Faecal microbiota transfer in patients with microscopic colitis – a pilot study in collagenous colitis

Figures & data

Table 1. Data and sample collection throughout the course of the study.

Assessment	-2 weeks	0 weeks	2 weeks	4 weeks	6 weeks	8 weeks	12 weeks	6 months
	Baseline	FMT 1 (colonoscopy)	FMT 2 (enema)	FMT 3 (enema)	Follow-up 1	Follow-up 2	Follow-up 3	Follow-up 4
Daily diary and questionnaires	x^a	x^a	x	x	x	x	x	x
Adverse events reporting		x	x	x	x	x	x	x
Blood collection	x				x
Colon mucosa biopsy sampling	x	x^b			x
Faecal sample collection	x^a	x^a	x	x	x	x	x	x

^a The average of both time points was used as the baseline value.

^b During the colonoscopy for the first FMT, colonic biopsies were taken in order to confirm CC diagnosis.

FMT: faecal microbiota transfer.

Table 2. Exclusion criteria of FMT donors.

1. Current communicable disease

2. Known organic gastrointestinal disease

3. Recent (gastrointestinal) infection (within the last 6 months)

4. First degree relative with inflammatory bowel disease

5. First degree relative with cardiovascular thrombosis before 50 years of age

6. History of or present gastrointestinal malignancy or polyposis

7. History of major gastrointestinal surgery

8. Eosinophilic disorders of the gastrointestinal tract

9. Human immunodeficiency viruses (HIV), hepatitis A, B, C or known exposure within the recent 12 months

10. Malignant disease and/or intake of systemic anti-neoplastic agents

11. Psychiatric diseases or other incapacity for adequate cooperation

12. Chronic neurological/neurodegenerative diseases (e.g., Parkinson’s disease, multiple sclerosis)

13. Metabolic syndrome

14. Obesity (BMI > 30)

15. Autoimmune disease and/or patients receiving immunosuppressive medications

16. Major relevant allergies

17. Chronic pain syndromes

18. Chronic fatigue syndrome

19. Females who are pregnant or breastfeeding

20. Other chronic use of drugs that may affect the microbiome, e.g., proton pump inhibitors

21. Antimicrobial treatment or prophylaxis within the last 3 months

22. Abuse of alcohol or drugs

23. Tattoo or body piercing within the last 6 months

24. Participation in high-risk sexual behaviours

25. Travelling in countries with low hygiene or high infection risk for endemic diarrhoea within the last 6 months

26. Positive stool testing for Clostridioides difficile, ova and parasites (e.g., Cyclospora, Isospora, Cryptosporidium), enteric pathogens (e.g., enterohaemorrhagic E. coli, Salmonella, Shigella, Yersinia, Campylobacter, Giarda antigen, amoebas)

27. Positive stool testing for multiresistant bacteria (e.g., extended-spectrum betalactamase (ESBL) producing organisms, vancomycin-resistant enterococci (VRE) or methicillin-resistant Staphylococcus aureus (MRSA))

28. Calprotectin > 50 μg/g of faeces

29. Positive blood testing for HIV, hepatitis A, B, C, syphilis, human T-lymphotropic virus (HTLV), cytomegalovirus (CMV) and Epstein Barr virus (EBV)

30. Known clinically significant abnormal laboratory values

31. Any clinically significant disease/condition which in the investigator’s opinion could interfere with the results of the trial

FMT: faecal microbiota transfer; BMI: body mass index.

Table 3. Overview of patient characteristics and study outcomes throughout the study.

Patient	Budesonide-free days before start of the study^a	Clinical active disease at baseline^b	Histological confirmation of CC diagnosis^c	FMT donor	Clinical remission at 6 w/8 w/12 w/6 m^d	Responder at 6 w/8 w/12 w/6 m^e
A	42	Yes	Yes	A	Yes/LF/LF/LF	Yes/LF/LF/LF
B	64	Yes	Yes	A	No/No/Bd/Bd	No/No/Bd/Bd
C	23	Yes	Yes	A	No/No /Bd/Bd	No/No/Bd/Bd
D	77	Yes	Yes	B	No/Yes/Yes/Yes	No/Yes/Yes/Yes
E	27	Yes	Yes	B	Yes/Yes/1/1	Yes/Yes/1/1
F	11	No	Yes	A	Yes/Yes/1/Yes	No/No/No/No
G	204	No	Yes	B	Yes/Yes/Yes/Yes	No/No/No/No
H	232	No	Yes	B	Yes/Yes/Yes/Yes	No/No/No/No
I	80	No	Yes	B	Yes/Yes/Yes/Yes	No/No/No/No

^a Patients were asked to withdraw from budesonide before start of the study.

^b Clinical active disease was defined as more than three stools per day whereof at least one watery.

^c Histopathological analysis of biopsies collected by whole colonoscopy during the first FMT.

^d Clinical remission was defined as less than three stools per day whereof less than one watery.

^e Responder was defined as having active disease at baseline and being in remission after FMT.

LF: lost-to-follow up; Bd: started with budesonide treatment; 1: on average one watery stool per day instead of less than one watery stool per day; w: weeks; m: months.

Table 4. Concomitant medications (until 12 weeks).

ATC code	Class of drugs	Number of patients
A02	Drugs for acid related disorders	4
A03	Drugs for functional gastrointestinal disorders	1^a
A07	Antidiarrhoeals, intestinal anti-inflammatory and anti-infective agents	1 + 6^a,b
A10	Drugs used in diabetes	3
A12	Mineral supplements	1
B01	Antithrombotic agents	2
B03	Antianemic preparations	2
C07	Beta blocking agents	1
C09	Agents acting on the renin-angiotensin system	2
C10	Lipid modifying agents	2
G04	Urologicals	1
H03	Thyroid therapy	1
N02	Analgesics	1
N05	Psycholeptics	1
N06	Psychoanaleptics	1
N07	Other nervous system drugs	1
R06	Antihistamines for systemic use	1
–	Relevant food supplements
	Fibres	1
	Omega-3	1

ATC: Anatomical Therapeutic Chemical Classification.

^a Patients occasionally took these medications during the course of the study.

^b Four patients (patients A, D, F, G) occasionally took loperamide during the course of the study, two additional patients resumed their initial budesonide treatment before the end of the study.

Table 5. Adverse events after FMT.

Adverse event	Up to 7 days after FMT 1 (colonoscopy)	Up to 7 days after FMT 2 (enema)	Up to 7 days after FMT 3 (enema)
Elevated temperature (>37.5 < 38.5°C)	1 (0)	1 (1)	2 (2)
Abdominal discomfort	5 (5)	6 (6)	3 (3)
Dizziness	1 (1)	0 (0)	1 (1)
Fatigue	1 (1)	2 (2)	1 (1)
Arthralgia	0 (0)	1 (1)	0 (0)
Vasovagal reaction	0 (0)	1 (0)	0 (0)
Upper respiratory tract infection	0 (0)	1 (0)	1 (0)
Inflammation of insulin pump	1 (0)	0 (0)	0 (0)
Flare-up	0 (0)	0 (0)	1 (1)

FMT: faecal microbiota transfer.

The number of all patients experiencing adverse events is reported, the number of those patients whose adverse event were possibly or probably related to FMT is shown in brackets.

Figure 1. Number of stools after FMT. a–c Number of stools per day of patients with active disease at baseline. d–f Number of stools per day of patients in remission at baseline. These patients were in remission also after FMT. The missing/excluded values of some patients during the later time points were replaced with the individual baseline values when performing the statistical tests. No statistically significant differences were found. Open symbols show clinical responders, dashed lines show patients who were already in remission at baseline.

Figure 2. Gastrointestinal symptom rating scale scores before and after FMT. * indicates p < .05, ** indicates p < .01 compared to baseline when adopting a conservative approach. The missing/excluded values of some patients during the later time points were replaced with the individual baseline values when performing the statistical tests. Open symbols show clinical responders, dashed lines show patients who were already in remission at baseline.

Figure 3. Hospital anxiety and depression scale scores before and after FMT. No statistically significant differences were found. The missing/excluded values of some patients during the later time points were replaced with the individual baseline values when performing the statistical tests. Open symbols show the clinical responders, dashed lines show patients who were already in remission at baseline.

Table 6. Short health scale questionnaire before and after FMT.

SHS subscore	Baseline	2 weeks	4 weeks	6 weeks	8 weeks	12 weeks	6 months
Symptom burden	3.5 (3.3–4.8)	2.0 (1.5–4.0)	2.0 (2.0–4.5)	2.0 (2.0–5.5)	2.0 (2.0–4.8)	2.0 (2.0–4.3)	2.0 (1.5–4.3)
Social function	4.0 (2.8–5.5)	3.0 (1.0–5.0)	3.0 (1.0–4.0)	1.0 (1.0–5.5)	1.0 (1.0–5.3)	2.0 (1.0–5.0)	2.0 (1.0–5.3)
Disease-related worries	2.5 (2.3–3.8)	2.0 (1.5–3.5)	2.0^a (1.0–2.5)	2.0 (1.0–3.5)	1.0^a (1.0–2.5)	1.0 (1.0–2.8)	1.0 (1.0–3.3)
General well-being	3.0 (2.3–4.0)	2.0 (1.5–4.0)	2.0 (2.0–4.0)	3.0 (1.5–4.0)	2.0 (2.0–4.0)	2.0 (2.0–4.0)	2.0 (1.5–4.0)

Median and IQR are presented. The missing/excluded values of some patients during the later time points were replaced with the individual baseline values prior to calculation of median and IQR and the statistical testing.

^ap < .05 compared to baseline.

Figure 4. EQ-5D-5L scores before and after FMT. ** indicates p < .01 compared to baseline when adopting a conservative approach. The missing/excluded values of some patients during the later time points were replaced with the individual baseline values when performing the statistical tests. Open symbols show the clinical responders, dashed lines show patients who were already in remission at baseline.

Figure 5. Maximal collagen layer thickness (a) and number of intraepithelial lymphocytes (IELs) (b) in distal colonic biopsies at baseline and six weeks. Open symbols show the clinical responders, dashed lines show patients who were already in remission at baseline.

Figure 6. Cell counts after isolation of intraepithelial lymphocytes (IELs) (a) and lamina propria lymphocytes (LPLs) (b) from colonic biopsies at baseline and six weeks. * indicates p < .05. Open symbols show the clinical responders, dashed lines show patients who were already in remission at baseline.