Low Sulfur Fecal Transplant for Ulcerative Colitis

The purpose of this study is to evaluate the engraftment of donor microbiota's sulfate reducing bacteria (SRB) in subjects with active ulcerative colitis (UC) following sequential fecal microbiota transplant (FMT). Specifically this study will evaluate if low SRB donor microbiota translates to lower SRB microbiota in the UC recipient. It is widely unknown if the microbiota in UC is dysfunctional and therefore perpetuates inflammation, or if the ongoing inflammation shapes the microbiota. Patients with UC have a higher relative abundance of SRB compared to healthy controls. It is the aim of this study to determine if the microbiota in UC can be altered to favor a low SRB fraction.

Inflammatory bowel disease (IBD) is a chronic, relapsing remitting inflammatory disease of the intestine. The two main forms of IBD are Crohn's disease (CD) and Ulcerative Colitis (UC). There is no cure for IBD and the etiology is unknown, however IBD is thought to arise as an aberrant immune response to the intestinal microbiota. The intestinal microbiota closely correlates with inflammation in IBD. Currently, the treatment of IBD is based on suppressing the aberrant immune response in the intestine. This often takes the form of systemic immunosuppression, which in turn carries a multitude of risks including infection and malignancy. Thus there is an urgent need for safe, effective therapies that ultimately have the potential to cure IBD. Fecal microbiota transplantation (FMT) is the process of transferring fecal microbiota from one individual to another. FMT has revolutionized the treatment of multiple recurrent Clostridium difficile infection with a cure rate around 90%. Given the success of FMT in C. difficile colitis, attention turned to other forms of colitis, in particular IBD. Early pilot studies demonstrated a mixed result for the use of FMT in IBD. One of the key issues surrounding the use of FMT in IBD is the challenge of engrafting a new microbiota. Additionally IBD flares following FMT for C. difficile infection have been reported, although it is difficult to account for the confounding of the underlying C. difficile infection. This study will examine how FMT donor selection can impact the engraftment of the microbiota into patients with UC.

The placebo consists of a mixture of trehalose and crystalline methylcellulose (Avicel) in 6:1 (w/w) ratio that is packaged in size 0 swedish orange capsules, which are then double encapsulated in size 00 natural colored capsules to make them visibly indistinguishable from encapsulated active product. Two capsules taken daily for 8 weeks.

Change in quantitative PCR of sulfate reducing genes from baseline to week 12 between FMT arm and placebo arm.

Change in quantitative PCR of sulfate reducing genes at week 1, 2, 3 and 4 between FMT arm and placebo arm

Partial mayo score at week 12 between those with low sulfate reducing microbiota or not low sulfate reducing microbiota

Inclusion Criteria: Able and willing to provide consent English speaking Diagnosis of ulcerative colitis based on typical clinical-histopathic diagnosis Diagnosis of ulcerative colitis > 3 months Active disease on endoscopy (endoscopic Mayo subscore ≥ 1) Evidence of inflammation extending beyond a minimum of 20cm Any ongoing ulcerative colitis therapy must be at stable doses for 4 weeks prior to study and remain stable over the course of the study Exclusion Criteria: Extensive bowel resection Presence of ileostomy or colostomy Suspicion of ischemic colitis, radiation colitis or microscopic colitis Diagnosis of Crohn's disease Diagnosis of per-anal fistula or abscess Adenomatous polyps that have not been removed Use of pre or probiotics within 30 days of randomization Pregnancy Severe food allergies End stage liver disease or cirrhosis An absolute neutrophil count < 500 cell/µL Life expectancy < 6 months