Introduction

Risankizumab (RZB), a humanised monoclonal antibody targeting the p19 subunit of interleukin-23 (IL-23), demonstrated substantial improvements in clinical and endoscopic outcomes in patients (pts) with active Crohn’s disease (CD) in the phase 3 studies (ADVANCE [NCT03104413], MOTIVATE [NCT03105128], and FORTIFY [NCT03105102]).^1-2 In the FORTIFY study, clinical remission rates at week 52 were higher than expected in responders to induction RZB who were randomized to placebo (WD PBO) for maintenance, suggesting a durable effect of RZB. In this study, we investigated the molecular mechanisms associated with sustained clinical effects of RZB in CD pts in the phase 3 studies.

Aims & Methods

Bulk RNA sequencing was performed on colon biopsies collected longitudinally from a subset of pts in the phase 3 studies (True PBO, n=23; WD PBO, n=29; pooled RZB 180 and 360 mg, n=77) with matched samples at baseline (BL), wk12 (induction), and wk52 (maintenance). Differentially expressed genes (DEGs) from BL to wk52 were identified with linear mixed-effect models (false discovery rate ≤0.05) in all pts as well as in pts who achieved clinical remission (average daily stool frequency ≤2.8 and not worse than BL and average daily abdominal pain score ≤1 and not worse than BL) at wk52 and those who achieved maintenance of clinical remission from wk12 to wk52. Pathway enrichment analyses were performed with Ingenuity Pathway Analysis (IPA). Cell type enrichment analyses based on gut cell signatures from Buckley et al³ was conducted using Gene Set Variation Analysis (GSVA).

Results

Analysis of DEGs in colon biopsies from all pts yielded a highly significant subset of genes modulated from BL to wk52 in the WD PBO and RZB treatment arms. Shared upregulated DEGs across the WD PBO and RZB groups (MT-ND6, MT-ND4, MT-ND5, MT-ATP6, MT-ND4L, MT-ND1, MT-ND2, MT-CYB, MT-ND3, MT-CO2, MT-CO3, MT-CO2 and EIF3C) are associated with reduced mitochondrial dysfunction and upregulation of mitochondrial oxidative phosphorylation. Modulation of these genes were also enriched in pts who achieved wk52 clinical remission as well as pts who achieved maintenance of clinical remission from wk12 to wk52. Next, we validated the enrichment of the MT genes (based on the top 13 upregulated genes) at the patient level and found that all 13 shared MT gene signatures were significantly enriched at wk52 compared to BL and wk12 in both the WD PBO and RZB treatment arms. Additionally, the MT signature scores were comparable between the WD PBO and RZB arms at wk52. Cell type enrichment analyses further revealed that all 13 MT genes were expressed at higher levels in epithelial cells compared to other immune cell subsets, highlighting their potential role in epithelial cell function. These MT genes were also enriched in colonocytes, enterocytes, and LRG+ stem cells of pts who achieved wk52 clinical remission in both WD PBO and RZB groups, with significantly higher expression at wk52 compared to BL and wk12.

Conclusion

In this study, we identified molecular mechanisms indicating an immunometabolic shift, characterized by downregulation of canonical inflammatory pathways (such as neutrophil degranulation) and an enrichment of oxidative phosphorylation and enhanced mitochondrial activity in RZB-treated pts who demonstrated sustained clinical remission through 52 weeks of drug withdrawal. Durable clinical effects observed with RZB could be due to the enrichment of MT genes in colonic epithelial cells in the gut, which may signify RZB’s ability to restore mitochondrial function and energy metabolism.

References

1. Schreiber SW, et al. J Crohn's Colitis. 2021;15(S1).
2. Ferrante M, et al. The Lancet. 2022;399(10340):2031-2046.
3. Thomas T, et al. Nat Immunol. 2024;25:2152–2165.

Disclosure

Author Disclosures
Nick Powell has received research grants from AstraZeneca, Bristol Myers Squibb, CCUK, Celltrion Healthcare, Helmsley Charitable Trust, Pfizer, and Takeda; received personal fees from AbbVie, Allergan, AstraZeneca, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, GlaxoSmithKline, Janssen, Pfizer, Takeda, and Roche; served as a speaker or on the advisory board for AbbVie, Allergan, AstraZeneca, Bristol Myers Squibb, Celgene, Dr Falk, Galapagos, and Vifor; and serves on the data safety monitoring board for AstraZeneca and Bristol Myers Squibb.
Bram Verstockt has received research support from AbbVie, Biora Therapeutics, Landos, Pfizer, Sossei Heptares and Takeda; speaker’s fees from AbbVie, Biogen, Bristol Myers Squibb, Celltrion, Chiesi, Falk, Ferring, Galapagos, Janssen, MSD, Pfizer, R-Biopharm, Takeda, Truvion and Viatris; consultancy fees from AbbVie, Alimentiv, Applied Strategic, Atheneum, Biora Therapeutics, Bristol Myers Squibb, Galapagos, Guidepont, Landos, Mylan, Inotrem, Ipsos, Janssen, Progenity, Sandoz, Sosei Heptares, Takeda, Tillots Pharma, and Viatris; and stock options from Vagustim.
Geert D’Haens has received consulting and/or lecture fees from AbbVie, ActoGeniX, AIM, Boehringer Ingelheim, Centocor, ChemoCentryx, Cosmo Technologies, Dr Falk Pharma, Elan Pharmaceuticals, enGene, Ferring, Galapagos, Giuliani SpA, Given Imaging, GlaxoSmithKline, Janssen, MSD, Neovacs, Novo Nordisk, Otsuka, PDL BioPharma, Pfizer, Receptos, Salix, SetPoint, Shire, Schering-Plough, Takeda, Tillotts, UCB Pharma, Versant and Vifor Pharma; research grants from AbbVie, Dr Falk Pharma, Given Imaging, Janssen, MSD and PhotoPill; and speaking honoraria from AbbVie, Ferring, MSD, Norgine, Shire, Tillotts, Tramedico and UCB Pharma.
Naim Al Mahi, Stephen Laroux, Ari Stromberg, Heath Guay, and Buvana Ravishankar are full-time employees of AbbVie and may own AbbVie stock or stock options.
James Lindsay has served as a consultant and an advisory board participant for AbbVie, Atlantic Healthcare, Bristol Myers Squibb, Celgene, Celltrion, Eli Lilly, Ferring Pharmaceuticals, Galapagos, Gilead, GSK, Janssen, MSD, Napp, Pfizer, Shire, Takeda, and Vifor Pharma; has received speaker fees and sponsorship for academic meetings from AbbVie, Ferring Pharmaceuticals, Janssen, MSD, Napp, Norgine, Pfizer, Shire, Tillotts Pharma, and Takeda; and has received investigator-led research grants from AbbVie, Gilead, Pfizer, Shire and Takeda.


Funding
AbbVie funded this trial and participated in the trial design, research, analysis, data collection, interpretation of data, and the review and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship. AbbVie and the authors thank the patients, study sites, and investigators who participated in this clinical trial.

Introduction

Small intestinal bacterial overgrowth (SIBO) is a clinical syndrome with abdominal complaints and malabsorption. Despite concerns over cure rates, recurrence, and antibiotic resistance, rifaximin (RIF) remains the primary treatment. Berberine (BBR), an affordable traditional medicine, has demonstrated gut microbiota modulation, making it a promising alternative.

Aims & Methods

We conducted an open-label, non-inferiority randomized controlled trial (BRIEFSIBO) comparing BBR and RIF in SIBO patients. Patients were randomly assigned to receive either RIF or BBR. The primary outcome was breath test (BT) conversion to negative, with symptom scores and the Bristol stool scale as secondary outcomes.

Results

A total of 186 patients completed the study. No significant baseline differences were found between groups in age, gender, BMI, smoking, or alcohol use. BBR demonstrated non-inferior efficacy to RIF for primary outcome (BT eradication) at Week 2 (ITT: BBR 45%, RIF 51%, Z=2.407, P=0.008; PP: BBR 44%, RIF 47%, Z=2.4787, P=0.007) and Week 6 (ITT: BBR 53%, RIF 44%, Z=4.3244, P<0.001; PP: BBR 54%, RIF 45%, Z=4.077, P<0.001). What's more, BBR demonstrated non-inferior efficacy to RIF for secondary outcome (clinical improvement) at Week 2 (ITT: BBR 68%, RIF 75%, Z=2.9209, P=0.0017; PP: BBR 73%, RIF 72%, Z=3.3531, P=0.0004) and Week 6 (ITT: BBR 75%, RIF 80%, Z=2.8514, P=0.0022; PP: BBR 81%, RIF 86%, Z=3.0747, P=0.0011). Following a four-week period of discontinuation, the rate of combined expiratory and symptomatic relapse in patients treated with RIF was 8.57%. In contrast, no such relapses were observed in patients treated with BBR. BT values at 60–90 minutes and AUC decreased in both groups, though RIF showed recurrent peak values during follow-up. A novel breath peak acceleration parameter, reflecting local gut gas load, decreased in both groups. BBR significantly improved bloating at Week 6, whereas RIF improved bowel movement frequency. At Week 6, patients were classified into response, relapse, and nonresponse groups to identify optimal candidates for each drug. RIF responders showed significant improvement in bloating and bowel-related symptoms (P<0.05). Baseline gut microbiota analysis revealed significant β diversity differences between three groups in BBR but not in RIF. Genus-level microbiota composition differed between responders, with BBR responders exhibiting higher baseline proportions of Phascolarctobacterium, Klebsiella, and Haemophilus, and lower Coprobacter. At Week 6, both groups showed enriched Bacteroides, while BBR responders had elevated Phascolarctobacterium, Streptococcus, and Haemophilus, with lower Bifidobacterium.

Conclusion

BBR is non-inferior to RIF for SIBO treatment and offer a promising and cost-effectiveness new option.

References

1. Pimentel M, Saad RJ, Long MD, et al. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol 2020;115(2):165-78. doi: 10.14309/ajg.0000000000000501
2. Bushyhead D, Quigley EMM. Small Intestinal Bacterial Overgrowth-Pathophysiology and Its Implications for Definition and Management. Gastroenterology 2022;163(3):593-607. doi: 10.1053/j.gastro.2022.04.002
3. Quigley EMM, Murray JA, Pimentel M. AGA Clinical Practice Update on Small Intestinal Bacterial Overgrowth: Expert Review. Gastroenterology 2020;159(4):1526-32. doi: 10.1053/j.gastro.2020.06.090
4. Leite G, Rezaie A, Mathur R, et al. Defining Small Intestinal Bacterial Overgrowth by Culture and High Throughput Sequencing. Clin Gastroenterol Hepatol 2024;22(2):259-70. doi: 10.1016/j.cgh.2023.06.001
5. Svedlund J, Sjödin I, Dotevall G. GSRS--a clinical rating scale for gastrointestinal symptoms in patients with irritable bowel syndrome and peptic ulcer disease. Dig Dis Sci 1988;33(2):129-34.
6. Liu ZJ, Wei H, Duan LP, et al. [Clinical features of irritable bowel syndrome with small intestinal bacterial overgrowth and a preliminary study of effectiveness of Rifaximin]. Zhonghua Yi Xue Za Zhi 2016;96(24):1896-902. doi: 10.3760/cma.j.issn.0376-2491.2016.24.005
7. Guo H, Lu S, Zhang J, et al. Berberine and rifaximin effects on small intestinal bacterial overgrowth: Study protocol for an investigator-initiated, double-arm, open-label, randomized clinical trial (BRIEF-SIBO study). Front Pharmacol. 2023;14:1121435. doi:10.3389/fphar.2023.1121435

Introduction

Diagnosis of celiac disease (CeD) is dependent on serological markers like IgA antibodies against transglutaminase 2 (TG2) and IgG antibodies against deamidated gluten peptides (DGP) caused by dietary gluten. The underlying immunological drivers of antibody response are however still poorly characterized. Clarifying these drivers may improve serology-based diagnostics and offer valuable immunobiological insight for CeD.

Aims & Methods

In this project, we aimed to identify new serum factors that are associated with celiac disease and serological response. A total of 224 serum samples (161 untreated and 63 treated) from patients with CeD were selected from Oslo University Hospital’s Intestinal Disease Biobank collected between 2018 to 2024. Data on serological response and treatment status were collected and the samples were compared with 40 healthy individuals. Serum samples from treated CeD were paired samples of untreated CeD. Serum was analyzed using the Olink® Target 96 Inflammation panel, which uses PCR-amplified dual-antibody proximity extension. Analyses were performed at the Proteomic Core Facility at Oslo University Hospital and statistics were performed in R-based with the OlinkAnalyze package.

Results

Thirty-one proteins differed significantly across all comparisons (p < 0.05) and were more abundant in CeD than in healthy controls. When untreated CeD was compared with controls, 24 proteins were elevated, namely CXCL9, CXCL10, CXCL11 (all ligands for CXCR3), CCL25 (ligand for CCR9), IFN-gamma, IL12B, IL17A, IL7, IL8, IL10, IL15RA, LIF, CCL11, CCL20, CCL28, PD-L1, TNFRSF9, CD40, VEGFA, ARTN, MMP10, ADA, ST1A1 and STAMBP. In treated CeD, 9 proteins were elevated compared to controls, namely CXCL10, CXCL11, IL12B, IL7, CD40, TNFRSF9, CSF1, VEGFA and ST1A1. Paired comparisons of treated and untreated samples showed that CXCL9, CXCL11, CCL11, CCL25, IL17A, TNFRSF9 and ADA were significantly higher in the untreated group. The proteins CXCL11 and TNFRSF9 were significant in all 3 comparisons. No significant differences were noted when comparing IgA-TG2 and IgG-DGP responses; however, IL-17A and CXCL11 were significantly lower among those with only a TG2 response compared to double positives.

Conclusion

We here report that multiple serum proteins are significantly elevated in untreated and treated CeD patients compared to healthy individuals. Many of the same serum proteins have previously been reported in serum taken hours after gluten challenge. Of particular interest, IL7, which is upregulated in intestinal CeD mucosa, was significantly upregulated in serum compared to controls. Both CXCL11 and TNFRSF9 which were found to be significant in all comparisons are immunological proteins relevant for T-cell activation and regulations. Future analyses will incorporate clinical data, including Marsh grades and serological levels, to deepen our understanding of the immunological landscape in CeD.

Introduction

The first and further decompensation mark the natural history and the risk of mortality in patients with cirrhosis. We assessed the cumulative incidence of first and further (acute and non-acute) decompensation and evaluated their impact on liver-related death (LR-D) in patients with compensated advanced chronic liver disease (cACLD) due to metabolic dysfunction-associated steatotic liver disease (MASLD).

Aims & Methods

International multicenter retrospective study (17 centers) on 6,061 consecutive patients with clinical (LSM>10 kPa) or biopsy-proven (F3-F4 fibrosis) diagnosis of cACLD due to MASLD. First and further decompensation were defined according to Baveno VII criteria. Competing risk analysis by cumulative incidence functions and Cause-specific Cox models with baseline and time-dependent variables were performed. A multistate model was built to better assess the clinical course of cACLD due to MASLD.

Results

The cumulative incidence of the first decompensation was 3.5% (95% C.I 3.0-4.1) at 5 years, increasing 19-fold the risk of LR-D using Cox analysis; the cumulative incidence of further decompensation was 43.9% (95% C.I 37.2-50.2) at 5 years among patients with first decompensation, additionally increasing 1.5-times the risk of LR-D. Ascites, followed by variceal bleeding, were the most common events in both first and further decompensation. Hepatocellular carcinoma (HCC) further independently increased the risk of LR-D by 3- and 1.4-fold in the whole cohort of cACLD due to MASLD and in those who experienced first decompensation, respectively.

Conclusion

The first and further decompensations represent tipping points in the clinical course of patients with cACLD due to MASLD, increasing 19-times and additionally 1.5-times the risk of LR-D. HCC is an independent predictor of LR-D in patients with cACLD due to MASLD, resulting in an additional risk of LR-D when associated with both first and further decompensation.