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 20 minutes

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 F prausznitzii lower Ruminococcus lower Smits/Nieuwdorp, Gastroenterology 2013 [in press]

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

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

Koch’s postulates for 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

Effects of fecal transplantations in clostridium difficile diarroea Van Nood, NEJM 2013

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 effect on weight 6 weeks after lean donor FMT 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 composition Gutmicrobiota diversity increased F prausznitzii higher Ruminococcus higher A.Vrieze, Gastroenterology 2012

Small intestinal gut microbiota composition A.Vrieze, Gastroenterology 2012

Koch’s postulates 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 Eiseman (Surgery 1958)

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 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<0.05 Mann Whitney U Cyanobacteria: 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 TEE was determined, using Weir's equation: (3.9 × VO2) + (1.1 × VCO2) Udayappan/Manneras, submitted Mean ±SEM

Insulin sensitivity (clamp) increased upon E. hallii * Peripheral insulin sensitivity Udayappan/Manneras, submitted

E. hallii increases fecal secondary bile acids Mean ±SEM

Ehallii treatment: effect on fecal SCFA P<0.05 Mean ±SEM

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

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 Ruud Kootte MD Fleur van der Valk, MD Erik Stroes AMC Willem de Vos WUR/Helsinki Fredrik backhed Gothenborg Hans Romijn AMC Ruud Kootte MD Fleur van der Valk, MD Pim Gilijamse, MD Loek Smits, MD Sophie Bernelot Moens, MD Mara Sandberg, MD Kristien Bouter, MSc Pieter de Groot, MD Annick Hartstra MD Han Levels PhD Geesje Dallinga, PhD Alinda Schimmel, Bsc I Anne Vrieze MD PhD AMC Shanti Udayappan Mireille Serlie MD PhD AMC Louise Manneras