| | Bifidogenic growth stimulator for the treatment of active ulcerative colitis: a pilot studyReceived 6 September 2004; accepted 19 April 2005. published online 13 October 2005. Abstract ObjectivesExperimental studies have shown that luminal antigens are involved in chronic intestinal inflammatory disorders. Bifidogenic growth stimulator (BGS) is a prebiotic preparation produced by Propionibacterium freudenreichii isolated from Swiss cheese. Previously BGS was shown to act in the colon as a growth stimulator of Bifidobacteria. This study investigated the efficacy and safety of BGS in the treatment of ulcerative colitis. MethodsTwelve patients with mildly to moderately active ulcerative colitis received orally 4.5 g of BGS daily for 4 wk in an open-label treatment protocol while the baseline anti-inflammatory therapy was continued. The response to treatment was evaluated clinically and endoscopically. Concentrations of short-chain fatty acids and the composition of commensal bacteria, including Bifidobacteria, Enterobacteria and Bacteroides species, were studied in stool samples. ResultsPatients showed improvement in their clinical activity index scores, with a significant decrease in the score from 7.4 ± 2.8 to 4.7 ± 1.5 (mean ± standard error of the mean, P < 0.01). The endoscopic index score decreased from 4.4 ± 1.7 to 2.8 ± 1.8 (P < 0.05) with treatment. Patients showed an increase in stool butyrate concentrations after BGS treatment (P < 0.05). There were no significant changes in stool levels of bacteria as a result of BGS treatment. No side effects related to BGS were observed. ConclusionsOral BGS therapy may represent a non-toxic way to treat ulcerative colitis. However, controlled studies are needed to demonstrate its efficacy in the treatment of this disorder.
Introduction  Ulcerative colitis (UC) is an idiopathic inflammatory disorder of the gastrointestinal tract. Although the causes of UC remain incompletely understood, many experimental and clinical observations have suggested involvement of intestinal microflora in its pathogenesis [1], [2], [3]. In genetically susceptible individuals, tissue damage can result from failure of normal regulatory constraints on the mucosal immune responsiveness to intestinal bacteria [4], [5]. Therefore, restoring the microbial balance may represent a plausible therapeutic approach in the treatment of UC. Recently, clinical and experimental efficacies of the manipulation of microflora by the use of prebiotics or probiotics have been reported in patients with gut inflammation, including UC, Crohn’s disease, and pouchitis [6], [7] and in animal models of enterocolitis [8]. Many of these studies have supported a possible beneficial effect from probiotic bacteria, such as Bifidobacteria or Lactobacilli [9], [10], [11], [12]. In addition, prebiotics, which are non-digestible food ingredients that beneficially affect the host by selectively stimulating the growth or activity of a limited number of gut bacteria, have been shown to improve gut inflammation [13], [14]. Bifidogenic growth stimulator (BGS) is a prebiotic preparation that selectively stimulates the growth of Bifidobacteria through the action of its component 1,4-dihydroxy-2-naphthoic acid that is produced by Propionibacterium freudenreichii ET-3 isolated from Swiss cheese [15], [16], [17]. The 1,4-dihydroxy-2-naphthoic acid component has growth stimulatory activity for Bifidobacteria at an extremely low concentration in vitro [15], [16], [17]. A recent report has shown that BGS benefits healthy individuals by modulating intestinal microflora without any side effects [16]. However, nothing is known about the clinical effect of BGS in any disease condition, including gut inflammation. The aim of this study was designed to determine the potential therapeutic effect of a new prebiotic preparation, BGS, in patients with active UC. Materials and methods Bifidogenic growth stimulator BGS (Meiji Dairies Co., Tokyo, Japan) is produced by propionibacterium used in the manufacture of Swiss cheese [16]. Its chemical composition is listed in Table 1 [16]. BGS is stable to heat, proteolytic enzymes, and a wide range of pH levels [15]. Patient selection and study design A non-randomized, open-label, preliminary trial was conducted at our hospital. Approval for the trial was granted by the local ethical committee, and all patients gave informed written consent. Twelve patients with UC (seven men and five women, mean age 37.2 y, age range 18–49 y, mean duration of UC 4.0 y) were studied (Table 2). Patients who used antibiotics and probiotics were excluded from the study. The diagnosis of UC was based on characteristic clinical, endoscopic, radiologic, and histologic features. | | |  | Case no. | Age (y)/Sex | Disease duration (y) | Disease extent | Disease activity | Concomitant medication | |
|---|
| 1 | 46/M | 6 | Rectum to transverse colon | Moderate | SASP PO, PSL PO, betamethasone enema | |
| 2 | 39/M | 8 | Rectum | Mild | 5-ASA PO | |
| 3 | 38/F | 4 | Rectum to transverse colon | Mild | 5-ASA PO, 5-ASA enema, betamethasone enema | |
| 4 | 67/F | 2 | Rectum | Mild | — | |
| 5 | 29/F | 0.5 | Entire colon | Moderate | — | |
| 6 | 27/M | 2 | Rectum to transverse colon | Mild | 5-ASA PO, 5-ASA enema | |
| 7 | 49/M | 1 | Rectum to transverse colon | Moderate | 5-ASA PO, PSL PO | |
| 8 | 18/F | 0.5 | Entire colon | Mild | 5-ASA PO, PSL PO | |
| 9 | 41/M | 1.5 | Entire colon | Mild | PSL PO | |
| 10 | 38/M | 0.5 | Entire colon | Mild | PSL PO | |
| 11 | 26/F | 5 | Rectum | Mild | SASP PO | |
| 12 | 28/M | 17 | Entire colon | Moderate | PSL PO | | | | |
Five patients had pancolitis, four had left colon involvement, and three had disease limited to the rectum. Each patient had mild to moderate UC (eight with mild UC and four with moderate UC) based on the criteria of Truelove and Witts [18]. Patients had been unresponsive to or intolerant of standard treatment (oral sulfasalazine, 5-aminosalicylic acid [5-ASA], and low-dose prednisolone) for at least 4 wk. All drug therapies were kept constant throughout the study. No dietary alterations were made once patients entered the study. Patients received nine tablets (4.5 g) orally per day of BGS (given three times a day) for up to 4 wk. The dosage regimen used for our patients was an arbitrary one based on the dose used in healthy subjects [16] and in animals (data not shown) to induce improvement in the intestinal microflora. Clinical activity index score A clinical activity index score, which has been shown to reflect changes in the clinical status of patients with UC [19], was defined and consisted of the sum of the 1) number of episodes of diarrhea (0 to 4), 2) presence of nocturnal diarrhea (0 to 1), 3) degree of visible blood in stool (0 to 3), 4) presence of fecal incontinence (0 to 1), 5) degree of abdominal pain or cramping (0 to 3), 6) general well-being (0 to 5), 7) degree of abdominal tenderness (0 to 3), and 8) need for antidiarrheal drugs (0 to 1). Because the variables have equal weights, the overall clinical activity score can range from 0 to 21. The activity index was determined at baseline and every 2 wk thereafter by two physicians who were unaware of patients’ treatment assignments or the results of any laboratory studies. Endoscopic index score Colonoscopic examination was performed before and after the treatment period and the macroscopic appearance of the mucosa was evaluated by an endoscopist who was blinded to the mode of treatment [20]. Each of five variables—erythema, edema, friability, granularity, and erosions—was scored as absent (grade 0), mild (grade 1), or severe (grade 2). The sum of the scores was considered to be an endoscopic index, with a range of 0 to 10. The endoscopic index calculated at the time of the procedure was compared with the index based on a review of endoscopic photographs obtained previously. Laboratory parameters Routine clinical laboratory methods were used to assess acute-phase indicators, including blood cell counts, erythrocyte sedimentation rate, and serum C-reactive protein concentrations. Interleukin-6 concentrations were quantified by enzyme-linked immunosorbant assay (R&D Systems, Minneapolis, MN, USA). Short-chain fatty acid measurement Fresh morning stool was collected in sterile plastic containers, put into gas pouches, and transported to the laboratory. Acetic, propionic, and butyric acids in stool were analyzed by high-performance liquid chromotography with a pH indicator. The Shodex lonpak column KC-811 (8 × 300 mm; Showadenko, Tokyo, Japan) was operated at 45°C. The eluant was 3 mmol/L of perchloric acid and the flow rate was 1.0 mL/min. The absorbance detector was operated at 445 nm. The pH indicator contained 0.2 mmol/L of bromthymol blue, 15 mmol/L of Na2HPO4, and 2 mmol/L of NaOH. Analysis of microflora A bacteriological study was performed according to a previously reported method [21]. One gram of stool was weighed and transferred to 9 g of prereduced phosphate buffered saline containing 0.1% (w/v), purified agar, and 0.05% (w/v) cysteine-HCl. Serial 10-fold dilutions were made. Selective and non-selective media for total aerobes were inoculated with 10−1, 10−3, 10−5, and 10−7 dilutions. For total bacterial counts, non-selective media were inoculated with 10−6, 10−7, and 10−8 dilutions. Plates for anaerobic cultures were incubated for 72 h in anaerobic jars by using the steel wool method in which reduced steel wool is placed in a jar and the atmosphere replaced by CO2. Plates with aerobic cultures were incubated at 37°C for 24 to 48 h. After incubation, different colony types were counted and identified to the genus level by Gram’s stain characteristics and cell morphology. The lower limit of detection was 2 × 102 bacteria per gram of wet stool. Statistical analysis Data are expressed as mean ± standard error of the mean. Student’s t test for paired data or the Kruskal-Wallis test was used where appropriate. P < 0.05 was considered statistically significant. Results Response to therapy Figure 1 shows the serial changes in the clinical activity index during the study period. The score was 7.4 ± 2.8 before treatment and decreased to 4.7 ± 1.5 after 4 wk of treatment with BGS (P < 0.01). These patients were followed for another 4 wk after the end of BGS treatment. The clinical activity index score did not change at the end of follow-up. Further, a significant decrease in the endoscopic index was noted (Fig. 2). The score was 4.4 ± 1.7 before treatment and decreased to 3.0 ± 1.3 after 4 wk of treatment with BGS (P < 0.05). Changes in the clinical and endoscopic indices were independent of disease extent. A favorable trend also was observed in laboratory parameters of inflammation, with a significant improvement in serum hemoglobin and albumin concentrations (Fig. 3). Serum C-reactive protein concentrations, interleukin-6 concentrations, and erythrocyte sedimentation rate tended to decrease but did not reach statistical significance, probably due to the relatively mild inflammatory responses of the patients who were enrolled in our study. Stool short-chain fatty acid concentrations We next evaluated the short-chain fatty acid (SCFA) concentrations in the stool samples of four patients. After treatment with BGS, there was a trend towards an increase in all SCFA concentrations measured. The difference was statistically significant, especially for butyrate concentrations (P < 0.05; Fig. 4). Analysis of microflora We also determined the stool levels of commensal bacteria in four patients with UC. However, there were no significant changes in stool levels of bacteria, including Bifidobacteria, Enterobacteria, and Bacteroides species, as a result of BGS treatment. Side effects Administration of BGS was well tolerated. All patients felt well and did not develop side effects. Febrile and allergic reactions were not observed. No changes were noted on the routine biochemical parameters or urinalyses after treatment. No adverse events related to BGS were observed. Discussion The medical therapy of UC has changed relatively little over the past decade. Corticosteroids and immunosuppressive agents sometimes have intolerable side effects. Many patients are intolerant of sulfasalazine preparations. Therefore, safe and more effective treatment for UC is needed. Recently, clinical and experimental efficacies of the manipulation of microflora in the treatment of UC have been reported [6], [7], [8], [9], [10], [11], [12]. BGS is a new prebiotic preparation that selectively activates host Bifidobacteria and is easily delivered to the colon because of its stability [15]. In the present study, we focused on the efficacy and safety of BGS in the treatment of UC. Our trial showed that 4 wk of administration of BGS resulted in clinical and endoscopic improvements of UC independent of disease extent. The results are promising because the patients who received BGS in this study were refractory to previous medical treatment. Further, the advantage of BGS is the complete lack of side effects or toxicity. In particular, BGS treatment caused no allergic symptoms, and no significant changes in routine laboratory parameters occurred during the study period. These results suggest that BGS therapy may represent a non-toxic way to treat UC. However, controlled studies are needed to demonstrate its efficacy in the treatment of this disorder. The mechanisms by which BGS mediates its therapeutic effects are not fully understood. Recent reports have shown that BGS selectively stimulates the activation and growth of Bifidobacteria in vivo [16] and in vitro [15]. Hojo et al. [16] demonstrated an increase in stool levels of Bifidobacteria after BGS administration to healthy subjects. However, we could not demonstrate such an increase in patients with UC despite the favorable clinical response. Beneficial bacteria act through their production of SCFA, especially butyrate [13], [22]. Our study demonstrated a significant increase in post-treatment concentrations of stool butyrate, an important nutrient for colonocytes and a substance that has been shown to inhibit the production of cytokines and the activation of nuclear factor-κB [23]. Clinical trials have shown the effectiveness of SCFA [24], [25], [26] or butyrate enemas [27], [28] in treating UC. In general, Bifidobacteria species do not produce butyrate. Therefore, BGS may maintain mucosal integrity and prevent gut injury by increasing butyrate production through the improvement of microfloral balance rather than through the activation of Bifidobacteria. Because of the small population used in this study, a study in a larger population is needed to clarify the mechanisms underlying the actions of BGS. Standard medical therapy for UC uses drugs that largely affect intestinal immune-component cells, such as lymphocytes and macrophages, to decrease various inflammatory mediators. Our results support the hypothesis that BGS mediates competitive interactions, production of antimicrobial metabolites, influences on the epithelium, and immunomodulation. Restoring the microbial balance using BGS may represent the most physiologic and non-toxic way to prevent or treat UC. At present, our finding of a clinical response to BGS in UC is preliminary. However, the evidence that BGS promotes luminal butyrate production in UC encourages us to perform further clinical investigations. Previous data have indicated that 5-ASA in combination with butyrate is superior to 5-ASA alone in decreasing histologic severity in a rat model of experimental colitis [29]. To date, there is no information on the potential interference of SCFA metabolism in colonocytes by 5-ASA. Combination therapy using BGS plus standard drugs is of interest and requires further evaluation. In conclusion, oral BGS resulted in clinical and endoscopic improvements in patients with UC. Treatment with BGS is safe and well tolerated and does not require dietary restrictions. These encouraging preliminary results lead us to propose a randomized, controlled trial of BGS in patients with UC. Acknowledgments The authors thank Meiji Dairies Co. (Tokyo, Japan) for providing BGS and members of the Gastrointestinal Unit, Second Department of Medicine Kurume University, for invaluable help. References [1].
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a Second Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan b Research Center for Innovative Cancer Therapy and Center of the 21th Century COE Program for Medical Science, Kurume University, Fukuoka, Japan  Corresponding author. Tel.: +81-942-31-7561; fax: +81-942-34-2623.
This work was supported in part by Grants-in-Aid from the Japanese Ministry of Education, Culture and Science and the Japanese Ministry of Health and Welfare. PII: S0899-9007(05)00236-4 doi:10.1016/j.nut.2005.04.013 © 2006 Elsevier Inc. All rights reserved. | |
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