FMT: Can we cure obesity and insulin resistance?

Max Nieuwdorp MD PhD

Internist-endocrinologist

Dept of Vascular Medicine Amsterdam

Wallenberg Laboratory, Gothenberg, Sweden

session Panacea or Pandora’s Box 17th august 2014: 0840-0905am

Disclosure slide

• Scientific advisory board Seres Health

• Founder Caelus pharmaceuticals

Take home message• Decreased butyrate producing bacteria in obesity

associated with malign obesity and insulin resistance

• FMT incudes changes in (small) iIntestinal microbiota and affects insulin resistance (but it is not a panancea)

• Using FMT as a working model can derive novel probiotics on top of current treatment for insulin resistance

Intestinal microbiota in obesity and MetSyn

Benign vs malign obesity• 66% metabolically

healthy obese

• 34% insulin resitance and DM2

• Low grade inflammation involved Samocha-bonet et al, obesity Reviwws 2014.

Gut microbiota and obesity/type 2 diabetes mellitus

Qin, Nature 2012

Le Chatelier, Nature 2013

Karlsson, Nature 2013

Ridaura, Science 2013

Diagnostic and clinical value of gut microbiota composition in Dm2

• Reduced short-chain fatty acid butyrate producers (Roseburia species and Faecalibacterium prausnitzii) in DM2

• Enrichment of Lactobacillus gasseri and Streptococcus mutans in fecal sample has predictive value for developing insulin resistance

Karlsson, Nature 2013

Results of these cohort based studies using fecal samples

Smits/Nieuwdorp, Gastroenterology 2013 [in press]

F prausznitzii lower

Ruminococcus lower

Major disadvantages of current fecal sample centered approach

• 1. Small intestine is more involved

in metabolism than the colon

• 2. Association is not causality!

• 3. Sequencing vs culturing bacteria

Hartstra/nieuwdorp, Diabetes Care 2014. pH dictates bacterial survival and gutmicrobiota composition

Koch’s postulatesfor causality

• The microorganism must be identified/isolated from a diseased organ(ism).

• The microorganism should be associated with

disease (association/intervention).

• The cultured microorganism should induce beneficial or adverse effects when introduced into an organism (inoculation).

Manipulating gut microbiota by fecal transplant

Van Nood, NEJM 2013

Effects of fecal transplantations in clostridium difficile diarroea

Gutmicrobiota Diversity in Cdiff After FMT

Correction of Low Diversity of Patients by Transplantation

Diverse Community Stably Maintained for Over 2 Months

FMT Randomized controlled trials performed at AMC

• Since 1958 casereport by Eiseman, at least 4500 patients treated worldwide with donor feces (since 2007 at AMC),

• RCT superiority of fecal Tx in clostridium difficile diarrhea and MetSyn

• At AMC ongoing/finished RCT’s for:

-IBD (Colitis ulcerosa, TURN trial)

- insulin resistance

-NAFLD/NASH

• Long term side effects not seen yet

Smits/Nieuwdorp, Gastroenterology 2013 [in press]; van Nood/Nieuwdorp, NEJM 2013

• No adverse effects!

• No effect on weight 6 weeks after lean donor FMT

A.Vrieze, Gastroenterology 2012

Effect donor faeces on periferal insulin sensitivity

A.Vrieze, Gastroenterology 2012

Fecal gut microbiota compositionGutmicrobiota diversity increased

A.Vrieze, Gastroenterology 2012

F prausznitzii higher

Ruminococcus higher

A.Vrieze, Gastroenterology 2012

Small intestinal gut microbiota composition

Koch’s postulates

Eiseman (Surgery 1958)

• Fecal transplant doesn’t induce a definate cure!

• The cultured microorganism should induce beneficial or adverse effects when introduced into a healthy organism (3rd postulate)

• Concentrations of Eubacterium hallii in small intestinal biopsies correlated significantly with improved insulin sensitivity upon lean donor Fecal Tx

Manipulating gutmicrobiota by Eubacterium hallii : effect on

insulin resistance

Eubacterium hallii• belongs to Firmicutes phylum (spore

former)• Anaerobic gram positive lactate-utilizing

SCFA butyrate- producing bacterial strain

• Can produce butyrate at pH 5-6 (small intestine) as well as at pH 6-7 (colon)

• Sensitive to vancomycine

Studyprotocol I • Db/db male mice (8 weeks old), n=8 per group

• Daily gavage (100ul/mouse) with E. Hallii (stored in 10% glycerol at -80C), gavage within 1 hour after thawing for 4 weeks with: -10^6 CFU/ml

- 10^8 CFU/ml

- 10^10 CFU/ml

- placebo (dissolvens = 10% glycerol)

Insulin tolerance test (insulin sensitivity)

E. Hallii normalises insulin sensitivity (ITT) compared to placebo

0 10 20 30 40 50 60 70 80 90 100 110 120 13050

60

70

80

90

100

110

120

130

140

150placebo (10% glycerol)

106 CFU/ml E.Hallii

1010 CFU/ml E.Halii

108 CFU/ml E.Hallii

*

*

Time (min)

Udayappan/Manneras, submitted

Gutmicrobiota analyses: Ehallii treatment significantly increases

Ehallii in cecum

Mean ±SEM

Studyprotocol II • Db/db male mice (8 weeks old), n=7-9 per group

(Gothenborg university, Sweden)

• Daily gavage (100ul/mouse) with alive or heat inactivated E. Hallii 10x6CFU/ (stored in 10% glycerol at -80C), gavage within 1 hour after thawing for 4 weeks followed by:

• -48h in Metabolic cages (Somedic cages)

- hyperinsulinemic normoglycemic clamp

Effect E. Halli on food intake and bodyweight

Udayappan/Manneras, submitted

10^8 E.hallii treatment significantly increases E.halli in cecum

P<0.05

Udayappan/Manneras, submitted

Active E. Hallii treatment significantly increases verruco bacteria, cyanobacteria, deferribacteres and fusobacteria

* Significant p<0.05Mann Whitney UCyanobacteria: p=0.015(2-

tailed), .007 (1-tailed)

Deferribacteres: p=0.028 (2-tailed), .0014 (1-tailed)

Fusobacteria: p=0.028 (2-tailed), .0014 (1-tailed)

Verrucomicrobia: p=0.028 (2-tailed), .0014 (1-tailed)

Red: E hallii 10x8CUF

Green: plaecbo

Resting energy increased upon E. hallii

Mean ±SEM

Udayappan/Manneras, submitted

*

Per

iphe

ral i

nsul

in s

ensi

tivity

Udayappan/Manneras, submitted

Insulin sensitivity (clamp) increased upon E. hallii

Mean ±SEM

E. hallii increases fecal secondary bile acids

Mean ±SEM

Ehallii treatment: effect on fecal SCFA

P<0.05

E.Halli as novel therapeutic in in insulin resistance?

• Has beneficial effects on insulin sensitivity

• Potential mechanism via bileacids and brown fat (Increased Energy Expenditure)

• Human intervention phase 1 dosefinding trial with E.hallii curently ongoing at AMC

•

De Vos WM and Nieuwdorp M. Nature 2013; 498(7452):48-9

Eubacterium hallii

Take home message• Decreased butyrate producing bacteria in obesity

associated with malign obesity and insulin resistance

• FMT incudes changes in (small) iIntestinal microbiota and affects insulin resistance (but it is not a panancea)

• Using FMT as a working model can derive novel probiotics on top of current treatment for insulin resistance

Acknowledgments

Willem de Vos WUR/Helsinki

Mireille Serlie MD PhD AMC

Ruud Kootte MDFleur van der Valk, MDPim Gilijamse, MDLoek Smits, MDSophie Bernelot Moens, MDMara Sandberg, MDKristien Bouter, MScPieter de Groot, MDAnnick Hartstra MD

Han Levels PhDGeesje Dallinga, PhDAlinda Schimmel, Bsc

Anne Vrieze MD PhD

AMC

Fredrik backhedGothenborg

Louise Manneras

Shanti Udayappan

Erik Stroes AMCHans Romijn

AMC