CLINICAL TARGETS FOR PROBIOTICS

Transcription

1 CLINICAL TARGETS FOR PROBIOTICS Where can probiotics or synbiotics make the biggest human health impact? ISAPP 2008 Group 3

2 1. Established indications (evidence of clinical efficacy exists, recommendations to improve effect needed, etc) 2. Probable new indications (under current research, studies inconsistent, effect size negligible, how to improve efficacy?) 3. Possible new targets (hypothetically sound but unproven, promising findings in animal studies, fishing expeditions with interesting outcomes, etc) ISAPP 2008 Group 3

3 James Versalovic Baylor College of Medicine Francisco Guarner University Hospital Vall d Hebron Jean Michel Antoine Danone Company Thomas Brewer Bill and Melinda Gates Foundation Robert Britton Michigan State University Michael Cabana University of California, San Francisco Duanne Charbonneau P&G Greg Gloor University of Western Ontario Michael Hsieh Baylor College of Medicine Ruben Hummelen ErasmusMC University Medical Center Rotterdam Flavia Indrio University of Bari Policlinico Todd Klaenhammer North Carolina State University Michel Klein AmVac Maryse Lamoureux Agropur Niklas Larsson Probi Ravi Menon General Mills Dan Merenstein Georgetown University Medical Center Eveliina Myllyluoma University of Helsinki Nicolas Page Nestle Yanni Papanikolaou Kellogg Canada M. Sudam Pathirana Wyeth Consumer Healthcare Bruno Pot Institut Pasteur de Lille Tamar Ringel Kulka University of North Carolina at Chapel Hill Ali Shah The Dow Chemical Company Lothar Steidler Actogenix Carissa Thomas Baylor College of Medicine Thomas Tompkins Institut Rosell Steven Weil Biocodex

4 James Versalovic, Baylor College of Medicine Selection of Probiotics: Tailoring Probiotics for Personalized Medicine Francisco Guarner, University Hospital Vall d Hebron Perspectives in IBD Robert Britton, Michigan State University Consideration of Microbial Physiology when Identifying Candidate Probiotic Strains Flavia Indrio, University of Bari Policlinico Effect of Probiotics on Infantile Regurgitation Dan Merenstein, Georgetown University Medical Center Prevention in Our Foods Eveliina Myllyluoma, University of Helsinki Effects of Probiotic Supplementation on Irritable Bowel Syndrome

5 Tamar Ringel Kulka, University of North Carolina at Chapel Hill Probiotics in Child Care Centers Day Care Absenteeism, Work Absenteeism and Utilization of Health Care Intestinal Microflora and Obesity Lothar Steidler, Actogenix Actobiotics: GM Microflora for Precision Intervention in Human Disease Michael Hsieh, Baylor College of Medicine Probiotics for Ob/Gyn and Urology Michael Cabana, University of California Asthma and allergic diseases Bruno Pot, Institut Pasteur de Lille Applications where large impact is expected

6 The Core and Variable Components of the Is there are Definable Core Microbiome? Can one change the composition of the core with probiotics and prebiotics? Is targeting the core microbiome a feasible approach and will it make a difference for health and disease? Microbiome Turnbaugh PJ et al. Nature 2007;449:

7 The Core and Variable Components of the Microbiome Is the variable component the practical and only malleable target for probiotics or prebiotics? Can we make an impact in terms of promoting health and preventing disease by altering the variable component of the microbiome? Do probiotics and prebiotics have different potential roles in altering the core versus the variable components of the microbiome? Is there a hypervariable portion of the microbiome and a less variable component?

8 healthy individuals / 5 Crohn s subjects in remission / stool Libraries of clones of 40 kb each (2 billions pb in total) Screening of 16S rdna / clones S rdna sequences Comparaison Helathy and Crohn s libraries FISH to validate the results Guarner

9 Healthy library Metagenomic clone name (Adhufec x) clone number Bifidobacterium longum (7) 78 Bifidobacterium sp. (6) 81 Corynebacterium lipophiloflavum (3) 80 Brachybacterium paraconglomeratum (1) 84(15) 82 Coriobacterium sp. (17) 83(1) 19 HuCC28 (14) 20 (6) 21 Adhufec61 (51) 22 Adhufec41 (9) 25 Bacteroides splanchnicus (2) 16 Adhufec367 (22) 18 Bacteroides vulgatus (77) 17 HuCB3 (5) 15 Adhufec151 (10) 12 (33) 13 (10) 14 (4) 7 HuCA21 (1) 8 Bacteroides caccae (1) 4 (1) 3 (1) 1 Bacteroides thetaiotaomicron (4) 6 HuCC30 (3) 5 Bacteroides ovatus (3) 10 Bacteroides stercoris (16) 9 Bacteroides uniformis (56) 11 Bacteroides eggerthi (4) 24 Bacteroides merdae (3) 23 Baceroides distasonis (17) 30 (1) 34 (2) 33 (1) 31(1) 32(1) 26 (1) 27 (2) 29 Bacteroides putredinis (4) 28 HuCB23 (5) 89 Bilophila wadsworthia (4) 88 Escherichia coli K12 (16) 87 (1) 86 (3) 85(1) 71 Cadhufec079h7 (1) 72 Dialister invisus (1) 70 Eubacterium biforme (1) 44 (1) 45 (2) 46 Cadhufec14h7 (11) 48 (2) 47 Ruminococcus sp. (1) 49 (1) 51 ckcm323 B (1) 50 (1) 39 p Wb (3) 40 HuCB5 (8) 41 p F5 (2) 42 butyrate producing M12/2 (5) 43 Adhufec365 (2) 35 Adhufec311 (1) 36 p 2053 s95 (1) 37 Adhufec269 (2) 38 p 953 s962 (1) 75 (1) 77 (1) 76 (1) 73 HuCA6 (1) 74 (1) 69 Clone p 2722 (1) 54 Adhufec406 (1) 52 (1) 53 Butyrovibrio crossotus (4) 62 C. catus (1) 58 Uncultured bacterium A20 (5) 60 Uncultured bacterium G36 (1) 59 HuCB12 (2) 57 HuCA22 (1) 55 p 3075 SwA (1) 56 (2) 61 Cadhufec001h7 (2) 66 p G (1) 68 HuCB10 (2) 67 (1) 64 butyrate producing M104/1 (8) 65 butyrate producing M72/1 (1) 63 Lachnospira pectinoschiza(1) 45 clones 17 OTUs 35 clones 17 OTUs Phylogenetic trees Crohn library Actinobacteria 50 clones 7 OTUs Bacteroidetes 371 clones 33 OTUs Proteobacteria 25 clones 5 OTUs Clostridium leptum group Clostridium coccoides group Firmicutes 89 clones 43 OTUs Metagenomic clone name (Cadhufec x) Coriobacterium sp. (1) 56 Desulfovibrio piger (1) 49 Bifidobacterium pseudolongum (28) 50 (1) 40(5) 39 (4) 41 (3) 42 (2) 43 (1) 47 (3) 38 (1) 36 (4) 34 HuCB5 (3) 35 butyrate producing M21/2 (2) 37 (1) 45 (1) 44 (7) 52 Escherichia coli K12 (27) 55 (1) 54 (1) 53 (1) 29 (1) 23 Bacteroides putredinis (38) 31 (3) 30 (1) 22 (1) 28 (1) 24 (6) 25 (57) clone number 26 (30) 27 (1) 21 Bacteroides splanchnicus (9) 19 Bacteroides merdae (34) 18 Bacteroides distasonis (10) 20 (1) 33 (37) 32 (12) 16 (2) 11 HuCC21 (2) 14 (3) 15 (1) 17 (7) 13 (1) 12 Adhufec61 (68) 9 (5) 6 Bacteroides vulgatus (91) 5 Adhufec367 (18) 7 (1) 8 (3) 4 Bacteroides stercoris (15) 10 (7) 1 Bacteroides ovatus (2) 2 HuCC30 (17) 3 Bacteroides uniformis (71) 30 clones 7 OTUs 15 clones 6 OTUs 14 clones 5 OTUs 31 clones 5 OTUs Actinobacteria Clostridium coccoides group Clostridium leptum group Proteobacteria Bacteroidetes 556 clones 33 OTUs Guarner Firmicutes 37 clones 13 OTUs

10 Understanding why microbial physiology is important Probiotics = live microorganisms Survive multiple forms of stress Stress during production and storage Host stress: acid, bile, innate immunity Produce beneficial functions in vivo Are bacterial products identified in the laboratory made in the host? Britton

11 Rationale behind selecting strains for clinical trials History as an established probiotic formulation over scientific rationale Often no logical mechanistic basis for using a particular probiotic strain is apparent Are many clinical trials are doomed to fail from the start? Britton

12 Indrio

13 Formula+LR Breast milk Formula+placebo Fasting antral area Formula+LR Breast milk Formula+placebo Gastric emptying rate Fasting antral area (cm 2 ) % GE rate

14 Probiotics can Reduce Mean Daily Crying Times Crying time (min/day) Breast feed infant (BF) Formula feed infants +placebo (FP) Formula feed infants Lactobacillus Reuterii (FR) P<0.01 Indrio

15 Participant Flow Chart 745 Screened 106 Not Eligible 681 Assessed for Eligibility 638 Randomized ITT Population 314 Allocated Intervention 324 Allocated Control Merenstein

16 Primary and Secondary Outcomes Primary Outcomes Active (SE) LSmean (SE) Placebo (SE) LSmean (SE) P-value Incidence Rate of CID per 100 person day 7.8 (0.4) 9.8 (0.7) Rate of days with Change in activity due to illness per 100 person day 2.23 (0.21) 2.27 (0.21) 0.91 Secondary Outcomes Rate of Missed daycare or preschool days per 100 person day 1.62 (0.15) 1.70 (0.15) 0.67 Rate of Missed parental work pre 100 person day 0.84 (0.12) 0.83 (0.12) 0.98 Rate of Diarrhea per 100 person day 0.72 (0.11) 0.93 (0.11) 0.19 Rate of Vomiting per 100 person day 0.55 (0.08) 0.73 (0.08) 0.10 Rate of Stomach pain per 100 person day 1.23 (0.21) 1.50 (0.21) 0.36 Rate of Constipation per 100 person day 0.81 (0.18) 0.71 (0.18) 0.68 Rate of Runny nose per 100 person day 7.88 (0.63) 8.65 (0.63) 0.39 Rate of Cough per 100 person day 9.18 (0.63) 8.37 (0.63) 0.36 Rate of Decreasing appetite per 100 person day 2.58 (0.31) 2.31 (0.31) 0.54 Rate of Fever per 100 person day 1.34 (0.14) 1.34 (0.14) 0.99 Rate of Rash per 100 person day 1.17 (0.23) 0.76 (0.23) 0.21 Merenstein

17 The Probiotic Alleviates Bloating and Abdominal Pain Baseline Change to end of trial P-value Placebo Probiotic Placebo Probiotic Mean (SD) Mean (SD) Mean (95% CI) Mean (95% CI) Total sympt. 33 (16) 38 (21) -3 (-8 to 1) -14 ( -19 to -9) Abd. pain 6 (4) 8 (6) 0 (-2 to 2 ) -3 (-5 to -2) Bloating 10 (7) 11 (7) -1 (-3 to 1) -4 (-6 to -2) Flatulence 12 (6) 12 (6) -2 (-4 to -0) -4 (-6 to -2) 0.11 Rumbling 5 (5) 6 (6) -1 (-2 to 0) -3 (-4 to -1) Analysis of covariance, baseline as covariate Kajander et al Myllyluoma ISAPP meeting, London Ontario

18 Phase 1 clinical study in CD patients using LL-IL10 Phase 1 clinical study results have shown: Safety and tolerability of LL-IL-10 Indication of efficacy based on CDAI scores and CRP levels Biological containment Steidler

19 AG013: Preclinical Efficacy Data in Hamster Model of Oral Mucositis 4 Vehicle Healthy Vehicle irradiated M ean M ucositis score LL-TFF3 LL-control * * * * * * * * 0 * Day *: significant improvement Steidler

20 Migration of Pathogens from the Gut to the Female Genitourinary Tract Hsieh

21 Bacterial Vaginosis L. acidophilus douches: Drago et al. J Altern Complement Med 2007 (open label) GR-1 and RC-14 compared to, after, or in combination with metronidazole gel: Reid et al., FEMS Immunol Med Microbiol 2003; Anukam et al., Microbes Infect 2006 (2 studies) L. gasseri, L. rhamnosus and L. fermentum (MediPharm) after metronidazole: Eriksson et al., Acta Derm Venereol 2005 negative study Ecovag (L. gasseri, L. rhamnosus) after metronidazole: Larsson et al., BMC Women s Health 2008 Hsieh

22 Atopic Dermatitis Prevention Study (Year) Treatment Population Results Kalliomaki (2003) 1 x 10^10 CFU of LGG daily Started 2 to 4 weeks before delivery and continued 6 months postnatally 107 Finnish mothers Four-year follow-up of original cohort Decreased risk of atopic dermatitis (AD) No difference in sensitization Taylor (2007) 3 x 10^9 CFU L acidophillus once a day vs. placebo For first 6 months of life 231 Australian families with an atopic pregnant mother No difference in development of atopic dermatitis (AD) and no difference in severity Increased risk of sensitization (by positive skin prick test, SPT) in the L acidophillus group f/u at 1 year of age No difference in rates of infections Kopp (2008) 5 x 10^9 CFU LGG twice a day vs. placebo Started 4 to 6 weeks before delivery and continued 6 months postnatally. 105 German families with at least one member with atopic disease No difference in development of atopic dermatitis and no difference in severity. No difference in respiratory tract infections. Greater proportion of children with >5 episodes of wheezy bronchitis in LGG group (p<0.05) f/u at 2 years of age Cabana

23 Objective: To test the effectiveness of a probiotic supplement in preventing the development of early markers of asthma Subjects: 278 infants at high risk for developing asthma Cabana Intervention Daily infant probiotic dietary supplementation (LGG) Funding: National Institutes of Health

24 Large Expected Impact: More established Applications Gastric and Enteric Infections (diarrhea) 3rd world (cost effective, through food chain,...) Bacterial (Salmonella, Listeria, Campylobacter, Helicobacter ) and viral infections (Rotavirus) Candida infections, parasites?? Alternatives to therapies with severe secondary effects IBD: AB, steroids IBS: AB Supporting therapy for severely ill patients Pre- and post-surgery applications Immunosuppressed patients (HIV, cancer) Vaccination Improve vaccination efficiency (influenza) Oral vaccinations on very wide scale Prevention in general Cancer (colon, bladder,...) Elimination of (endo)toxins NEC Liver cirrhosis Antibiotic-associated diarrhea, Traveler s diarhea Pot

25 Probiotics and Meta-Analyses (Cochrane Database of Systematic Reviews) Crohn Disease no benefit Ulcerative Colitis maintenance of remission Necrotizing Enterocolitis Reduction of severe NEC and mortality Pediatric Antibiotic-Associated Diarrhea Promising but intention-to-treat not significant Allergies and Food Hypersensivity in Infants No benefit Acute Gastroenteritis in children Effective for disease prevention May reduce duration of acute disease Pediatric Atopic Dermatitis Possible role in disease prevention, not treatment

26 The Next Tier: Current and Future Applications Difficult to treat diseases Bacterial Vaginosis (and Vaginitis) Urinary Tract Infections and Urologic applications Application of designer probiotics allergy mucosal delivery of therapeutic molecules (anti-inflammatory) immune boosters / regulators (optimized strains, e.g. cell wall mutants) fortifying the epithelial barrier (inhibitors of translocation) Probiotics targeting the gut-brain axis Diabetes, obesity, autism Enteric nervous system and Endocrinology Probiotics and Systemic Immunity Allergy and Atopy

27 Discussion Points and Summary The human microbiome and microbial ecology new concepts and implications for probiotics Challenge to funding agencies to support systems biology studies of prebiotics/probiotics and effects on microbiome/metabonome Windows of opportunity and risk / benefit Impacts on specific diseases Colonization and sustained effects Add-on therapy versus exclusive, single agent therapy Mixtures versus single strains

28 Promotion of Health Key Issues Clarify criteria or endpoints Disease Prevention and Reduction of Risk Risk factors and Disease Incidence Probiotics for prevention Treatment or Mitigation of Disease Natural Probiotics versus GMOs Drug versus Food Risk factors (food) Disease prevention (drug?)

29 Recommendations Define probiotic strains specifically with appropriate genotypic methods and compositional information re: combinations Emphasize reduction of disease risk and prevention Can we remove disease prevention from the list of drug considerations? Cure, treat, mitigate disease = drug Reduction of risk or prevention = food / supplement Primary disease prevention versus prevention of disease recurrences