La immunoterapia "aspecifica" e la flora intestinale a cura del Dott. Claudio Romano

1. La immunoterapia
“aspecifica”
e la flora intestinale
Claudio Romano, MD
Consultant Pediatric
Gastroenterology,
Pediatric HUB IBD Unit
University of Messina, Italy

2. ASSENZA DI CONFLITTO DI INTERESSI

3. LA VERA PUBBLICITA’
……..?

4. Innate immunity
Adaptive immunity
Macrophages
Innate immunity
Platelets
Foods
Dendritic
cells
Flora
Regulatory
Effector T cells
T cells
Plasma
cells
PMNs
B cells
Endothelial
cells
Mesenchymal
cells
NK cells
Pathogens
Epithelial
cells
Extracellular
matrix

5. RICERCA CLINICA
1. RELAZIONE MICROBI ED ORGANISMO (FUNZIONE
GENOMICA E METABOLICA) ?
2. MICROBIOTA E MATURAZIONE DEL SISTEMA
IMMUNE INTESTINALE ?
3. MICROBIOTA ED AMBIENTE ?
4. DIETA E MODIFICA DI COMPOSIZIONE DEL
MICROBIOTA ?
RICERCA TRASLAZIONALE
RICERCA TRASLAZIONALE

6. TIPIZZAZIONE MICROBIOTA
Clonaggio e seq SSU rRNA
Studi filogenetici
FISH, real-time qPCR
Quantificazione di
specifici gruppi
DGGE e
TGGE
Profilo della comunità
microbica
(fingerprint approach)
DNA microarrays
Pyrosequencing
High-throughput method

7. HUMAN GUT MICROBIOTA
> 90% 2 ceppi dominanti
( Bacteroidetes,
Firmicutes)
< 10% 5 sub-dominanti ceppi
( Actinobacteria,
Proteobacteria,
Fusobacteria,
Cyanobacteria and
Verrucomicrobia )
1000-1200 “filotipi”
Verdu EF, Gut 2006
Gwee KA, Gut 2003
50-80% Firmicutes dominanti
Clostridium cluster IV e
XIVa

8. (Buccigrossi et al., 2010)

9. G.Reid: CID, 2004

13. DISBIOSI INTESTINALE
(Buccigrossi et al., 2013)

15. •
Patients were randomized to receive LCT
Reuteri, DSM 17938, 10 8 CFU/day, (n° 30
pts) or matching placebo (n° 26 pts), orally, for
4 weeks (LCT reuteri and placebo were
manufactured from NOOCS, Italy)
•
Randomization was carried out with computer
generated lists.
•
Documentation in follow-up was carried out with
a diary to record symptoms and frequency of
pain, drug use and any symptom which is
considered important
•
The Faces Pain Scale, which is a scale for
measurement of pain intensity by self-reported,
was used to assess the severity of the pain

16. -
Perdita della “biodiversita’”
(ambiente, clima, specie)
-
Metagenomica: modifica
composizione microbiota (pelle
ed intestino)
-
Deprivazione microbica e
disfunzione immunitaria (T-cell)
-
Incremento di patologie
infiammatorie (allergie, asma, IBD,
obesità)
-
Tolleranza orale

19. Th1
imbalance
DISBIOSI
Overexpression of
pro-inflammatory
cytokines
IL-2
Il-12
Interferon IFN-α
Fattore di necrosi
tumorale TNF-ß
IBD
Sharara AI, AJG, 2006
Th2
imbalance
Overexpression
of anti-inflammatory
cytokines
IL-3
Il-4
IL-5
IL-6
Il-9
IL-10
IL-13
Atopic disease
and allergies

21. Probiotic Administration in Early Life, Atopy, and Asthma: A Meta-analysis of
Clinical Trials
Nancy Elazab, Angelico Mendy, Janvier Gasana, Edgar R. Vieira, Annabelle Quizon
and Erick Forno
Pediatrics ; originally published online August 19, 2013;
DOI: 10.1542/peds.2013-0246
Probiotic Administration in Early Life, Atopy, and Asthma: A Meta-analysis of
Clinical Trials
Nancy Elazab, Angelico Mendy, along with updated information and services,Quizon
Janvier Gasana, Edgar R. Vieira, Annabelle is
The online version of this article,
and Erick Forno
located on the World Wide Web at:
Pediatrics ; originally published online August 19, 2013;
http://pediatrics.aappublications.org/content/early/2013/08/13/peds.2013-0246
DOI: 10.1542/peds.2013-0246
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2013/08/13/peds.2013-0246
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
IgE

22. Probiotic Administration in Early Life, Atopy, and Asthma: A Meta-analysis of
Clinical Trials
Nancy Elazab, Angelico Mendy, Janvier Gasana, Edgar R. Vieira, Annabelle Quizon
and Erick Forno
Pediatrics ; originally published online August 19, 2013;
DOI: 10.1542/peds.2013-0246
Probiotic Administration in Early Life, Atopy, and Asthma: A Meta-analysis of
Clinical Trials
Nancy Elazab, Angelico Mendy, along with updated information and services,Quizon
Janvier Gasana, Edgar R. Vieira, Annabelle is
The online version of this article,
and Erick Forno
located on the World Wide Web at:
Pediatrics ; originally published online August 19, 2013;
http://pediatrics.aappublications.org/content/early/2013/08/13/peds.2013-0246
DOI: 10.1542/peds.2013-0246
-
< IgE totali
-
No differenze per
asma e wheezing
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
-
Effetto long-term
http://pediatrics.aappublications.org/content/early/2013/08/13/peds.2013-0246
-
Somministrazione
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication,
PEDIATRICS is owned,
in epoca pre-nataleit has been published continuously since 1948.Pediatrics, 141 Northwest Point
published, and trademarked by the American Academy of
60007. Copyright
by the American
e post-natale Boulevard, Elk Grove Village, Illinois, ISSN: 0031-4005. © 2013ISSN: 1098-4275.Academy
of Pediatrics. All rights reserved. Print
Online
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point

23. -
40.614 bambini
consumo alimenti funzionali
RRs (relativo rischio) di asma, eczema e rinocongiuntivite
-
< RRs a 6 mesi per eczema atopico
< RRs a 18 mesi per rinocongiuntivite

24. PROBIOTICI E PREVENZIONE ALLERGIA
Investigators
Population
characteristics
Organisms and dosage
Prenatal
administr.
Postnatal
administr.
Eczema reduction
Kalliomaki, Isolauri
et al. (2001, 2002,
2003)
Any first degree
relative with allergic
disease (N=132)
LGG (1x1010 CFU daily)
only to mother if
breast feeding post
natally
Yes
Yes
Yes
2-4 wks before
delivery
6 m only directly to
baby if not
breastfeeding
at 2, 4 and 6 yrs
Rautava, Isolauri et
al. (2006)
Any need for artificial
feeding before 2
months of age (N=72)
LGG (1x1010 CFU daily
Bifidobacterium lactis
(1x1010 CFU daily)
Added to infant
formula
No
Yes
No
Taylor, Prescott et
al. (2007)
Mother with SPT+
allergic disease
(N= 189)
Lactobacillus
acidophillus (3x108 CFU
daily)
No
Kukkonen, Kuitunen
et al. (2007)
One or both parents
with allergic disease
(N= 925)
LGG & LC705
(both 5x109 CFU twice
daily); and
Bifidobacterium breve
and
Proprionibacterium
freudenreichii (both
2x109 CFU twice daily)
Before 2 m
(depending on age
started formula)
until 12 months
Yes
No
6 months
direct to infant
At 1 year
Yes
Yes
Yes
2–4 wks
before
delivery
6 months
direct to infant
At 2 years
Berni Canani R and Di Costanzo M Nutrients 2013

25. PROBIOTICI E PREVENZIONE ALLERGIA
Investigators
Population
characteristics
Organisms and dosage
Abrahamsson,
Oldaeus et al.
(2007)
Any first degree
relative
with allergic disease
(N= 188)
Lactobacillus reuteri
(1x108 CFU daily)
Kopp, Urbanek et
al. (2007)
Any first degree
relative
with allergic disease
(N= 94)
LGG, 1x1010 CFU daily
to mother if breast
feeding post-natally for
3 m and than to
neonates for 3 m
Wickens, Crane et
al. (2008)
One or both parents
with allergic disease
(N= 474)
L. rhamnosus
HN001 (1x1010 CFU
daily) OR
Bifidobacterium lactis
(1x1010 CFU daily)
HN019
Soh, Skek, Aw et al.
(2008)
Any first degree
relative with SPT+
allergic disease
(N= 245)
L. rhamnosus
(1x109 CFU daily) and
Bifidobacterium longum
(6x108 CFU daily)
Prenatal
administ.
Postnatal
administ.
Eczema
reduction
Yes
Yes
No
2–4 wks before
delivery
12 m
direct to infant
At 2 years
Yes
Yes
No
4–6 wks
before
delivery
6 months
direct to infant
At 2 years
Yes
Yes
Yes
2–5 wks
Before
delivery
2 yrs to infant
regardless
of feeding method
At 2 years
No
Yes
No
6 months
in infant formula
At 1 year
Berni Canani R and Di Costanzo M Nutrients 2013

26. PROBIOTICI E PREVENZIONE ALLERGIA
Investigator
Population
characteristics
Organisms and dosage
Prenatal
administ.
Postnatal
administ.
Eczema
reduction
Yes
Yes
No
From first
trimester
By the end of
exclusive
breastfeeding
Yes
Yes
6 wks
Before
delivery
12 m (direct to
infant)
Yes
Huurre, Laitinen,
et al. (2008)
Mother with current
atopic disease
(N= 140)
LGG and Bifidobacterium
lactis (1x1010 CFU daily)
Niers, Rijkers,
et al. (2009)
Atopic disease in
either mother or
father plus at least
one sibling
(N= 98)
Lactococcus lactis W58
Bifidobacterium lactis
W52 Bifidobacterium
bifidum W23 (1x109 CFU
each daily)
West, Hernell,
et al. (2009)
Atopic disease in
either mother, or
sibling (N=171)
L. paracasei
strain F19 (1x108 CFU daily
in weaning cereal)
No
Rautava,
Kainonen, et al.
(2013)
Mothers with allergic
disease
and atopic
sensitization (N=241)
Lactobacillus rhamnosus
LPR and Bifidobacterium
longum BL999; or
L paracasei ST11 and B
longum(1x109CFU each
daily)
Yes
Yes
Yes
2m
before delivery
first 2 months of
breast-feeding
At 24 mm
Yes
Yes
4–13 months
(during weaning)
Berni Canani R and Di Costanzo M Nutrients 2013

27. EFFETTI LUME INTESTINALE
EFFETTI LUME INTESTINALE
• •Modulazione microbiota
Modulazione microbiota
• •Idrolisi peptidi antigenicii
Idrolisi peptidi antigenicii
LGG
Gut lumen
EFFETTI A LIVELLO
MUCOSALE:
• Modulazione della
permeabilità intestinale
Intestinal epithelial cells
•Stimolazione della crescuta e
differenziazione cellulare
EFFETTI AL DI FUORI DELLA MUCOSA
INTESTINALE:
• Impatto sul SNE
• Modulazione della risposta immune innata ed
adattiva
• Induzione della tolleranza orale
Berni Canani R. Functional Food Review 2012

28. LGG regola anche i meccanismi del CMA
Maassen CBM et al. Vaccine 2000
Ghadimi D et al. Immunobiology 2008
Oksaharju A et al. WJG 2011
Berni Canani R, et al. Pharmaceuticals 2012

29. -
Composizione del microbiota fecale in
bambini con allergia e senza allergia
-
Sequenziamento 16S rRNA
-
1 mese : analisi comparativa > generi
Bacteroides, Clostridium, ed alcuni
generi di Proteobacteria con riduzione
Bifidobacteria
-
2 mesi: no differenze
-
Età di transizione = rischio di atopia

30. Microbiota ed Atopia….………
• prevenzione eczema
atopico nei primi 2 anni di
vita ma non evidenze sulla
prevenzione del rischio
atopico nelle epoche
successive
• approccio combinato pre-e
post-natale sembra piu’
efficace per ridurre rischio
atopico
• effetto ceppo specifico con
evidenze su L.
rhamnosus GG
Pfefferle, Prescott, Kopp. J Allergy Clin Immunol, 2013
Elazab, et al. Pediatrics, 2013

31. 1. Questi
risultati
sono
riproducibili in ogni setting
?
2. Gli outcome di questi studi
sono rilevanti ?