Is Lactobacillus GG Helpful in Children With Crohn’s Disease? Results of a Preliminary, Open-Label Study docx

Methods: In this open-label pilot evaluation viewed as a nec-essary preliminary step for a possible subsequent randomized placebo-controlled trial, four children with mildly to moder-at

Short Communication

Is Lactobacillus GG Helpful in Children With Crohn’s Disease?

Results of a Preliminary, Open-Label Study Puneet Gupta, Haikaeli Andrew, Barbara S Kirschner, and Stefano Guandalini

Section of Pediatric Gastroenterology, Hepatology and Nutrition, The University of Chicago Children’s Hospital,

Chicago, Illinois, U.S.A.

ABSTRACT

Background: Lactobacillus GG is a safe probiotic bacterium

known to transiently colonize the human intestine It has been

found to be useful in treatment of several gastrointestinal

con-ditions characterized by increased gut permeability In the

cur-rent study, the efficacy of Lactobacillus GG was investigated in

children with Crohn’s disease

Methods: In this open-label pilot evaluation viewed as a

nec-essary preliminary step for a possible subsequent randomized

placebo-controlled trial, four children with mildly to

moder-ately active Crohn’s disease were given Lactobacillus GG

(1010 colony-forming units [CFU]) in enterocoated tablets

twice a day for 6 months Changes in intestinal permeability

were measured by a double sugar permeability test Clinical

activity was determined by measuring the pediatric Crohn’s

disease activity index

Results: There was a significant improvement in clinical

ac-tivity 1 week after starting Lactobacillus GG, which was

sus-tained throughout the study period Median pediatric Crohn’s disease activity index scores at 4 weeks were 73% lower than baseline Intestinal permeability improved in an almost parallel fashion

Conclusions: Findings in this pilot study show that

Lactoba-cillus GG may improve gut barrier function and clinical status

in children with mildly to moderately active, stable Crohn’s disease Randomized, double-blind, placebo-controlled trials

are warranted for a final assessment of the efficacy of

Lacto-bacillus GG in Crohn’s disease JPGN 31:453–457, 2000 Key

Words: Children—Crohn’s disease—Intestinal permeability—

Lactobacillus GG—Probiotics © 2000 Lippincott Williams &

Wilkins, Inc

There is increasing experimental evidence to support a

role for intestinal bacteria in the pathogenesis of Crohn’s

disease Spontaneous colitis develops in mice deficient in

interleukin (IL)-2 (1), IL-10 (2), and T-cell receptors

only in the presence of luminal bacteria and not in mice

raised in germ-free conditions The intestinal mucus

layer from patients with inflammatory bowel disease has

a high number of bacteria compared with that of control

subjects (3) Antibiotics such as metronidazole and

ciprofloxacin are useful in treatment of Crohn’s disease

Recently, probiotic organisms have been used to treat

gastrointestinal disorders with altered gut microflora

Lactobacillus GG (LGG; American Type Culture no.

53103) is the most widely studied probiotic bacterium

that has been shown to survive gastric and bile

secre-tions, adhere to intestinal epithelial cells, and colonize

the intestine (4) It has been used in treatment of small bowel bacterial overgrowth in children with short gut,

antibiotic-associated diarrhea (5), and Clostridium

diffi-cile colitis (6) Lactobacillus species have been shown to

prevent colitis in IL-10–deficient mice (7) Preliminary data show that probiotics may be useful in maintaining

remission in patients with ulcerative colitis (8)

Lacto-bacillus GG has been shown to promote gut

immuno-globulin (Ig)A response and thereby improve gut immu-nologic barrier in patients with Crohn’s disease(9) We thus conducted an open-label pilot trial to assess the effect of LGG supplementation on intestinal permeabil-ity and clinical parameters in children with Crohn’s dis-ease

METHODS Patient Selection

Children in whom Crohn’s disease was diagnosed by estab-lished clinical, radiographic, and endoscopic criteria were in-cluded in the study Patients with mildly to moderately active disease, despite concomitant therapy with prednisone and im-munomodulatory drugs, such as 6-mercaptopurine (6-MP),

aza-Received May 9, 2000; accepted July 18, 2000.

Address correspondence and reprint requests to Prof Stefano

Guandalini, Section of Pediatric Gastroenterology, Hepatology and

Nu-trition, The University of Chicago Children’s Hospital, 5839 South

Maryland Avenue, MC 4065, Chicago IL 60637, U.S.A.

453

thioprine (AZA), or methotrexate were included in the study A

Pediatric Crohn’s Disease Activity Index (PCDAI) of 10 or

higher was used to define the active disease(10,11) The

PC-DAI is a multi-item index including subjective reporting of

abdominal pain, general well-being, and diarrhea and physical

findings, including linear growth and laboratory parameters

(hematocrit, serum albumin, and erythrocyte sedimentation

rate) All patients had to be receiving stable doses of

immuno-modulatory drugs for at least 3 months before screening and

stable doses of prednisone for at least 4 weeks before the

screening visit Patients were allowed to decrease the steroid

dose during the study period as clinically indicated Patients

with intestinal strictures that are likely to necessitate surgery,

patients receiving antibiotics other than metronidazole, and

those with concurrent intestinal or systemic infection were

ex-cluded from the study

Protocol Design

The study was a 6-month open-label pilot evaluation of the

efficacy of LGG at a dose of 1010colony-forming units (CFU)

in enterocoated tablets twice a day The dosage was based on

previous studies that demonstrated adequate, albeit transient,

colonization at this dose The LGG was provided by Valio

(Helsinki, Finland) The trial was conducted at the University

of Chicago Children’s Hospital The University of Chicago’s

institutional review board approved the protocol, and all

pa-tients or their guardians gave informed written consent before

the patients were enrolled in the trial

Subjects were screened 1 week before the initiation of LGG

therapy Clinical features and disease activity were assessed at

baseline and at 1, 4, 12, and 24 weeks of LGG therapy The

PCDAI was calculated at each visit Stools were cultured at

each follow-up visit to assess colonization by LGG

Intestinal permeability was assessed by a

cellobiose-mannitol sugar permeability test at each visit After an

over-night fast, patients drank a sugar test solution containing 2 g

mannitol and 5 g cellobiose made up to 100 mL with tap water

to give an osmolality of approximately 270 mOsm, and their

unine was collected for the next 5 hours The ratio of

concen-trations of cellobiose and mannitol in urine was determined

according to published methods Ratios higher than 0.022 were

considered abnormal (12)

Statistical Analysis

Quantitative variables are described as medians with ranges

in parentheses The significance of changes was evaluated

us-ing analysis of variance (ANOVA) for parametric variables and the Mann–Whitney test for nonparametric variables

RESULTS

Four patients were enrolled All were male with a median age of 14.5 years (range, 10–18) Two patients had ileocolonic disease and two others had gastrocolonic disease None had a fistula Median duration of Crohn’s disease was 3 years (range, 1–5) All patients were taking prednisone at entry, with a median dose of 22.5 mg (range, 15–50 mg) All patients had also been taking immunomodulator drugs (6-MP or azathioprine) at a dose of 1 to 2 mg/kg, for an average of 10 months (range, 4.5–18) Two patients were also receiving metronida-zole All patients had mildly to moderately active disease

at the beginning of the study The median PCDAI score

at entry was 19 (range, 12–35) The cellobiose-mannitol ratio was also high at baseline, reflecting altered intesti-nal permeability (median, 0.12; range, 0.023–0.17) Pa-tients’ characteristics are shown in Table 1

There was effective transient intestinal colonization with LGG in all patients The LGG was in fact recovered

in stool samples of all the patients at each follow-up visit Fecal concentrations ranged from 107 to 109 CFU/g stool Treatment of Crohn’s disease with metronidazole did not inhibit intestinal colonization with LGG (Fig 1) The patients showed significant improvement in Crohn’s disease activity, when measured by PCDAI

scores (P⳱ 0.02) 1 week after beginning LGG, and this improvement was sustained throughout the study period Median PCDAI score at 4 weeks was 5 (range, 0–12.5), 73% lower than baseline and three patients (75%) had a PCDAI score of less than 10 indicative of inactive dis-ease (Fig 2) In three patients, it was possible to taper the dose of steroids while they were receiving LGG Aver-age reduction in steroid dose in these patients was 50%

at 12 weeks

The intestinal permeability, measured by a double

sugar permeability test, improved significantly (P <

0.05) at 12-week follow-up (median 0.021; range, 0.009– 0.046) This improvement was largely because of a de-crease in cellobiose levels in urine, which suggests that LGG improves the intestinal paracellular permeability However, this improvement was not sustained at

24-TABLE 1 Baseline features of individual study patients

Patient

Age (yr) Disease location

Duration

of CD (yr) Medications at initiation of LGG

3 10 Gastric, colonic 3 Azulfidine, metronidazole, prednisone, 6-mercaptopurine

4 16 Gastric, colonic 2 Pentasa, metronidazole, prednisone, azathioprine

CD, Crohn’s disease; LGG, Lactobacillus GG.

week follow-up (Fig 3) No patient reported any adverse

effects during the study period

Follow-up

Three patients had relapse of Crohn’s disease within 4

to 12 weeks of discontinuation of LGG One patient

sub-sequently needed colectomy and one patient had

ileoce-cal resection

DISCUSSION

Although the cause of Crohn’s disease is unknown,

there is increasing evidence that suggests that

endog-enous bacterial flora plays an important role in the

ini-tiation and perpetuation of the disease(13,14) It has been

hypothesized that the intestinal inflammatory response is

the result of an exaggerated intestinal host immune

re-sponse to commensal enteric bacteria or their

compo-nents in genetically predisposed individuals A defect in

mucosal barrier function could allow luminal bacterial

antigens to initiate a chronic relapsing inflammation

Several studies have shown an increased intestinal

per-meability for various sugar molecules in patients with

Crohn’s disease and their healthy relatives, which sup-ports the role of mucosal barrier defect in initiation of Crohn’s disease (15)

The normal intestinal microflora may offer resistance

to colonization by pathogens and thus functions as an important constituent of the gut defense barrier Re-cently, probiotic micro-organisms have been shown to be effective in treatment of altered intestinal microflora (8,16) The most frequently studied probiotic is LGG It

is stable in acid and bile, adheres to human epithelial cells, and transiently colonizes the human intestine (17)

It inhibits attachment of pathogens to intestinal mucus (18) Recently, LGG has been shown to enhance the expression of mRNA for two predominant mucins MUC2 and MUC3 These glycoproteins are known to inhibit adherence of pathogenic bacteria such as

entero-pathogenic Escherichia coli (19) Lactobacillus GG has

also been shown to secrete inhibitory products that have antimicrobial properties against potential pathogens (20)

In clinical studies, LGG has been shown to be effec-tive in prevention and treatment of antibiotic associated

diarrhea (5), C difficile colitis, traveler’s diarrhea, and

acute childhood diarrhea, particularly when caused by

rotavirus enteritis (21) Lactobacillus GG also acts by

modulating host immune response Several studies have shown that LGG enhances immune response during ro-tavirus diarrhea, including nonspecific humoral immune response and rotavirus-specific antibodies and shortens

the duration of diarrhea (22) Lactobacillus GG has also

been shown to stabilize the gut mucosal barrier It re-verses the increased intestinal permeability induced by cow’s milk in young rats (23) and promotes intestinal barrier function in children with food allergy (24) These studies show that LGG may be effective in treatment of Crohn’s disease by several potential mechanisms such as altering the intestinal mucins, promoting local immune response, and stabilizing the gut mucosal barrier

Lactobacillus GG also has an impressive record of

safety Indeed, although a liver abscess due to a

Lacto-bacillus rhamnosus strain indistinguishable from LGG

FIG 2 The Pediatric Crohn’s Disease Activity Index (PCDAI)

during Lactobacillus GG (LGG) therapy Variations of PCDAI with

time are reported for each patient.

FIG 3 Cellobiose-mannitol ratio during Lactobacillus GG (LGG)

therapy Variations of the cellobiose-mannitol ratio with time are reported for each patient.

FIG 1 Fecal recovery of Lactobacillus GG (LGG)

Concentra-tions of LGG are expressed as colony-forming units per gram of

feces in patients either receiving or not receiving oral therapy with

metronidazole.

has been recently reported (25), lactic acid bacteria

(LAB) in foods have a long history of safe use and have

been given generally recognized as safe (GRAS) status

(26) In a study from Finland, lactobacilli were identified

in only 8 of 3317 blood culture isolates (0.2%), and none

of the isolates was similar to LGG, in spite of its

wide-spread use in that country (27)

Based on the observations made in this open-label

pilot study Lactobacillus GG appears to be effective in

ameliorating the disease activity in children with mildly

to moderately active, stable Crohn’s disease A dose of

1010CFU twice a day resulted in intestinal colonization

in all the patients, including those taking metronidazole

All patients in this study had active Crohn’s disease,

despite use of steroids and immunomodulatory drugs

Their PCDAI scores improved significantly during LGG

therapy, and this improvement was sustained throughout

the study period Median PCDAI score at 4 weeks was

73% lower than baseline Three patients were also able to

achieve a 50% reduction in steroid dose No patient

re-ported any adverse effects on LGG In our patients, the

cellobiose-mannitol ratio was elevated at baseline,

mainly as a result of increased cellobiose absorption,

reflecting increased intestinal paracellular permeability

This parameter improved significantly on treatment with

LGG, mainly as a result of a decrease in cellobiose

lev-els, again suggesting a reduction in paracellular

perme-ability After 24 weeks of treatment, the intestinal

per-meability showed a trend toward increase, although it

remained at levels below baseline

Overall, the improvement in clinical activity appeared

to be accompanied by a reduction in paracellular

intes-tinal permeability In two patients, however, the clinical

improvement documented by a lower PCDAI preceded

the effect on intestinal permeability Thus, it is unclear

whether LGG acted by stabilizing gut mucosal barrier or

by other mechanisms It clearly was well beyond the

scope of this preliminary investigation to address the

question of underlying mechanisms of action of this

pro-biotic in Crohn’s disease

In conclusion, and fully acknowledging the limitations

of an open-label study in only four patients, we believe

that this study provides preliminary evidence that LGG is

safe and may be effective in improving gut barrier

func-tion and clinical response in pediatric patients with

mildly to moderately active Crohn’s disease It is

obvi-ously that only in randomized double-blind

placebo-controlled trials in large numbers of patients that

signifi-cant, solid evidence of efficacy can be reached Until

then, use of this and any probiotic in inflammatory bowel

diseases does not appear warranted Also, it is our

opin-ion that future research in this area should be designed to

verify whether continuous or cyclic administration of

LGG is preferable in achieving a more prolonged

main-tenance of remission in patients with pediatric Crohn’s

disease

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Clinical Quiz Joseph F Fitzgerald, NASPGN Clinical Quiz Editor Riccardo Troncone, ESPGHAN Clinical Quiz Editor Maria Del Rosario Valicenti, Ganesh Venkataraman, and Benjamin Shneider, Contributors

Department of Pediatrics, Mount Sinai School of Medicine, New York, New York, U.S.A.

A 9-year-old boy with diagnoses of hepatitis and cholecystitis was transferred to Mount Sinai Medical Center for further management He developed intermittent right upper quadrant abdominal pain 5 months before admission He traveled with his family to Ecuador 2 months before admission and stayed for 1 month His abdominal pain increased 5 days before admission, and he developed nausea, vomiting, and jaundice 3 days later He denied fever and pruritus An abdominal sonogram showed marked thickening of the walls of the gallbladder He was started on intravenous antibiotics (for a possible gangrenous gallbladder) and transferred Laboratory data included the following: hemoglobin 13.6 g/dL; white blood cell count 7000/mm 3 (46% polymorphonucleotides, 39% lymphocytes, 7% monocytes, 5% eosinophils); platelets 351,000/mm 3 ; alanine aminotransferase level 1725 U/L; asparatate aminotransferase level 1185 U/L; alkaline phosphatase 353 U/L; gamma-glutamyl transpeptidase 199 U/L, total bilirubin 5.6 mg/dL, direct bilirubin 3.4 mg/dL; PT 15.9 seconds; and albumin 38 g/L Repeat fasting hepatobiliary ultrasound showed a shrunken, edematous gallbladder whose wall thickness was 14.1 mm, a normal sized liver, no evidence of intrahepatic biliary dilation, and common bile duct diameter of 3 mm (Fig 1) The carbamoyl-methyl iminodiacetic acid (HIDA) scan revealed delayed hepatic uptake with filling of the gallbladder and intestinal excretion of the radionuclide (Fig 2).

What is the most likely diagnosis?

A Acalculous cholecystitis D Gangrenous gallbladder

C Ascaris lumbricoides

ANSWER: See page 463.