Introduction

The mortality rate of severe acute pancreatitis is still high and no causative treatment is currently available. Growing evidence suggest a critical role of CRAC channel activation, disruption of Calcium homeostasis and unresolved chronic ER stress in the pathogenesis of the disease. In addition, recent clinical trials are currently analyzing the therapeutic potential of specific CRAC channel inhibitors in patients with acute pancreatitis.

Aims & Methods

Here, we studied the role and impact of the calcium responsive Nuclear Factor of Activated T-Cells 1 (NFATc1) in CRAC channel mediated signaling and inflammation during the course of acute pancreatitis.
We employ Caerulein-induced in-vivo and in-vitro pancreatitis models, using genetically modified mice with differential activation of NFATc1 and freshly isolated primary acinar cells. For functional characterization, Western-Blot, qPCR and Immunofluorescence microscopy have been conducted. Currently whole proteome Mass-Spectrometry based approaches, as well as RNA Sequencing are being established to gain understanding of global transcriptional and translational changes.

Results

We show that Caerulein induced rapid NFATc1 expression, nuclear translocation and activation in pancreatic tissues, primary acinar cells and in cultured acinar cells. NFATc1 induction is associated with upregulation of ER-stress related proteins, altered intracellular calcium signaling and induction of key inflammatory cytokines. Moreover, inhibition of NFATc1 – either genetically or following application of CRAC channel inhibitors (CM4620/Auxora) significantly reduces expression and release of pro-inflammatory cytokines in primary acinar cells. In addition, genetic inactivation of NFATc1 reduces the severity of acute pancreatitis and prevents immune cell infiltration in mice. The therapeutic potential of CM4620 mediated CRAC channel/NFATc1 signaling inhibition in acute pancreatitis prevention and treatment is currently under investigation.

Conclusion

We propose that CRAC channel - NFATc1 signaling promotes inflammation and tissue damage in acute pancreatitis through regulation of cell-stress responses, cytokine release and immune cell infiltration. Moreover, pharmacological inactivation of the CRAC-NFATc1 pathway might offer novel therapeutic option in treatment of severe acute pancreatitis.

Introduction

There are currently no studies comparing vonoprazan-dual, vonoprazan-triple therapies and classic bismuth quadruple therapy.

Aims & Methods

We aimed to compare efficacy of vonoprazan-dual or triple therapies and bismuth-quadruple therapy for treatment-naive Helicobacter pylori (HP) infection in Southern China, where primary resistance rates of clarithromycin and levofloxacin are >30%.
Between March 2022 and August 2023, treatment-naïve HP-infected adults were randomly assigned to receive one of the three 14-day regimens (1:1:1 ratio): vonoprazan-dual (VA-dual; vonoprazan 20mg twice daily and amoxicillin 1g thrice daily), vonoprazan-triple (VAC-triple; vonoprazan 20mg/amoxicillin 1g/clarithromycin 500mg twice daily), or bismuth-quadruple therapy containing bismuth, esomeprazole, tetracycline and metronidazole. Primary outcome was noninferiority in HP eradication, evaluated by UBT 4-6 weeks post-treatment by intention-to-treat (ITT) (based on all recruited subjects who took at least one dose of treatment regimen, and those lost to follow-up were considered as treatment failure cases), modified intention-to-treat (mITT) (based on patients who took at least one dose of the treatment and completed follow-up) and per-protocol (PP) analysis (based on subjects who completed 14-day treatment and rechecked UBT). Bonferroni-adjusted p-value of <0.017 was used to determine statistical significance. Primary outcome was noninferiority in HP eradication, evaluated by UBT 4-6 weeks post-treatment by intention-to-treat (ITT) and per-protocol (PP) analysis (based on subjects who completed 14-day treatment and rechecked UBT). Comparative non-inferiority between bismuth-quadruple and VA-dual or VAC-triple was assessed by one-sided μ test and derivation of a two-sided 95% confidence interval (CI), with noninferiority being determined by a lower 95% CI end more than –10% with a Bonferroni-adjusted p-value of <0.017. A two-sided p-value of 0.05 was used to define statistical significance for other analyses.

Results

298 subjects (mean age:35.7±8.4 years; male:134 [45.0%]; body mass index:23.2±3.5 kg/m²; VC-dual:100, VAC-triple:98, bismuth-quadruple:100) were enrolled, and 292 (98.0%) had UBT rechecked. ITT analysis showed both VA-dual (eradication rate of 96.0%) and VAC-triple therapies (95.9%) were non-inferior to bismuth-quadruple therapy (92.0%) (difference:4.0%, 95% CI:-2.9% to 11.5%, p<0.001; and 3.9%, 95% CI:-3.1% to 11.5%, p<0.001, respectively). mITT analysis also showed non-inferiority of VA-dual and VAC-triple therapies to bismuth-quadruple therapy (97.0% and 96.9% vs 95.8%, with difference:1.1% and 1.1%, p=0.002 and 0.002, respectively). Similar observation was noted for PP analysis (96.7% and 96.7% vs 97.4%, with difference:-0.7% and -0.7%, p=0.009 and 0.010, respectively) (Table 1). The frequency of adverse events was 39.0%, 56.1% and 71.0% in VA-dual, VAC-triple and bismuth-quadruple therapies, respectively.

Table 1. Helicobacter pylori eradication rates of vonoprazan-dual, vonoprazan-triple and bismuth-quadruple therapies

Conclusion

VA-dual and VA-triple therapies were non-inferior to bismuth-quadruple therapy in Southern China. Given the lower adverse effects and fewer antibiotic use, VA-dual therapy is the preferred first-line treatment for HP infection.

Disclosure

This study was supported by the National Natural Science Foundation of China (Grant No. 81903581), the Shenzhen Science and Technology Program (Grant Nos. JCYJ20190807150005699 and RCBS20200714115000009), the Shenzhen Key Medical Discipline Construction Fund (Grant No. SZXK059), the Shenzhen Key Laboratory of Prevention and Treatment of Severe Infections (Grant No. ZDSYS20200811142804014), and the Health Commission Grant of Guangdong Province, China (ref. no. B2021239).

Introduction

A marked decrease of Faecalibacterium prausnitzii is a well-established hallmark of Crohn’s disease (CD)-associated dysbiosis and predicts disease relapse (1-2). Several strains of F. prausnitzii exhibit anti-inflammatory effects in vitro and in rodents colitis models, positioning this species as a promising therapeutic candidate (3-4). However, it has never been administered to humans. Here, we present the development and first-in-human evaluation of F. prausnitzii strain EXL01 for CD treatment.

Aims & Methods

F. prausnitzii EXL01, isolated from a healthy donor, was selected based on strict safety and preliminary in vitro efficacy criteria. Its anti-inflammatory effect was tested in trinitrobenzenesulfonic acid (TNBS)-induced colitis in rats and dextran sodium sulfate (DSS)-induced colitis in mice. After favorable toxicological studies, a first-in-human, open-label, single-arm study (Part A) was conducted in patients with mild to moderate ileal CD (CDAI 180–350), following clinical remission (CDAI <150) or response (CDAI decrease ≥70) after corticosteroids (CS). EXL01 (10¹⁰ total cell count/day) was administered orally for 24 weeks, with a 6-week CS taper. Colonoscopies were performed at baseline and week 24. The primary endpoint was safety; secondary endpoints included clinical efficacy, blood/fecal biomarkers, transcriptomic analysis, and gut microbiota profiling. Part B, initially planned as a placebo-controlled phase, was not pursued due to low recruitment.

Results

According to classical evaluation endpoints, EXL01 demonstrated dose-dependent anti-inflammatory effects in both TNBS and DSS models. Between March 2023 and October 2024, 8 patients were enrolled across Belgium and Poland. Baseline characteristics were consistent with the target CD population. After corticosteroid induction, the parameters were as follow: CDAI = 78.1 (42-105); SES-CD= 6.9 (2-17); CRP = 5.7mg/l (3-13). EXL01 was well tolerated; no treatment-related serious adverse events or safety signals were observed. Six participants (75%) completed the 24-week treatment; two discontinued due to disease flare. Compared to patients who remained in remission, those who flared during the study showed higher baseline systemic inflammation markers (CRP, neutrophils, platelets) and innate immunity gene expression, with limited corticosteroid response. While gut microbiota composition remained largely stable, transcriptomic analyses revealed distinct changes in ileal gene expression following EXL01 treatment, notably modulation of immune-related genes and upregulation of energy metabolism pathways, similar to what we saw previously in vitro (bioRxiv 2024.10.06.616495).

Conclusion

EXL01, administered during and after CS tapering, was safe and well tolerated for up to 24 weeks in patients with CD. Though limited by small sample size, the study supports the biological activity of EXL01, notably through its impact on ileal gene expression. A phase 2 randomized controlled trial is ongoing to further assess efficacy.

References

1. Rajca S, Grondin V, Louis E, et al. Alterations in the intestinal microbiome (dysbiosis) as a predictor of relapse after infliximab withdrawal in Crohn's disease. Inflamm Bowel Dis. 2014 Jun;20(6):978-86. doi: 10.1097/MIB.0000000000000036. PMID: 24788220.
2. Pascal V, Pozuelo M, Borruel N, et al. A microbial signature for Crohn's disease. Gut. 2017;66(5):813-22.
3. Sokol H, Pigneur B, Watterlot L, et al. Faecalibacterium prausnitzii is an anti-inflammatory commensal bacterium identified by gut microbiota analysis of Crohn disease patients. Proc Natl Acad Sci U S A. 2008;105(43):16731-6.
4. Martin R, Chain F, Miquel S, et al. The commensal bacterium Faecalibacterium prausnitzii is protective in DNBS-induced chronic moderate and severe colitis models. Inflamm Bowel Dis. 2014;20(3):417-30.

Disclosure

HS, PhL and BH are co-founder of Exeliom. PR, DS, BH are employees of Exeliom Biosciences