Fecal Microbiota Therapy Vs 5-aminosalicylates for Induction of Remission in Newly Diagnosed Mild-moderately Active UC

Study Overview
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Brief Summary
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Ulcerative colitis is a chronic idiopathic inflammatory disease of the colon that is characterized by abdominal pain and bloody diarrhea. The pathogenesis of UC involves a complex interplay of genetic factors, immune dysregulation and environmental triggers. Conventional therapies for UC (including 5-aminosalicylates, corticosteroids, azathioprine or 6-mercaptopurine and biologics) focus on altering the immune response by suppression of immune cells. However, the primary pathogenic mechanism underlying UC maybe gut microbiota dysbiosis and a dysfunctional intestinal barrier resulting in an aberrant host immune response. Several studies have shown reduced microbial diversity in UC patients with under representation of anti-inflammatory phyla (Bacteroides and Firmicutes), and a relative increase of pro-inflammatory phyla (Proteobacteria and Actinobacteria). Motivated by this, therapies targeting intestinal dysbiosis (prebiotics, probiotics, synbiotics and fecal microbiota transplant (FMT)) have thus been tried in patients with UC. Though several case series and subsequently four high quality randomized controlled trails have established the efficacy of FMT in induction of remission in active UC, all these studies have used it as an add-on therapy, along with the previously ongoing conventional therapies. The investigators aim to assess the safety and efficacy of FMT as the sole modality for induction of remission in patients with newly diagnosed active UC.

Detailed Description
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This will be a prospective randomised placebo-controlled trial. Newly diagnosed treatment naive patients with mild to moderately severe UC will be recruited (n=15). The patients will be randomized into 3 groups; i.e group I (n=5): FMT with placebo, group II (n=5): FMT with mesalamine, group III (n=5): Placebo infusion with mesalamine. The patients will undergo colonoscopic administration of fecal slurry (groups I and II) or placebo (group III) at weeks 0,2,6,10 and 14. Mesalamine will be administered in a dose of 4g/day. In case of clinical worsening during the study, a short course of steroids will be added. The primary end point will be clinical remission (Mayo score ≤2, all subscores ≤ 1) at week 14. Secondary end points will be achievement of endoscopic remission (endoscopic Mayo score 0) and histological remission (Nancy grade 0, 1) at the end of 14 weeks.

Official Title
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Fecal Microbiota Therapy Vs 5-aminosalicylates for Induction of Remission in Newly Diagnosed Mild-moderately Active UC : a Pilot Study

Conditions
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Ulcerative Colitis Chronic Mild, Ulcerative Colitis Chronic Moderate

Intervention / Treatment
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* Biological: Fecal Microbiota Transplantation
* Drug: Mesalamine Granules
* Other: Placebo infusion
* Other: Placebo granules


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Active UC: UC diagnosed based on history of chronic (>4 weeks), inflammatory (with blood and mucous) diarrhoea Total Mayo Score 4-10, Mayo endoscopic sub-score of >1 Histopathology suggestive of UC Exclusion Criteria: Severe UC (Total Mayo 11-12, Endoscopic Mayo Score 3) Uncertainty about diagnosis of UC : Infective colitis/ Indeterminate Colitis/ Crohn's Colitis Associated irritable bowel syndrome (IBS) Past history of surgery or colorectal surgery Exposure to antibiotics or probiotics in the last 4 weeks Patients with evidence of infections like C. difficile, cytomegalovirus, HIV, parasitic infections or extra-intestinal infections requiring antibiotics. Significant cardiopulmonary co-morbidities (high risk for repeated colonoscopy) Pregnancy Refusal to consent for repeated colonoscopies. Donor Single donor (voluntary healthy individual) after informed consent Inclusion criteria for donor No personal or family history of UC or any other autoimmune disease or malignancy Screened by stool microscopy and culture for common detectable enteric pathogens (Salmonella, Shigella, Campylobacter, Vibrio cholera, E. coli, Clostridium difficile, Giardia lamblia and Cryptosporidium) at the start of the study and every 4 weeks thereafter. Negative for antibodies against hepatitis A, C and E, hepatitis B surface antigen (HBsAg), syphilis and human immunodeficiency virus (HIV). Exclusion criteria for donor High-risk sexual behaviors Communicable illnesses Antibiotic treatment within the past 3 months Intrinsic gastrointestinal illnesses such as irritable bowel syndrome, inflammatory bowel disease, gastrointestinal malignancies or major gastrointestinal surgical procedures Ongoing immune-modulator therapy for any concurrent illness Chronic pain syndromes Neurologic/neurodevelopmental disorders Metabolic syndrome Obesity (BMI >30 kg/m2) Malignant illnesses Donor's diet will be monitored with a diet diary.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: FMT Vs Placebo<br>Fecal microbiota transplantation (fresh sample, colonoscopic administration at weeks 0,2,6,10,14) plus placebo granules (4g/day) | Biological: Fecal Microbiota Transplantation<br>* Freshly passed stools (80 g) will be diluted with normal saline (200 ml) and homogenized using a blender, filtered, filled into 4 syringes (50 ml each) and used within 1 hour of preparation or 6 hours of passage of stools. Polyethylene glycol lavage will be done for bowel preparation and the slurry administered into the ileum and/or caecum by colonoscopy. Post FMT, recipients will be encouraged to retain the slurry for 4-6 hours. FMT sessions will be scheduled at weeks 0,2,6,10,14.<br>Other: Placebo granules<br>* Granules resembling mesalamine granules, 4 grams a day<br>|
| Active Comparator: FMT Vs Mesalamine<br>Fecal microbiota transplantation (fresh sample, colonoscopic administration at weeks 0,2,6,10,14) plus mesalamine granules (4g/day) | Biological: Fecal Microbiota Transplantation<br>* Freshly passed stools (80 g) will be diluted with normal saline (200 ml) and homogenized using a blender, filtered, filled into 4 syringes (50 ml each) and used within 1 hour of preparation or 6 hours of passage of stools. Polyethylene glycol lavage will be done for bowel preparation and the slurry administered into the ileum and/or caecum by colonoscopy. Post FMT, recipients will be encouraged to retain the slurry for 4-6 hours. FMT sessions will be scheduled at weeks 0,2,6,10,14.<br>Drug: Mesalamine Granules<br>* Mesalamine granules 4 grams a day<br>* Other names: Rowasa;|
| Active Comparator: Placebo Infusion Vs Mesalamine<br>Placebo infusion (colonoscopic administration at weeks 0,2,6,10,14) plus mesalamine granules (4g/day) | Drug: Mesalamine Granules<br>* Mesalamine granules 4 grams a day<br>* Other names: Rowasa;Other: Placebo infusion<br>* Water with food grade colour to resemble fecal slurry<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Clinical remission | Mayo score ≤2, each subscore ≤1 | Week 14 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Clinical response | Reduction of Mayo score ≥30% and ≥3 points compared to baseline | Weeks 0,2,6,10,14 | 
| Endoscopic remission | Endoscopic Mayo subscore 0 | Week 14 | 
| Histological remission | Nancy grade 0 or 1 | Week 14 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Fecal Microbiota Transplantation, Ulcerative Colitis, Induction of Remission