Claudio Romano, MDConsultant Pediatric Gastroenterology, Pediatric HUB IBD Unit University of Messina, Italy

La immunoterapia “aspecifica”

e la flora intestinale

ASSENZA DI CONFLITTO DI INTERESSI

LA VERA PUBBLICITA’ ……..?

FoodsFoods

Innate immunityInnate immunityInnate immunityInnate immunity

MacrophagesMacrophages

PMNsPMNs

NK cellsNK cells

Dendriticcells

Dendriticcells

Epithelial cellsEpithelial cells

FloraFlora

PathogensPathogens

B cellsB cells

EffectorT cellsEffectorT cells

PlasmacellsPlasmacells

Adaptive Adaptive immunityimmunityAdaptive Adaptive immunityimmunity

Innate immunityInnate immunityInnate immunityInnate immunity

MesenchymalcellsMesenchymalcells

EndothelialcellsEndothelialcells

ExtracellularmatrixExtracellularmatrix

PlateletsPlatelets

RegulatoryT cellsRegulatoryT cells

RICERCA CLINICA

1. RELAZIONE MICROBI ED ORGANISMO (FUNZIONE GENOMICA E METABOLICA) ?

2. MICROBIOTA E MATURAZIONE DEL SISTEMA IMMUNE INTESTINALE ?

3. MICROBIOTA ED AMBIENTE ?

4. DIETA E MODIFICA DI COMPOSIZIONE DEL MICROBIOTA ?

RICERCA TRASLAZIONALERICERCA TRASLAZIONALE

Studi filogenetici

Clonaggio e seq SSU rRNA

Profilo della comunità microbica

(fingerprint approach)

DGGE e TGGE

Quantificazione di specifici gruppi

FISH, real-time qPCR

High-throughput method

DNA microarrays Pyrosequencing

TIPIZZAZIONE MICROBIOTA TIPIZZAZIONE MICROBIOTA

HUMAN GUT MICROBIOTA

> 90% 2 ceppi dominanti (Bacteroidetes, Firmicutes)

< 10% 5 sub-dominanti ceppi (Actinobacteria, Proteobacteria, Fusobacteria, Cyanobacteria and Verrucomicrobia)

1000-1200 “filotipi”

50-80% Firmicutes dominanti Clostridium cluster IV e XIVa

Verdu EF, Gut 2006Gwee KA, Gut 2003

(Buccigrossi et al., 2010)

G.Reid: CID, 2004

http://upload.wikimedia.org/wikipedia/it/c/cf/Indiana_Jones_02.jpg

(Buccigrossi et al., 2013)

DISBIOSI INTESTINALE

• Patients were randomized to receive LCT Reuteri, DSM 17938, 10 8 CFU/day, (n° 30 pts) or matching placebo (n° 26 pts), orally, for 4 weeks (LCT reuteri and placebo were manufactured from NOOCS, Italy)

• Randomization was carried out with computer generated lists.

• Documentation in follow-up was carried out with a diary to record symptoms and frequency of pain, drug use and any symptom which is considered important

• The Faces Pain Scale, which is a scale for measurement of pain intensity by self-reported, was used to assess the severity of the pain

- Perdita della “biodiversita’” (ambiente, clima, specie)

- Metagenomica: modifica composizione microbiota (pelle

ed intestino)

- Deprivazione microbica e disfunzione immunitaria (T-cell)

- Incremento di patologie infiammatorie (allergie, asma, IBD, obesità)

- Tolleranza orale

Th2 imbalance

Overexpressionof anti-inflammatory cytokinesIL-3Il-4IL-5IL-6Il-9IL-10IL-13

Atopic disease and allergies

Th1 imbalance

Overexpression of pro-inflammatory cytokinesIL-2Il-12Interferon IFN-αFattore di necrosi tumorale TNF-ß

IBD

DISBIOSI DISBIOSI

Sharara AI, AJG, 2006

IgE

- < IgE totali

- No differenze per asma e wheezing

- Effetto long-term

- Somministrazione in epoca pre-natale e post-natale

- 40.614 bambini- consumo alimenti funzionali - RRs (relativo rischio) di asma, eczema e rinocongiuntivite

- < RRs a 6 mesi per eczema atopico- < RRs a 18 mesi per rinocongiuntivite

PROBIOTICI E PREVENZIONE ALLERGIA PROBIOTICI E PREVENZIONE ALLERGIA Investigators Population

characteristicsOrganisms and dosage Prenatal

administr.Postnatal administr.

Eczema reduction

Kalliomaki, Isolauri et al. (2001, 2002, 2003)

Any first degree relative with allergic

disease (N=132)

LGG (1x1010 CFU daily) only to mother if

breast feeding post natally

Yes

2-4 wks before delivery

Yes

6 m only directly to baby if not

breastfeeding

Yes

at 2, 4 and 6 yrs

Rautava, Isolauri et al. (2006)

Any need for artificial feeding before 2

months of age (N=72)

LGG (1x1010 CFU daily Bifidobacterium lactis

(1x1010 CFU daily) Added to infant

formula

No Yes

Before 2 m(depending on age

started formula)until 12 months

No

Taylor, Prescott et al. (2007)

Mother with SPT+allergic disease

(N= 189)

Lactobacillusacidophillus (3x108 CFU

daily)

No Yes

6 monthsdirect to infant

No

At 1 year

Kukkonen, Kuitunenet al. (2007)

One or both parents with allergic disease

(N= 925)

LGG & LC705(both 5x109 CFU twice

daily); andBifidobacterium breve

and Proprionibacteriumfreudenreichii (both

2x109 CFU twice daily)

Yes

2–4 wksbefore

delivery

Yes

6 monthsdirect to infant

Yes

At 2 years

Berni Canani R and Di Costanzo M Nutrients 2013

Investigators Population characteristics

Organisms and dosage Prenatal administ.

Postnatal administ.

Eczema reduction

Abrahamsson,Oldaeus et al. (2007)

Any first degree relativewith allergic disease(N= 188)

Lactobacillus reuteri(1x108 CFU daily)

Yes

2–4 wks beforedelivery

Yes

12 mdirect to infant

No

At 2 years

Kopp, Urbanek et al. (2007)

Any first degree relativewith allergic disease(N= 94)

LGG, 1x1010 CFU dailyto mother if breastfeeding post-natally for 3 m and than to neonates for 3 m

Yes

4–6 wksbefore

delivery

Yes

6 monthsdirect to infant

No

At 2 years

Wickens, Crane et al. (2008)

One or both parents with allergic disease(N= 474)

L. rhamnosusHN001 (1x1010 CFU daily) OR Bifidobacterium lactis(1x1010 CFU daily)HN019

Yes

2–5 wksBefore

delivery

Yes

2 yrs to infant regardless

of feeding method

Yes

At 2 years

Soh, Skek, Aw et al. (2008)

Any first degree relative with SPT+ allergic disease(N= 245)

L. rhamnosus(1x109 CFU daily) andBifidobacterium longum(6x108 CFU daily)

No Yes

6 monthsin infant formula

No

At 1 year

PROBIOTICI E PREVENZIONE ALLERGIAPROBIOTICI E PREVENZIONE ALLERGIA

Berni Canani R and Di Costanzo M Nutrients 2013

Investigator Population characteristics

Organisms and dosage Prenatal administ.

Postnatal administ.

Eczemareduction

Huurre, Laitinen,et al. (2008)

Mother with current atopic disease(N= 140)

LGG and Bifidobacteriumlactis (1x1010 CFU daily)

Yes

From firsttrimester

Yes

By the end of exclusive

breastfeeding

No

Niers, Rijkers,et al. (2009)

Atopic disease in either mother or father plus at leastone sibling(N= 98)

Lactococcus lactis W58Bifidobacterium lactisW52 Bifidobacteriumbifidum W23 (1x109 CFU each daily)

Yes

6 wksBefore

delivery

Yes

12 m (direct to infant)

Yes

West, Hernell, et al. (2009)

Atopic disease in either mother, or sibling (N=171)

L. paracaseistrain F19 (1x108 CFU daily in weaning cereal)

No Yes

4–13 months(during weaning)

Yes

Rautava, Kainonen, et al. (2013)

Mothers with allergic diseaseand atopic sensitization (N=241)

Lactobacillus rhamnosus LPR and Bifidobacterium longum BL999; or L paracasei ST11 and B longum(1x109CFU each daily)

Yes

2 mbefore delivery

Yes

first 2 months of breast-feeding

Yes

At 24 mm

PROBIOTICI E PREVENZIONE ALLERGIAPROBIOTICI E PREVENZIONE ALLERGIA

Berni Canani R and Di Costanzo M Nutrients 2013

EFFETTI LUME INTESTINALE

• Modulazione microbiota• Idrolisi peptidi antigenicii

EFFETTI LUME INTESTINALE

• Modulazione microbiota• Idrolisi peptidi antigenicii

EFFETTI A LIVELLO MUCOSALE:

• Modulazione della permeabilità intestinale

•Stimolazione della crescuta e differenziazione cellulareEFFETTI AL DI FUORI DELLA MUCOSA

INTESTINALE:

• Impatto sul SNE• Modulazione della risposta immune innata ed adattiva• Induzione della tolleranza orale

Gut lumen

Intestinal epithelial cells

Berni Canani R. Functional Food Review 2012

LGG

LGG regola anche i meccanismi del CMALGG regola anche i meccanismi del CMA

Maassen CBM et al. Vaccine 2000Ghadimi D et al. Immunobiology 2008Oksaharju A et al. WJG 2011Berni Canani R, et al. Pharmaceuticals 2012

- Composizione del microbiota fecale in bambini con allergia e senza allergia

- Sequenziamento 16S rRNA

- 1 mese : analisi comparativa > generi Bacteroides, Clostridium, ed alcuni generi di Proteobacteria con riduzione Bifidobacteria

- 2 mesi: no differenze

- Età di transizione = rischio di atopia

Microbiota ed Atopia….………Microbiota ed Atopia….………• prevenzione eczema

atopico nei primi 2 anni di vita ma non evidenze sulla prevenzione del rischio atopico nelle epoche successive

• approccio combinato pre-e post-natale sembra piu’ efficace per ridurre rischio atopico

• effetto ceppo specifico con evidenze su L. rhamnosus GG

Pfefferle, Prescott, Kopp. J Allergy Clin Immunol, 2013Elazab, et al. Pediatrics, 2013

1. Questi risultati sono riproducibili in ogni setting ?

2. Gli outcome di questi

studi sono rilevanti ?