Alexander Shikhman MD, PhD Institute for Specialized Medicine July 20, 2013
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1 Alexander Shikhman MD, PhD Institute for Specialized Medicine July 20, 2013
2 SPONDYLOARTHROPATHIES The spondyloarthropathy family consists of the following entities: Ankylosing spondylitis Undifferentiated spondyloarthritis Reactive arthritis Psoriatic arthritis Spondyloarthritis associated with IBD Juvenile onset spondyloarthritis
3 ANKYLOSING SPONDYLITIS AND GUT Subclinical gut inflammation has been described in up to two-thirds of patients with spondyloarthropathies Two histologic types of gut inflammation in patients with SpA can be distinguished: acute and chronic inflammation
4 ANKYLOSING SPONDYLITIS AND GUT The acute type mimics the acute bacterial enterocolitis and is mainly seen in patients with reactive arthritis: The mucosal architecture is well preserved There is a polymorphonuclear infiltration of the ileal villi and crypts There is an increased number of inflammatory cells (granulocytes, lymphocytes and plasma cells) in the lamina propria
5 ANKYLOSING SPONDYLITIS AND GUT The chronic type is often indistinguishable from Crohn s disease (CD): The mucosal architecture is clearly disturbed The villi are irregular, blunted and fused The crypts are distorted The lamina propria is edematous and infiltrated by mononuclear cells In some cases aphthoid ulcers and sarcoid-like granulomas are present Chronic lesions are more present in undifferentiated SpA and AS.
6 ANKYLOSING SPONDYLITIS AND GUT Increased intestinal permeability or leaky gut syndrome is a key mechanism contributing to the development and chronic course of ankylosing spondylitis and other autoimmune diseases and inflammatory arthritis. Tight junctions (TJs) represent the major barrier within the pathway between intestinal epithelial cells that line the digestion tract The leaky gut allows substances such as toxins, microbial antigens, undigested food, waste, or larger than normal macromolecules to leak through an abnormally permeable gut wall and trigger cascades of inflammatory reactions.
7 ANKYLOSING SPONDYLITIS AND Zonulin is a protein regulating intestinal permeability via modulation of tight junction GUT Small intestines exposed to enteric bacteria secrete zonulin This secretion occurs only on the luminal aspect of the bacteria-exposed small intestinal mucosa and is followed by an increase in intestinal permeability
8 ANKYLOSING SPONDYLITIS AND GUT Mielants H, Veys EM, De Vos M, Cuvelier C. Increased intestinal permeability in ankylosing spondylitis. Gut Aug;33(8):1150. Martínez-González O, Cantero-Hinojosa J, Paule-Sastre P, Gómez- Magán JC, Salvatierra-Ríos D. Intestinal permeability in patients with ankylosing spondylitis and their healthy relatives. Br J Rheumatol Jul;33(7): Liu Y, Xu B, Cai X. The role of intestinal permeability in the pathogenesis of ankylosing spondylitis. Zhonghua Nei Ke Za Zhi Feb;34(2):91-4. Vaile JH, Meddings JB, Yacyshyn BR, Russell AS, Maksymowych WP. Bowel permeability and CD45RO expression on circulating CD20+ B cells in patients with ankylosing spondylitis and their relatives. J Rheumatol Jan;26(1):
9 ANKYLOSING SPONDYLITIS AND Gut microbiota consists of a complex of microorganism species that live in the digestive tract The human body carries about 100 trillion microorganisms in its intestines, a number ten times greater than the total number of human cells in the body The metabolic activities performed by these bacteria resemble those of an organ, leading some to liken gut bacteria to a "forgotten" organ GUT MICROBIOTA
10 ANKYLOSING SPONDYLITIS AND Gut microbiota primary benefits the host by generating energy from the fermentation of undigested carbohydrates and the subsequent absorption of short chain fatty acids. The most important of these are butyrates, metabolized by the colonic epithelium and normalizing intestinal permeability. GUT MICROBIOTA
11 ANKYLOSING SPONDYLITIS AND GUT MICROBIOTA
12 ANKYLOSING SPONDYLITIS AND HLA B27 influences the composition of the body s endogenous flora and the B27- shaped flora predisposes to ankylosing spondylitis HLA-B27 transgenic mice do not develop spondylitis-like lesions in germ-free enviroment Antibiotic therapy prevents spondylitis and colitis in HLA- B27 transgenic rats GUT MICROBIOTA THE HLA-B27 CONNECTION
13 ANKYLOSING SPONDYLITIS THERAPEUTIC GOALS NORMALIZATION OF INTESTINAL PERMEABILITY OPTIMIZATION OF GUT MICROFLORA OPTIMIZATION OF TOXIN REMOVAL REDUCTION OF LOCAL/MUCOSAL INFLAMMATION REDUCTION OF SYSTEMIC INFLAMMATORY RESPONSES AND PREVENTION OF ANKYLOSIS
14 NORMALIZATION OF INTESTINAL PERMEABILITY BUTYRATE Peng L, Li ZR, Green RS, Holzman IR, Lin J. Butyrate enhances the intestinal barrier by facilitating tight junction assembly via activation of AMP-activated protein kinase in Caco-2 cell monolayers. J Nutr Sep;139(9): L-GLUTAMINE dos Santos Rd, Viana ML, Generoso SV, Arantes RE, Davisson Correia MI, Cardoso VN. Glutamine supplementation decreases intestinal permeability and preserves gut mucosa integrity in an experimental mouse model. JPEN J Parenter Enteral Nutr Jul- Aug;34(4): BERBERINE Gu L, Li N, Gong J, Li Q, Zhu W, Li J. Berberine ameliorates intestinal epithelial tight-junction damage and down-regulates myosin light chain kinase pathways in a mouse model of endotoxinemia. J Infect Dis Jun 1;203(11):
15 OPTIMIZATION OF GUT PROBIOTICS live microorganisms which beneficially improve intestinal microbial balance PREBIOTICS non-digestible polysaccharides that stimulate the growth and/or activity of good bacteria in the digestive system SYNBIOTICS nutritional supplements combining probiotics and prebiotics BUTYRATE DIGESTIVE ENZYMES MICROBIOTA
16 OPTIMIZATION OF GUT MICROBIOTA CLINICAL TRIALS UTILIZING PROBIOTICS IN ANKYLOSING SPONDYLITIS limited number of published clinical trials insufficient number of participants to make any meaningful conclusions absence of reliable clinical or/and laboratory markers to measure the trials outcome poor clinical design (low dose of probiotics, poor selection of the probiotic strains)
17 OPTIMIZATION OF GUT MICROBIOTA PROBIOTICS THE RIGHT DOSE THE RIGHT STRAIN(S) THE RIGHT TIME OF ADMINISTRATION SPACING OUT PROBIOTICS FROM ANTIBIOTICS AND DMARDs
18 OPTIMIZATION OF GUT MICROBIOTA no published clinical trials PREBIOTICS experimental data utilizing beta-glucan and mannanoligosaccharides based prebiotics demonstrated negative effect in animals with experimental colitis and Crohn s disease
19 OPTIMIZATION OF GUT MICROBIOTA DIGESTIVE ENZYMES enzymes of animal origin (pancreatic enzymes/pancreatin) plant-based enzymes medicinal mushrooms/medicinal molds-based enzymes
20 OPTIMIZATION OF TOXIN REMOVAL Calcium glucarate Psyllium/apple pectin Triphala Citrulline malate Acetyl-L-carnitine
21 REDUCTION OF LOCAL/MUCOSAL INFLAMMATION TRADITIONAL THERAPY Sulfasalazine 5-ASA Corticosteroids COMPLEMENTARY THERAPY Curcumin Boswellia Devil s claw Berberine N-acetylglucosamine Omega-3 polyunsatturated fatty acids Oral bovine immunoglobulins
22 REDUCTION OF SYSTEMIC INFLAMMATORY RESPONSES Biologics NSAIDs TRADITIONAL THERAPY Sulfasalazine 5-ASA Corticosteroids COMPLEMENTARY THERAPY Curcumin Boswellia Devil s claw Omega-3 polyunsatturated fatty acids
23 GUT-FOCUSED THERAPY IN ANKYLOSING SPONDYLITIS TRADITIONAL THERAPY + COMPLEMENTARY THERAPY = INTEGRATIVE APPROACH SULFASALAZINE + BUTYRATE/GLUTAMINE + BERBERINE TRIPHALA + CALCIUM GLUCARATE + CITRULLINE MALATE BACILLUS COAGULANS + DIGESTIVE ENZYMES + BOVINE IMMUNOGLOBULINS OMEGA-3 + DEVIL S CLAW + BOSWELLIA/CURCUMIN
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