GLEPAGLUTIDE, A LONG-ACTING GLP-2 ANALOG, SIGNIFICANTLY REDUCES NEED FOR PARENTERAL SUPPORT IN PATIENTS WITH SHORT BOWEL SYNDROME: RESULTS OF EASE SBS-1, A RANDOMIZED, DOUBLE-BLIND, 24-WEEK PHASE 3 TRIAL

Background: Marine omega-3 fatty acids (MO3FAs) - which include eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), and docosahexaenoic acid (DHA) - are fatty acids that have anti-inflammatory properties, reducing C-reactive protein (CRP) and proinflammatory cytokines. Additionally, gut microbes may interact with MO3FA, but it is unknown how MO3FA intake shapes gut microbiome activity and thereby influences systemic inflammation in humans.
Methods: In a sub-cohort of 307 generally healthy men from a prospective cohort study established in 1986, we collected up to two pairs of stools 6 months apart, assessed MO3FA intake from two sets of 7-day diet records, and measured plasma CRP as a marker for chronic systemic inflammation at stool collection (Fig. 1A). Using metagenomic shotgun sequencing, we calculated the abundances of microbial species, functional pathways (MetaCyc), and enzyme families (ECs). We assessed the association of MO3FA intake with microbial features using MaAsLin 2 and the modifying effect by microbial species on the association of MO3FA intake with plasma CRP levels.
Results: MO3FA intake was associated with changes in specific microbial abundances (although not overall composition), with EPA and DHA showing distinct patterns from DPA (Fig. 1G). The strongest association was found between higher EPA and DHA intakes and increased abundance of Lachnospira pectinoschiza (FDR q = 0.011 for EPA and 0.007 for DHA), one of a broad set of gut microbes associated with strict anaerobicity and eubiosis(Fig. 1H). Similar associations were identified for L. pectinoschiza ECs and pathways (Fig. 1I,L). Gut microbial features modified the association between MO3FA intakes and lower plasma CRP levels, with a stronger association among participants with the presence of Eubacterium rectale (P_interaction = 0.017 for EPA, 0.011 for DPA, 0.005 for DHA, Fig. 2B) and the absence of Phocaeicola vulgatus (P_interaction = 0.001 for EPA and 0.008 for DHA, Fig. 2C). Both taxa are prevalent gut residents, with E. rectale again associated with strict anaerobicity and P. vulgatus known to have strain-dependent influences on immune and inflammatory responses. Similar significant interactions were found for the 4 MetaCyc pathways contributed by E. rectale (Fig. 2D,E), and 5 ECs and 1 MetaCyc pathway contributed by P. vulgatus (Fig. 2F,G). A higher level of phosphatidyl-myo-inositol alpha-mannosyltransferase (mannosyltransferase PimA) contributed by P. vulgatus, an enzyme related to the synthesis of surface-exposed lipoglycans, reversed the association of MO3FA intake and plasma CRP from a negative to positive direction (Fig. 2I).
Conclusions: Our findings support the potential role of MO3FA intake in gut microbiome composition and function, and the effect modification by the gut microbiome on the effect of MO3FA on systemic inflammation.

Background: Cystic Fibrosis (CF) is a chronic, debilitating disease of the lungs, intestines, and other organs that reduces life expectancy and is caused by mutations in the CF transmembrane conductance regulator (CFTR) gene. Permanent restoration of endogenous CFTR function using gene-editing techniques is a highly desirable approach to treat CF patients for whom current therapies are not effective. Cas9 fusion proteins (i.e., base editors) permit efficient C-G to T-A or A-T to G-C base changes with limited to no off-target effects. The W1282X mutation in humans is one of the most common nonsense mutations in CFTR. Successful treatment of CF with base editing has not yet been achieved in in vivo models, a prerequisite for clinical translation. In addition, efficient delivery of cargo is a challenge for repair in the gastrointestinal tract.

Methods: In recently published work, we discovered a newly evolved, cross-species compatible AAV (cc.47) that demonstrates substantially increased transduction efficiency across multiple tissues compared to the parental AAV9 capsid. Here, we tested the efficacy of intravenous and colonoscopy-guided injection of AAV.cc47 packaging a self-complementary CBh-Cre recombinase cassette to transduce the intestinal epithelium in Ai9 tdTomato fluorescent reporter mice. We created a CF mouse model carrying the W1282X nonsense mutation in Cftr using CRISPR/Cas9 gene editing and assessed Cftr loss of function in intestinal organoids using a forskolin swelling assay. Mouse embryonic fibroblasts were derived from W1282X/W1282X mice and then transduced using electroporation with an adenine base editor and sgRNA to determine editing efficiency in vitro.

Results: We found that AAV.cc47 infects intestinal stem cells with remarkably high (~ 70%) efficiency (Figure 1). We tested AAV.cc47 for targeted delivery to the colon via colonoscopy-guided injection in mice, which demonstrated moderate transduction efficiency in colonic stem cells. The W1282X Cftr mouse model recapitulated key features of human disease, including defective Cftr function based on a forskolin swelling assay in intestinal organoids. The adenine base editor successfully repaired the W1282X Cftr point mutation in vitro in mouse embryonic fibroblasts at the correct nucleotide position (Figure 2).

Conclusions: We demonstrated efficient transduction of intestinal stem cells with a newly evolved AAV that we recently published. We showed that an adenine base editor successfully repairs a CF point mutation in vitro. We will now assess the ability of an optimized AAV base editor system to repair the W1282X Cftr point mutation in our mouse model and to edit intestinal stem cells in wild-type pigs. Results from these studies will lead to the development of this gene editing technology to target intestinal disease associated with CF and other inborn genetic disorders.

Objective:
The United States Preventative Service Taskforce concluded there is insufficient evidence to recommend population screening for celiac disease. This study examined the outcomes of mass screening-identified celiac disease at baseline and follow up to help inform screening practices.

Methods:
From 2019 to 2022 the mass screening study, Autoimmunity Screening for Kids, offered free testing for autoantibodies against tissue transglutaminase (TTG). TTG+ children were referred for clinical evaluation, and if diagnosed with celiac disease, via biopsy or ESPGHAN criteria, followed up after 12 months on a gluten-free diet (GFD). Demographics, clinical data, and health-related quality of life (HRQoL) at baseline and follow-up were compared. Paired parametric and non-parametric tests were applied as appropriate. For individual symptoms coded with five different levels, ordinal logistic regression with a generalized estimation equation was used to evaluate odds of improvement from baseline to follow up.

Results:
81% of enrolled children completed baseline and follow up assessments. At initial screening, 29 children reported no gastrointestinal symptoms. However, 93% reported symptoms on a more extended questionnaire, completed after knowing the screen was positive. Overall, symptoms improved on the GFD (Figure 1). At 12 months, 93% of families reported good to excellent adherence on GFD. 74% of children with low baseline ferritin improved with GFD (p<0.001). HRQoL also improved after 12 months of treatment with the GFD (Figure 2). There was no statistical difference in anthropometric, anxiety, or depression measures at follow up. Patients who did not complete follow up were more likely to be male (70%, p= 0.034), non-white race (African American and “other race,” 60%, p=0.0056), with household income <$100,000/yr (66.6%, p=0.02), insured by government-funded healthcare insurance (30% compared to 7.1% responders, p=0.033), and older (average age of 12.54 (+/- 3.84) compared to 9.45 (+/-3.99) for responders, p=0.03).

Conclusions:
Mass screening, diagnosis, and implementation of a GFD may be beneficial with respect to symptoms, iron deficiency, and quality of life. Screening and treatment did not negatively impact adherence. Future studies are needed to determine if mass screening is cost effective and how these outcomes compare to established targeted screening practices.

Aims: Although several angiogenesis-related factors are reportedly involved in the pathogenesis of ulcerative colitis (UC), the mechanisms by which they contribute to disease are unclear. We previously examined the expression of many angiogenesis-related factors in inflamed colorectal tissue of UC patients using antibody array, and found that urokinase-type plasminogen activator (uPA) is highly expressed in neutrophils of the inflamed mucosa of UC patients. We also found that the disease activity of dextran sulfate sodium (DSS)-induced colitis in uPA knockout (uPA-/-) mice was lower than in uPA+/+ mice. In this study, we assessed therapeutic effect of uPA inhibitor using murine DSS-induced colitis models, and investigated the mechanism underlying its anti-inflammatory effects using mice with pharmacological uPA blockade and genetic uPA deletion.
Methods: For induction of colitis, C57BL/6J mice were administered with 2% DSS in drinking water for 7 days. Mice were intraperitoneally injected with 2mg/kg or 4mg/kg of uPA-selective inhibitor, UK122, or vehicle once per day for 7 days. Disease severity was evaluated by disease activity index and histological score at day7. uPA-/- mice and littermate controls were also administered with 2% DSS in drinking water for 7 days. Cytokine/chemokine levels in colitis tissue of UK122-treated or uPA-/- mice and their control mice were measured by multiplex cytokine assay.
Results: The disease activity index in mice was significantly decreased by UK122 in a dose-dependent manner. There was a statistically significant difference between control mice and UK-122 (4mg/kg)-treated mice (6.00 ± 0.40 vs 3.21 ± 0.50; p=0.0008). The histological score of the colorectum in mice was also significantly decreased by UK122 in a dose-dependent manner. There was a statistically significant difference between control mice and UK-122 (4mg/kg)-treated mice (18.21 ± 2.91 vs 9.00 ± 1.81; p=0.0157). Among the 23 cytokines, only RANTES level was significantly lower in both colorectal tissues of UK122 (4mg/kg)-treated mice (25.49 ± 3.86pg/mg protein) and uPA-/- mice (70.77 ± 7.02pg/mg protein) compared with each control mice (111.64 ± 35.80pg/mg protein, 128.04 ± 22.17pg/mg protein).
Conclusions: uPA inhibitor significantly ameliorated colitis in mice, concomitant with downregulation of RANTES. uPA-/- mice exhibited milder DSS-induced colitis, concomitant with downregulation of RANTES. Our data suggest that uPA plays an important role in pathogenesis of UC through upregulation of RANTES. uPA can be a promising target molecule for treatment of UC.

BACKGROUND AND AIMS: Treatment of short bowel syndrome (SBS) with intestinal failure (IF) is ultimately focused on achieving total enteral autonomy with complete weaning off from parenteral support (PS), thereby reducing the treatment burden and associated complications of PS. Glepaglutide is a novel, long-acting GLP-2 analog in a stable, aqueous formulation developed to improve intestinal absorption in patients with SBS-IF. We conducted a phase 3 trial to assess the efficacy and safety of glepaglutide in reducing the need for parenteral support in patients with SBS.
METHODS: EASE SBS-1 is a multi-center, placebo-controlled, randomized, parallel-group, double-blind phase 3 trial. Key inclusion criteria comprised diagnosis of SBS with chronic IF; requirement for PS at least 3 days per week; and age 18-90 years. Patients were randomized 1:1:1 to 24 weeks of treatment with subcutaneous injections of either 10 mg glepaglutide twice-weekly (TW), 10 mg glepaglutide once-weekly (OW), or placebo. PS volume requirements were evaluated using regular 48-hour balance periods. PS was reduced if the 48-hour urine volume exceeded the baseline value by ≥10%. The primary endpoint was change in weekly PS volume from baseline to week 24.
RESULTS: A total of 106 patients were randomized and dosed. Approximately half (54/106) had colon in continuity. Mean PS volume requirement at baseline was 14.4 L/week. Glepaglutide TW treatment significantly reduced PS requirements versus placebo (mean change of -5.13 vs. -2.85 L/week; estimated difference of -2.28 L/week [-3.83; -0.73]_{95% CI}; p=0.0039). Glepaglutide TW was also superior versus placebo for the key secondary endpoints of proportion of patients achieving clinical response defined as ≥ 20% PS volume reduction from baseline to week 20 and 24 (65.7% vs. 38.9%; estimated difference of 26.6% [4.3; 48.9]_{95% CI}; p=0.0243), and percentage of patients achieving a reduction in days on PS ≥1 day/week from baseline to week 24 (51.4% vs. 19.4%; estimated difference of 31.7% [11.4; 51.9]_{95% CI}; p=0.0043). In addition, complete weaning off from PS (‘enteral autonomy’) was achieved for 5 (14%) patients receiving glepaglutide TW versus for 0 patients receiving placebo. No statistically significant difference was established for glepaglutide OW versus placebo. Benefits of glepaglutide on patient-reported outcome were shown. Glepaglutide was assessed to be safe and well tolerated. More adverse events were reported in the glepaglutide treatment groups than for placebo, primarily attributable to mild injection site reactions reported for glepaglutide.
CONCLUSION: Treatment with the novel, long-acting GLP-2 analog glepaglutide resulted in significant and clinically relevant reductions in PS requirements for SBS patients with intestinal failure. One in seven patients treated with glepaglutide TW achieved enteral autonomy.