’s disease. Results, however, will not be available until late 2002.
~ 6-MP: B-mercaptopurine; AZA: azathioprine; IBD: inflammatory bowel disease; IL: inter&kin; L-GG: lactobacihs-GG; PCDAI: Paediatric Crohn’s Disease Activity Index.
-1
References ’ Sartor RB. Pathogenesis and immune mechanisms of chronic inflammatory bowel diseases. Am J Gastroenterol 1997;92(Suppl 12):S5-I I. z Merger M, Croitoru K. Infections in the immunopathogenesis of chronic inflammatory bowel disease. Semin lmmunol 1998;10:69-78. ’ Schultsz C, Van Den Berg FM, Ten Kate FW, Tytgat GN. Dankert J. The intestinal mucus layer from patients with inflammatory bowel disease harbors high numbers-of bacteria compared with controls. Gastroenterology 1999; 117: 1089-97. J Contractor NV, Bassiri H, Reya T, Park AY, Baumgart DC, Walsik MA. et al. Lymphoid hyperplasia, autoimmunity, and compromised intestinal intraepithelial lymphocyte development in colitis-free gnotobiotic IL-2- deficient mice. J Immunol 1998;160:385-94. ’ Sellon RK, Tonkonogy S, Schultz M, Dieleman LA, Grenther W. Balish E, et al. Resident enteric bacteria are necessary for development of spontaneous colitis and immune system activation in interleukin- 1O-deficient mice. Infect Immun 1998;66:5224-3 1. 6 Dianda L, Hanby AM, Wright NA, Sebesteny A, Hayday AC, Owen MJ. T cell receptor-alpha beta-deficient mice fail to develop colitis in the absence of a microbial environment. Am J Path01 1997;150:91-7. ’ Prantera C, Berto E, Scribano ML, Falasco G. Use of antibiotics in the treatment of active Crohn’s disease: experience with
metronidazole and ciprofloxacin. Ital J Gastroenterol Hepatol 1998;30:602-6. 8 Greenbloom SA, Steinhart, Greenberg G. Combination ciprofloxacin and metronidazole for active Crohn’s disease. Can J Gastroenterol 1998;12:53-6. y Madsen K, Doyle JS, Jewel1 LD, Tavernini MM, Fedorak RN. Lactobacillus species prevents colitis in interleukin 10 gene-deficient mice. Gastroenterology 1999; 116: 1 107- 14. ‘o Kuhn R Lohler J, Rennick D, Rajewsky K, Muller W. Interleukin-lb-deficient mice develop chronic enterocolitis. Cell 1993;75:263-74. ‘I Gionchetti P, Rizzello F, Venturi A, Brigidi P, Matteuzzi D, Bazzocchi G, et al. Maintenance treatment of chronic pouchitis: a randomized, placebo-controlled, double-blind trial with a new probiotic preparation. Gastroenterology 1998;114:A985. ‘? Kruis W, Schutz E, Fric P, Fixa B, Judmaier G, Stolte M. Doubleblind comparison of an oral Escherichia coli preparation and mesalazine in maintaining remission of ulcerative colitis. Aliment Pharmacol Ther 1997;11:853-8. I3 Rembacken BJ, Snelling AM, Hawkey PM, Chalmers DM, Axon AT. Non-pathogenic Escherichia coli versus mesalazine for the treatment of ulcerative colitis: a randomised trial. Lancet 1999;21:635-9. ” Venturi A, Gionchetti P, Rizzello F, Johansson R, Zucconi E, Brigidi P, et al. Impact on the composition of the faecal Flora by a new probiotic preparation: preliminary data on maintenance treatment of patients with ulcerative colitis. Aliment Pharmacol Ther 1999;1:1103-8. Is Gupta P, Andrew H, Kirschner BS, Guandalini S. Is lactobacillus GG helpful in children with Crohn’s disease? Results of a preliminary, open-label study. J Pediatr Gastroenterol Nutr 20003 1:453-7. I6 Hyams JS, Ferry GD, Mandel FS, Grybosky SD, Kisort GM, Kirschner BS, et al. Development and validation of a pediatric Crohn’s disease activity index. J Pediatr Gastroenterol Nutr 1991;12:439-47. ” Miki K, Moore DJ, Butler RN, Southcott E, Couper RT, Davidson GP. The sugar permeability test reflects disease activity in children and adolescents with inflammatory bowel disease. J Pediatr 1998; 133:750-4.
Use of Lactobacillus-GG S. Guandalini
in paediatric
Liver
Key words:
tivm
Prof. S. Guandalini Department of Paedi0tric.9, MC 4065, UniverSieyof Chicago, 5841 6. Maryland Ave, Chicago, IL tV637s USA. Fax: + I-773-7L32Ll666. E-mail: .sguandel@pt?ds.bsd. uchicago.edu
disease
The potential role of luminal bacteria in initiating the abnormal immune response seen in inflammatory bowel disease is stressed by many observations. A defect in mucosal barrier function could allow luminal bacterial antigens to initiate the chronic relapsing inflammation in Crohn’s disease. The potential role of luminal bacteria in initiating the abnormal immune response seen in inflammatory bowel disease is stressed by many observations. A pilot study to investigate the possible effect of Lactobacillus GG in children with active Crohn’s disease was conducted. Four male patients were enrolled, median age 14.5 years [range 1018]. In terms of clinical outcome, the patients showed significant improvement. In three patients on Lactobacillus GG, it was possible to taper the dose of steroids. Thus, although our data are obviously very preliminary Lactobacillus GG appears to be effective in improving the clinical status of children with Crohnk disease. A multicentre study is currently being carried out in 7 US University centres in a randomized, double-blind, placebo-controlled fashion to establish the efficacy of this probiotic in children with Crohn’s disease.
Digest
Department of Peediatrics, University of Chicago#IL, USA.
Crohn’s
Dis 2002;34ISuppl.21:S63-5 Crohn’s
disease;
inflammatory
bowel
disease;
Lactobacillus GG; lumlnal
bacteria
There is increasing evidence suggesting that endogenous bacterial flora plays an important role in the initiation and perpetuation of inflammatory bowel disease (IBD) ’ 2. It has been hypothesized that the intestinal inflammatory response is the result of an exaggerated intestinal host immune response to commensal enteric bacteria or their components in genetically predisposed individuals. A defect in mucosal barrier function could allow luminal bacterial antigens to initiate a chronic relapsing inflammation. The intestinal mucus layer from patients with IBD has a high number of bacteria compared to controls 3, and it was thus hypothesized that the intestinal mucus layer in this condition is less protective against the endogenous microflora than in controls. The potential role of luminal bacteria in initiating the abnormal immune response seen in IBDs is stressed by the observation that mice deficient in interleukin 2 (IL-2) 4, IL-10 5 and T cell receptors 6 develop spontaneous colitis only in the presence of luminal bacteria while they do not if raised in germ-free conditions. Finally, metronidazole and ciprofloxacin are useful in the treatment of Crohn’s disease 7 *. Do probiotics have any protective role in this scenario? Recently, Madsen et al. 9 reported that IL- 10 deficient mice, that develop a patchy, chronic colitis similar to human Crohn’s disease ‘” have, during the neonatal period, decreased levels of Lactobacillus specie; and increased colonic mucosa adherent as well as translocated bacteria when compared to normal controls. Normalising the levels of Luctobacihs sp. by daily rectal delivery of Lactobacillus reuteri or oral lactulose intake reduced the numbers of colonic mucosa adherent and translocated bacteria and markedly and significantly prevented the development of colonic inflammation. Very few data are, so far, available in humans, and then only in adults 11-‘4.They will not be reviewed here, as they are the subjects of another presentation.
S63
Use of L-GG in paediatric
CD
As a pilot study to investigate the possible effect of Lactobacillus-GG (L-GG) in IBD in children, we conducted I5 an open-label small-sized trial to assess the clinical efficacy of L-GG oral supplementation in children with Crohn’s disease. Children under 18 years old with Crohn’s disease, diagnosed by established clinical, radiographic and endoscopic criteria, were included in the study. Patients with mildly to moderately active disease, despite concomitant therapy with prednisone and immunomodulatory drugs like 6-mercaptopurine (6-MP), azathioprine (AZA) or methotrexate were included in the study. Active disease was defined as Pediatric Crohn’s Disease Activity Index (PCDAI) of >lO 16.All patients were on stable doses of immunomodulatory drugs and of prednisone for at least four weeks before enrolment. Subjects were screened one week before starting of L-GG therapy. Clinical features and disease activity (PCDAI) were assessed at baseline and at 1,4, 12 and 24 weeks on L-GG. Stools were cultured at each follow-up visit to assess colonization by L-GG. We also assessed intestinal permeability by the cellobiose/mannitol (C/M) sugar permeability test, at each visit. In fact, intestinal permeability is thought to reflect disease activity I7 and we hypothesized that L-GG might have been effective in improving its alteration. Four patients were enrolled. All were male with a median age of 14.5 years (range 1O-18). Two patients had ileo-colonic disease and the other two had gastro-colonic disease. None had fistulas. Median duration of Crohn’s disease was 3 years (range l-5). All patients were on prednisone at entry with a median dose of 22.5 mg and on immunomodulatory drugs, either 6-MP or imuran. Two patients were also on flagyl. Median PCDAI score at entry was 19 (range 12-35). Cellobiose/mannitol ratio was also high at baseline reflecting increased intestinal permeability (median 0.12, range 0.023-o. 17). There was successful intestinal colonization with L-GG in all patients: the probiotic was recovered in stool samples of all the patients at follow-up visits at a faecal concentration ranging from 10’ to 10” CFU/gm. Interestingly, concomitant treatment with metronidazole did not inhibit intestinal colonization with L-GG. We found that L-GG intake improved the intestinal permeability, as measured by the double sugar permeability test. Such decrease was evident already at 1 week, and peaked at 12-week follow-up (median 0.02 1, range 0.009-0.046, ~~0.05). However, intestinal permeability appeared to drift back at 24-week follow-up. In terms of clinical outcome, the patients showed significant improvement, as documented by repeated PCDAI assessments (p=O.O2, see Figure 1). Median PCDAI score at 4-week visit was 5 (range O-12.5). PCDAI score at 12 weeks was also significantly lower than baseline (median 7.5, range O-10). The median PCDAI at the 24-week fol-
I
I
I
Baseline
1 week
4 week
I 12 week
I 24 week
Fig. 1. PCDAI during LGG therapy. Box shows the 2EYhpercentile, mejian and 75th percentile. Whiskers show the range of the data. AbDreviations: see list.
low-up (a time when intestinal permeability seemed to return to increased values, as shown in Figure 2) was still lower than baseline, but not significantly so. In three patients on L-GG, we were able to taper the dose of steroids: average reduction in steroid dose in these patients was 50% at 12 weeks. Finally, no patient reported any adverse effects during the study period. Thus, although our data are obviously very preliminary, L-GG appears to be effective in improving the clinical status of children with Crohn’s disease. The intriguing improvement in intestinal permeability suggests that L-GG may act by enhancing the gut mucosal barrier directly or by offering resistance to colonization by bacteria that modulate tight junction permeability. A multicentre study is currently being carried out in 7 US University centres in a randomized, double-blind,
0
.$j 0.15 L 5 .E 5
0.10
s m 0
a 0 i 0
*
0.05
d 0.00
I Baseline
I 1-k
1 4week
I 12week
I 24-k
Fii. Z. Cellobios&lannitoI ratio during LGG therapy. Box shows the 2!F lercentile, median and 75* percentile. Whiskat% show range of data.
S. Guandalini
placebo-controlled fashion to establish the efficacy of this probiotic in children with Crohn’s disease. Results, however, will not be available until late 2002.
~ 6-MP: B-mercaptopurine; AZA: azathioprine; IBD: inflammatory bowel disease; IL: inter&kin; L-GG: lactobacihs-GG; PCDAI: Paediatric Crohn’s Disease Activity Index.
-1
References ’ Sartor RB. Pathogenesis and immune mechanisms of chronic inflammatory bowel diseases. Am J Gastroenterol 1997;92(Suppl 12):S5-I I. z Merger M, Croitoru K. Infections in the immunopathogenesis of chronic inflammatory bowel disease. Semin lmmunol 1998;10:69-78. ’ Schultsz C, Van Den Berg FM, Ten Kate FW, Tytgat GN. Dankert J. The intestinal mucus layer from patients with inflammatory bowel disease harbors high numbers-of bacteria compared with controls. Gastroenterology 1999; 117: 1089-97. J Contractor NV, Bassiri H, Reya T, Park AY, Baumgart DC, Walsik MA. et al. Lymphoid hyperplasia, autoimmunity, and compromised intestinal intraepithelial lymphocyte development in colitis-free gnotobiotic IL-2- deficient mice. J Immunol 1998;160:385-94. ’ Sellon RK, Tonkonogy S, Schultz M, Dieleman LA, Grenther W. Balish E, et al. Resident enteric bacteria are necessary for development of spontaneous colitis and immune system activation in interleukin- 1O-deficient mice. Infect Immun 1998;66:5224-3 1. 6 Dianda L, Hanby AM, Wright NA, Sebesteny A, Hayday AC, Owen MJ. T cell receptor-alpha beta-deficient mice fail to develop colitis in the absence of a microbial environment. Am J Path01 1997;150:91-7. ’ Prantera C, Berto E, Scribano ML, Falasco G. Use of antibiotics in the treatment of active Crohn’s disease: experience with
metronidazole and ciprofloxacin. Ital J Gastroenterol Hepatol 1998;30:602-6. 8 Greenbloom SA, Steinhart, Greenberg G. Combination ciprofloxacin and metronidazole for active Crohn’s disease. Can J Gastroenterol 1998;12:53-6. y Madsen K, Doyle JS, Jewel1 LD, Tavernini MM, Fedorak RN. Lactobacillus species prevents colitis in interleukin 10 gene-deficient mice. Gastroenterology 1999; 116: 1 107- 14. ‘o Kuhn R Lohler J, Rennick D, Rajewsky K, Muller W. Interleukin-lb-deficient mice develop chronic enterocolitis. Cell 1993;75:263-74. ‘I Gionchetti P, Rizzello F, Venturi A, Brigidi P, Matteuzzi D, Bazzocchi G, et al. Maintenance treatment of chronic pouchitis: a randomized, placebo-controlled, double-blind trial with a new probiotic preparation. Gastroenterology 1998;114:A985. ‘? Kruis W, Schutz E, Fric P, Fixa B, Judmaier G, Stolte M. Doubleblind comparison of an oral Escherichia coli preparation and mesalazine in maintaining remission of ulcerative colitis. Aliment Pharmacol Ther 1997;11:853-8. I3 Rembacken BJ, Snelling AM, Hawkey PM, Chalmers DM, Axon AT. Non-pathogenic Escherichia coli versus mesalazine for the treatment of ulcerative colitis: a randomised trial. Lancet 1999;21:635-9. ” Venturi A, Gionchetti P, Rizzello F, Johansson R, Zucconi E, Brigidi P, et al. Impact on the composition of the faecal Flora by a new probiotic preparation: preliminary data on maintenance treatment of patients with ulcerative colitis. Aliment Pharmacol Ther 1999;1:1103-8. Is Gupta P, Andrew H, Kirschner BS, Guandalini S. Is lactobacillus GG helpful in children with Crohn’s disease? Results of a preliminary, open-label study. J Pediatr Gastroenterol Nutr 20003 1:453-7. I6 Hyams JS, Ferry GD, Mandel FS, Grybosky SD, Kisort GM, Kirschner BS, et al. Development and validation of a pediatric Crohn’s disease activity index. J Pediatr Gastroenterol Nutr 1991;12:439-47. ” Miki K, Moore DJ, Butler RN, Southcott E, Couper RT, Davidson GP. The sugar permeability test reflects disease activity in children and adolescents with inflammatory bowel disease. J Pediatr 1998; 133:750-4.