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Alexander Shikhman MD, PhD
Institute for Specialized Medicine
July 20, 2013
SPONDYLOARTHROPATHIES
The spondyloarthropathy family consists of the
following entities:
 Ankylosing spondylitis
 Undifferentiated spondyloarthritis
 Reactive arthritis
 Psoriatic arthritis
 Spondyloarthritis associated with IBD
 Juvenile onset spondyloarthritis
ANKYLOSING SPONDYLITIS AND
GUT
 Subclinical gut inflammation has been described
in up to two-thirds of patients with
spondyloarthropathies
 Two histologic types of gut inflammation in
patients with SpA can be distinguished: acute
and chronic inflammation
ANKYLOSING SPONDYLITIS AND
GUT
The acute type mimics the acute
bacterial enterocolitis and is mainly
seen in patients with reactive
arthritis:
 The mucosal architecture is well
preserved
 There is a polymorphonuclear
infiltration of the ileal villi and
crypts
 There is an increased number of
inflammatory cells
(granulocytes, lymphocytes and
plasma cells) in the lamina propria
ANKYLOSING SPONDYLITIS AND
GUT
The chronic type is often indistinguishable
from Crohn’s disease (CD):
 The mucosal architecture is clearly
disturbed
 The villi are irregular, blunted and fused
 The crypts are distorted
 The lamina propria is edematous and
infiltrated by mononuclear cells
 In some cases aphthoid ulcers and
sarcoid-like granulomas are present
Chronic lesions are more present in
undifferentiated SpA and AS.
ANKYLOSING SPONDYLITIS AND
GUT
 Increased intestinal permeability or
leaky gut syndrome is a key
mechanism contributing to the
development and chronic course of
ankylosing spondylitis and other
autoimmune diseases and
inflammatory arthritis.
 The leaky gut allows substances
such as toxins, microbial antigens,
undigested food, waste, or larger
than normal macromolecules to
leak through an abnormally
permeable gut wall and trigger
cascades of inflammatory
reactions.
Tight junctions (TJs) represent the
major barrier within the pathway
between intestinal epithelial cells
that line the digestion tract
ANKYLOSING SPONDYLITIS AND
GUT
 Zonulin is a protein regulating
intestinal permeability via
modulation of tight junction
 Small intestines exposed to
enteric bacteria secrete zonulin
 This secretion occurs only on
the luminal aspect of the
bacteria-exposed small
intestinal mucosa and is
followed by an increase in
intestinal permeability
ANKYLOSING SPONDYLITIS AND
GUT
Mielants H, Veys EM, De Vos M, Cuvelier C. Increased intestinal
permeability in ankylosing spondylitis. Gut. 1992 Aug;33(8):1150.
Martínez-González O, Cantero-Hinojosa J, Paule-Sastre P, Gómez-
Magán JC, Salvatierra-Ríos D. Intestinal permeability in patients
with ankylosing spondylitis and their healthy relatives. Br J
Rheumatol. 1994 Jul;33(7):644-7.
Liu Y, Xu B, Cai X. The role of intestinal permeability in the
pathogenesis of ankylosing spondylitis. Zhonghua Nei Ke Za Zhi.
1995 Feb;34(2):91-4.
Vaile JH, Meddings JB, Yacyshyn BR, Russell AS, Maksymowych WP.
Bowel permeability and CD45RO expression on circulating CD20+
B cells in patients with ankylosing spondylitis and their relatives. J
Rheumatol. 1999 Jan;26(1):128-35.
ANKYLOSING SPONDYLITIS AND
GUT MICROBIOTA
 Gut microbiota consists of a
complex of microorganism
species that live in the digestive
tract
 The human body carries about
100 trillion microorganisms in
its intestines, a number ten
times greater than the total
number of human cells in the
body
 The metabolic activities
performed by these bacteria
resemble those of an
organ, leading some to liken
gut bacteria to a "forgotten"
organ
ANKYLOSING SPONDYLITIS AND
GUT MICROBIOTA
 Gut microbiota primary
benefits the host by
generating energy from the
fermentation of undigested
carbohydrates and the
subsequent absorption of
short chain fatty acids.
 The most important of these
are butyrates, metabolized
by the colonic epithelium
and normalizing intestinal
permeability.
ANKYLOSING SPONDYLITIS AND
GUT MICROBIOTA
ANKYLOSING SPONDYLITIS AND
GUT MICROBIOTA
 HLA B27 influences the
composition of the body’s
endogenous flora and the ‘B27-
shaped flora’ predisposes to
ankylosing spondylitis
 HLA-B27 transgenic mice do
not develop spondylitis-like
lesions in germ-free enviroment
 Antibiotic therapy prevents
spondylitis and colitis in HLA-
B27 transgenic rats
THE HLA-B27 CONNECTION
ANKYLOSING SPONDYLITIS
THERAPEUTIC GOALS
 NORMALIZATION OF INTESTINAL PERMEABILITY
 OPTIMIZATION OF GUT MICROFLORA
 OPTIMIZATION OF TOXIN REMOVAL
 REDUCTION OF LOCAL/MUCOSAL
INFLAMMATION
 REDUCTION OF SYSTEMIC INFLAMMATORY
RESPONSES AND PREVENTION OF ANKYLOSIS
NORMALIZATION OF INTESTINAL
PERMEABILITY
 BUTYRATE
Peng L, Li ZR, Green RS, Holzman IR, Lin J. Butyrate
enhances the intestinal barrier by facilitating tight
junction assembly via activation of AMP-activated
protein kinase in Caco-2 cell monolayers. J Nutr. 2009
Sep;139(9):1619-25.
 L-GLUTAMINE
dos Santos Rd, Viana ML, Generoso SV, Arantes
RE, Davisson Correia MI, Cardoso VN. Glutamine
supplementation decreases intestinal permeability and
preserves gut mucosa integrity in an experimental
mouse model. JPEN J Parenter Enteral Nutr. 2010 Jul-
Aug;34(4):408-13.
 BERBERINE
Gu L, Li N, Gong J, Li Q, Zhu W, Li J. Berberine
ameliorates intestinal epithelial tight-junction damage
and down-regulates myosin light chain kinase pathways
in a mouse model of endotoxinemia. J Infect Dis. 2011
Jun 1;203(11):1602-12
OPTIMIZATION OF GUT
MICROBIOTA
 PROBIOTICS
live microorganisms which
beneficially improve intestinal
microbial balance
 PREBIOTICS
non-digestible polysaccharides that
stimulate the growth and/or activity
of ‘good’ bacteria in the digestive
system
 SYNBIOTICS
nutritional supplements combining
probiotics and prebiotics
 BUTYRATE
 DIGESTIVE ENZYMES
OPTIMIZATION OF GUT
MICROBIOTA
CLINICAL TRIALS UTILIZING PROBIOTICS IN
ANKYLOSING SPONDYLITIS
 limited number of published clinical trials
 insufficient number of participants to make any
meaningful conclusions
 absence of reliable clinical or/and laboratory markers
to measure the trials outcome
 poor clinical design (low dose of probiotics, poor
selection of the probiotic strains)
OPTIMIZATION OF GUT
MICROBIOTA
PROBIOTICS
 THE RIGHT DOSE
 THE RIGHT STRAIN(S)
 THE RIGHT TIME OF
ADMINISTRATION
 SPACING OUT
PROBIOTICS FROM
ANTIBIOTICS AND
DMARDs
OPTIMIZATION OF GUT
MICROBIOTA
PREBIOTICS
 no published clinical trials
 experimental data utilizing beta-glucan and mannan-
oligosaccharides based prebiotics demonstrated
negative effect in animals with experimental colitis
and Crohn’s disease
OPTIMIZATION OF GUT
MICROBIOTA
DIETARY MODIFICATIONS
 Generic dietary approach (Mediterranean diet, anti-
inflammatory diet, vegan diet etc) has low success rate
 Individualized elimination diet
 Based on our experience, we do see the best correlation
with IgG4-based food intolerance testing system
 The IgG4-based food intolerance testing is performed in
IFSMED lab
 The benefits of elimination diet are typically observed in 6-
8 weeks
OPTIMIZATION OF GUT
MICROBIOTA
DIGESTIVE ENZYMES
 enzymes of animal
origin (pancreatic
enzymes/pancreatin)
 plant-based enzymes
 medicinal
mushrooms/medicinal
molds-based enzymes
OPTIMIZATION OF TOXIN REMOVAL
 Calcium glucarate
 Psyllium/apple pectin
 Triphala
 Citrulline malate
 Acetyl-L-carnitine
REDUCTION OF LOCAL/MUCOSAL
INFLAMMATION
TRADITIONAL THERAPY
 Sulfasalazine
 5-ASA
 Corticosteroids
COMPLEMENTARY
THERAPY
 Curcumin
 Boswellia
 Devil’s claw
 Berberine
 N-acetylglucosamine
 Omega-3
polyunsatturated fatty
acids
 Oral bovine
immunoglobulins
REDUCTION OF SYSTEMIC
INFLAMMATORY RESPONSES
TRADITIONAL
THERAPY
 Biologics
 NSAIDs
 Sulfasalazine
 5-ASA
 Corticosteroids
COMPLEMENTARY
THERAPY
 Curcumin
 Boswellia
 Devil’s claw
 Omega-3
polyunsatturated fatty
acids
GUT-FOCUSED THERAPY IN
ANKYLOSING SPONDYLITIS
TRADITIONAL THERAPY + COMPLEMENTARY THERAPY =
INTEGRATIVE APPROACH
SULFASALAZINE + BUTYRATE/GLUTAMINE
+ BERBERINE
TRIPHALA + CALCIUM GLUCARATE + CITRULLINE MALATE
BACILLUS COAGULANS + DIGESTIVE ENZYMES
+ BOVINE IMMUNOGLOBULINS
OMEGA-3 + DEVIL’S CLAW + BOSWELLIA/CURCUMIN

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Ankylosing Spondylitis the gut and the bugs: an integrative approach to treatment

  • 1. Alexander Shikhman MD, PhD Institute for Specialized Medicine July 20, 2013
  • 2. SPONDYLOARTHROPATHIES The spondyloarthropathy family consists of the following entities:  Ankylosing spondylitis  Undifferentiated spondyloarthritis  Reactive arthritis  Psoriatic arthritis  Spondyloarthritis associated with IBD  Juvenile onset spondyloarthritis
  • 3. ANKYLOSING SPONDYLITIS AND GUT  Subclinical gut inflammation has been described in up to two-thirds of patients with spondyloarthropathies  Two histologic types of gut inflammation in patients with SpA can be distinguished: acute and chronic inflammation
  • 4. ANKYLOSING SPONDYLITIS AND GUT The acute type mimics the acute bacterial enterocolitis and is mainly seen in patients with reactive arthritis:  The mucosal architecture is well preserved  There is a polymorphonuclear infiltration of the ileal villi and crypts  There is an increased number of inflammatory cells (granulocytes, lymphocytes and plasma cells) in the lamina propria
  • 5. ANKYLOSING SPONDYLITIS AND GUT The chronic type is often indistinguishable from Crohn’s disease (CD):  The mucosal architecture is clearly disturbed  The villi are irregular, blunted and fused  The crypts are distorted  The lamina propria is edematous and infiltrated by mononuclear cells  In some cases aphthoid ulcers and sarcoid-like granulomas are present Chronic lesions are more present in undifferentiated SpA and AS.
  • 6. ANKYLOSING SPONDYLITIS AND GUT  Increased intestinal permeability or leaky gut syndrome is a key mechanism contributing to the development and chronic course of ankylosing spondylitis and other autoimmune diseases and inflammatory arthritis.  The leaky gut allows substances such as toxins, microbial antigens, undigested food, waste, or larger than normal macromolecules to leak through an abnormally permeable gut wall and trigger cascades of inflammatory reactions. Tight junctions (TJs) represent the major barrier within the pathway between intestinal epithelial cells that line the digestion tract
  • 7. ANKYLOSING SPONDYLITIS AND GUT  Zonulin is a protein regulating intestinal permeability via modulation of tight junction  Small intestines exposed to enteric bacteria secrete zonulin  This secretion occurs only on the luminal aspect of the bacteria-exposed small intestinal mucosa and is followed by an increase in intestinal permeability
  • 8. ANKYLOSING SPONDYLITIS AND GUT Mielants H, Veys EM, De Vos M, Cuvelier C. Increased intestinal permeability in ankylosing spondylitis. Gut. 1992 Aug;33(8):1150. Martínez-González O, Cantero-Hinojosa J, Paule-Sastre P, Gómez- Magán JC, Salvatierra-Ríos D. Intestinal permeability in patients with ankylosing spondylitis and their healthy relatives. Br J Rheumatol. 1994 Jul;33(7):644-7. Liu Y, Xu B, Cai X. The role of intestinal permeability in the pathogenesis of ankylosing spondylitis. Zhonghua Nei Ke Za Zhi. 1995 Feb;34(2):91-4. Vaile JH, Meddings JB, Yacyshyn BR, Russell AS, Maksymowych WP. Bowel permeability and CD45RO expression on circulating CD20+ B cells in patients with ankylosing spondylitis and their relatives. J Rheumatol. 1999 Jan;26(1):128-35.
  • 9. ANKYLOSING SPONDYLITIS AND GUT MICROBIOTA  Gut microbiota consists of a complex of microorganism species that live in the digestive tract  The human body carries about 100 trillion microorganisms in its intestines, a number ten times greater than the total number of human cells in the body  The metabolic activities performed by these bacteria resemble those of an organ, leading some to liken gut bacteria to a "forgotten" organ
  • 10. ANKYLOSING SPONDYLITIS AND GUT MICROBIOTA  Gut microbiota primary benefits the host by generating energy from the fermentation of undigested carbohydrates and the subsequent absorption of short chain fatty acids.  The most important of these are butyrates, metabolized by the colonic epithelium and normalizing intestinal permeability.
  • 12. ANKYLOSING SPONDYLITIS AND GUT MICROBIOTA  HLA B27 influences the composition of the body’s endogenous flora and the ‘B27- shaped flora’ predisposes to ankylosing spondylitis  HLA-B27 transgenic mice do not develop spondylitis-like lesions in germ-free enviroment  Antibiotic therapy prevents spondylitis and colitis in HLA- B27 transgenic rats THE HLA-B27 CONNECTION
  • 13. ANKYLOSING SPONDYLITIS THERAPEUTIC GOALS  NORMALIZATION OF INTESTINAL PERMEABILITY  OPTIMIZATION OF GUT MICROFLORA  OPTIMIZATION OF TOXIN REMOVAL  REDUCTION OF LOCAL/MUCOSAL INFLAMMATION  REDUCTION OF SYSTEMIC INFLAMMATORY RESPONSES AND PREVENTION OF ANKYLOSIS
  • 14. NORMALIZATION OF INTESTINAL PERMEABILITY  BUTYRATE Peng L, Li ZR, Green RS, Holzman IR, Lin J. Butyrate enhances the intestinal barrier by facilitating tight junction assembly via activation of AMP-activated protein kinase in Caco-2 cell monolayers. J Nutr. 2009 Sep;139(9):1619-25.  L-GLUTAMINE dos Santos Rd, Viana ML, Generoso SV, Arantes RE, Davisson Correia MI, Cardoso VN. Glutamine supplementation decreases intestinal permeability and preserves gut mucosa integrity in an experimental mouse model. JPEN J Parenter Enteral Nutr. 2010 Jul- Aug;34(4):408-13.  BERBERINE Gu L, Li N, Gong J, Li Q, Zhu W, Li J. Berberine ameliorates intestinal epithelial tight-junction damage and down-regulates myosin light chain kinase pathways in a mouse model of endotoxinemia. J Infect Dis. 2011 Jun 1;203(11):1602-12
  • 15. OPTIMIZATION OF GUT MICROBIOTA  PROBIOTICS live microorganisms which beneficially improve intestinal microbial balance  PREBIOTICS non-digestible polysaccharides that stimulate the growth and/or activity of ‘good’ bacteria in the digestive system  SYNBIOTICS nutritional supplements combining probiotics and prebiotics  BUTYRATE  DIGESTIVE ENZYMES
  • 16. OPTIMIZATION OF GUT MICROBIOTA CLINICAL TRIALS UTILIZING PROBIOTICS IN ANKYLOSING SPONDYLITIS  limited number of published clinical trials  insufficient number of participants to make any meaningful conclusions  absence of reliable clinical or/and laboratory markers to measure the trials outcome  poor clinical design (low dose of probiotics, poor selection of the probiotic strains)
  • 17. OPTIMIZATION OF GUT MICROBIOTA PROBIOTICS  THE RIGHT DOSE  THE RIGHT STRAIN(S)  THE RIGHT TIME OF ADMINISTRATION  SPACING OUT PROBIOTICS FROM ANTIBIOTICS AND DMARDs
  • 18. OPTIMIZATION OF GUT MICROBIOTA PREBIOTICS  no published clinical trials  experimental data utilizing beta-glucan and mannan- oligosaccharides based prebiotics demonstrated negative effect in animals with experimental colitis and Crohn’s disease
  • 19. OPTIMIZATION OF GUT MICROBIOTA DIETARY MODIFICATIONS  Generic dietary approach (Mediterranean diet, anti- inflammatory diet, vegan diet etc) has low success rate  Individualized elimination diet  Based on our experience, we do see the best correlation with IgG4-based food intolerance testing system  The IgG4-based food intolerance testing is performed in IFSMED lab  The benefits of elimination diet are typically observed in 6- 8 weeks
  • 20. OPTIMIZATION OF GUT MICROBIOTA DIGESTIVE ENZYMES  enzymes of animal origin (pancreatic enzymes/pancreatin)  plant-based enzymes  medicinal mushrooms/medicinal molds-based enzymes
  • 21. OPTIMIZATION OF TOXIN REMOVAL  Calcium glucarate  Psyllium/apple pectin  Triphala  Citrulline malate  Acetyl-L-carnitine
  • 22. REDUCTION OF LOCAL/MUCOSAL INFLAMMATION TRADITIONAL THERAPY  Sulfasalazine  5-ASA  Corticosteroids COMPLEMENTARY THERAPY  Curcumin  Boswellia  Devil’s claw  Berberine  N-acetylglucosamine  Omega-3 polyunsatturated fatty acids  Oral bovine immunoglobulins
  • 23. REDUCTION OF SYSTEMIC INFLAMMATORY RESPONSES TRADITIONAL THERAPY  Biologics  NSAIDs  Sulfasalazine  5-ASA  Corticosteroids COMPLEMENTARY THERAPY  Curcumin  Boswellia  Devil’s claw  Omega-3 polyunsatturated fatty acids
  • 24. GUT-FOCUSED THERAPY IN ANKYLOSING SPONDYLITIS TRADITIONAL THERAPY + COMPLEMENTARY THERAPY = INTEGRATIVE APPROACH SULFASALAZINE + BUTYRATE/GLUTAMINE + BERBERINE TRIPHALA + CALCIUM GLUCARATE + CITRULLINE MALATE BACILLUS COAGULANS + DIGESTIVE ENZYMES + BOVINE IMMUNOGLOBULINS OMEGA-3 + DEVIL’S CLAW + BOSWELLIA/CURCUMIN