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1 Intestinal Helminths A New Approach to Therapy of Inflammatory Bowel Disease Douglas R. LaBrecque, MD Professor, Internal Medicine Director, Liver Service Univ. of Iowa Carver College of Medicine
2 Zach Johnson---Masters Champion
3 New Color Commentator for U. Colorado Football Team
4 What is IBD? Chronic inflammation of the digestive tract The cause is unknown, but is largely due to an abnormal immune system Inflammation causes dysfunction of the bowel Treatment is generally aimed at suppressing the immune system and reducing inflammation
5 All Treatments Have Problems 5-aminosalicylates not very effective Corticosteroids Wt. gain, osteoporosis, psychologic effects, fluid retention, acne Azathioprine/6-MP susceptible to infections Infliximab loses efficacy with time, high cost Cyclosporine / tacrolimus seizures, renal failure, hypertension Methotrexate liver injury, infections Mycophenolate mofetil diarrhea, infections
6 A New Approach is Needed First, what about the cause?
7 What goes wrong in IBD? Environmental triggers (infection, bacterial products) Failure to downregulate Chronic uncontrolled inflammation = IBD Moderately inflamed Down-regulate Normal gut controlled inflammationmation Normal gut controlled inflammation
8 Environmental triggers (infection, bacterial products) Failure to downregulate Chronic uncontrolled inflammation = IBD Moderately inflamed Down-regulate Normal gut controlled inflammation Normal gut controlled inflammation
9 Environmental triggers (infection, bacterial products) Failure to downregulate Chronic uncontrolled inflammation = IBD Moderately inflamed Down-regulate Normal gut controlled inflammation Normal gut controlled inflammation
10 Environmental triggers (infection, bacterial products) Failure to downregulate Chronic uncontrolled inflammation = IBD Moderately inflamed Down-regulate Normal gut controlled inflammation Normal gut controlled inflammation
11 What Causes IBD? Genes (Family trait) or Environment (External influence)
12 Evidence for a Genetic Influence Family clustering: sibs : parents : off-spring Empiric risk - 9% : 4% : 9% MZ Twin concordance CD~50%, UC~15% Spouse studies: = to population, < <siblings Genetic markers HLA subtype markers CARD 15 (NOD 2) Other candidate genes
13 Global Prevalence of IBD Environmental Influence High Medium Low
14 Environmental Influence? Helminthic Parasites High Incidence Moderate Incidence Low Incidence
15 Rise in Crohn s Disease Over Time
16 Emergence of Immune-Mediated Diseases (adapted from Bach, N.E.J.M. 347:911)
17 Our Hypothesis Immune mediated disease occurs in genetically predisposed persons IF they are not exposed to helminths. Helminths help to tame an overactive, misdirected and destructive response to environmental influences
18 Are all worms bad?
19 Worms are our friends
20 ~ ~ Where Have All the Good Worms Gone? ~ ~ ~ ~ ~
21 Colonization common in the 30 s
22 U.S. Hookworm Eradication First National Public Health Intervention Rockefeller Foundation US PHS s
23 U.S. Helminth Eradication WPA Flyer Distributed
24 Reported Cases of Trichinellosis in US (MMWR 53:1-79, 2006)
25 Our Lifestyle Has Changed
26 Hygiene Has a High Priority
27 Things Are Different in Some Parts of the World
28 Sometimes Very Different
29 Children Raised Differently
30 Environment vs. Genes Etiologic Interplay Nurture Nature IBD Genes Environment Eradication of Helminths
31 Supportive experimental evidence
32 Using Helminths to Treat IBD
33 Which Worm?
34 Helminths Nematodes (round worms) Trichuris trichiura (whipworm) Enterobius vermicularis (pinworm) Necator americanus (hookworm) Ascaris lumbricoides Platyhelminths (flat worms) Trematodes (flukes) Schistosoma (venous system) Clonorchis (biliary system) Fasciolopsis (intestine) Cestodes (tapeworms) Taenia saginata / solium Hymenolepsis nana
35 The Ideal Worm Egg Should not persist or multiply in the host Should not invade or cause disease Should not be a public health risk Should be stable and easy to produce
36 Meet Trichuris suis
37 Trichuris suis life cycle 3.Mucosal attachment 2.Larvae released 1.Ingestion Infective ova Internal External 4.Maturation 5.Egg excretion (Non-infective) 6.Embryonation in soil
38 Trichuris suis (Porcine whipworm) Colonization is self-limited Does not multiply in host No systemic phase No direct transmission Eggs stable and easy to produce
39 Trichuris suis Ova Therapy in Active Ulcerative Colitis Summers et al: Gastroenterology 2005;128:825-32
40 Response ( UCDAI >4)
41 Ulcerative colitis Pre-treatment Post-treatment
42 Change in Mean UCDAI ~Responders: Initial 8.8 ± 0.4 Week ± ± 0.6 ~No side effects, complications or lab changes
43 Time to Response P< Composite score Bleeding (0-3) Stool frequency (0-3)
44 Trichuris suis Ova Therapy in Active Crohn s s Disease Summers et al. Gut 2005;54:87-90
45 CD Open-Label Study Weeks Administered 2500 T. suis ova every 3 weeks
46 Remission/Response Rates ( CDAI >100) (CDAI <150)
47 Trichuris suis in the Human Colon
48 Change in Mean CDAI -Responders- (286 ± 10) (117 ± 13) (109 ± 12)
49 Overall Summary ~ Studied effects of Trichuris suis: 54 UC and 29 CD ~ In UC, T. suis superior to placebo ~ In CD, 72% remission rate 79% response rate ~ No side effects or complications Conclusion T. suis is safe and effective in IBD
50 So, T. suis off to work Incidently
51 We give eggs, not worms
52 Hygiene Hypothesis (The Restated Worm Version) Helminth Exposure Immune Regulatory Conditioning Prevents Excessive Inflammation Common Viral, Bacterial and Protozoan Infections Modern Hygiene Lacks Helminths Permits Immune Dysregulation Emergence of IBD and other Immume-mediated mediated Diseases
53 Home of the Helminths
54 Collaborators University of Iowa David Elliott Joel Kline Robert Summers Joel Weinstock Robin Thompson Betty Musgrave Dan Berg Art Blum Ahmed Metwali Tommy Setiawan Bushra Sulieman Andy Arsenescu Nedim Ince USDA, Maryland Joseph Urban University of Wisconsin Zsuzsa Fabry Matyas Sandor John Fleming Royal Institute, Denmark Darwin Murrel Allan Roepsdtorff
55 Who knows what the future holds
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