This is a prospective, phase III, randomized, double-blind, placebo-controlled, multicenter, national study to evaluate the use of FMT in preventing relapses of pouchitis in patients with UC who have undergone iIleo-Anal Anastomosis (IPAA).
Approximately 50 patients with active recurrent pouchitis after IPAA for UC will be enrolled at 12 expert French centers, with an average of four patients per center. Forty-two of these subjects who have responded after four weeks of antibiotherapy will be randomized to receive FMT or sham transplantation at a ratio of 1:1.
As mentioned above, no data has been published on the maintenance in remission after FMT in recurrent pouchitis.
There are approximately 80,000 patients with UC in France (EPIMAD register ), and as many as 10% to 20% will undergo proctocolectomy with IPAA as a result of refractory disease, dysplasia, or malignancies. Approximately 50% of people who have had an IPAA will develop pouchitis in the following years. Most of these patients are monitored in general or university hospitals.
We anticipate that 80% of the patients with chronic recurrent pouchitis will respond to antibiotherapy, with 5% of loss of view. We estimate that each center will include one patient per year (= 0.08 patient/month).
When including, during the screening visit, the study will be fully explained to the patient and informed consent will be obtained if the patient satisfies all inclusion and non-inclusion criteria (see Box 1).
It should be noted that the following drugs, which may interfere with the FMT, are prohibited:
- Antibiotics after transplantation
- Probiotics in the three months before transplantation and for the duration of the study
- Immunosuppressive therapy including chemotherapy in the three months before transplantation visit
- Biologic drugs are prohibited within the three months before transplantation visit
- Corticosteroids in the six weeks before transplantation visit.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) for the duration of the study.
The University Hospital of Nantes will collaborate with public or private organizations to recruit voluntary donors through public announcements or notices after asking previous donors as part of the care for the treatment of Clostridium difficile colitis.
We expect about 100 potential donors to give consent, in order to include 12 donors responding to the selection criteria of the ANSM (French regulatory authority) and considering those lost to follow-up. It should be noted that donors will receive a compensation fee.
When including them in the trial, during the screening visit, the study will be fully explained to the donor and informed consent will be obtained.
The donors must first meet the criteria of the preselection questionnaire to exclude any contraindications. This preselection questionnaire focuses on digestive disorders, drug treatment, and travel. The donor must then undergo a physical examination by a physician, including examination of the anal margin to search for lesions attributable to human papillomavirus (HPV) or herpes simplex virus (HSV). Blood and fecal testing will then be performed, as these tests are required by the ANSM’s dossier on FMT and its supervision in clinical trials  (see Box 2). It should be noted that for cytomegalovirus (CMV), Epstein–Barr virus (EBV), and Toxoplasma gondii, a seroconcordance with the receiver will be performed.
The main inclusion criteria for the donors are: adults of both sex (aged 18–65) with a body mass index of between 17 and 30 kg/m² and a usually regular transit of between 1 and 3 stools per day with corresponding to types 2–4 on the Bristol scale .
The non-inclusion criteria for the donors are divided into three classes relating to the patient’s status, previous or concomitant treatment, and infectious risk, and these are provided in Boxes 2 and 3.
As with patients, certain treatments are prohibited to donors before fecal donation:
- Antibiotic or antifungal in the three months preceding the donation
- Non-steroidal anti-inflammatory intake in the month preceding the donation
- Immunosuppressive drugs (e.g. calcineurin inhibitors, corticosteroids, biological agents, etc.) for antineoplastic chemotherapy in the three months preceding the donation
- Medication whatsoever in the 48 hours preceding the donation (except contraceptive treatment).
Forty-two of the subjects who respond after four weeks of antibiotherapy will be randomized at a ratio of 1:1 to receive either FMT or sham transplantation.
The randomization will be carried out via the Ennov Clinical website: https://nantes-lrsy.hugo-online.fr/CSOnline/ by study nurse. This randomization process is not stratified by any factors such as age, gender, or center.
However, in addition to the randomization described above, a seroconcordance of CMV, EBV, and toxoplasma gondii status between donor and receiver will be required.
Fecal microbiota or sham transplantation
All healthy donors will be recruited by the University Hospital of Nantes. Donors will be screened in accordance with ANSM recommendations, as described above . The donors’ feces will be collected in a special collection system and always transported on ice. The trial schedule of the donor is showed in SPIRIT Figure 1. Processing will be carried out under aerobic conditions. The stools will be weighed to determinate the optimal quantity for the screening tests, safety samples, and transplant preparation. If the stool weight is insufficient (less than 70 g), the stool donation will be used for the screening tests and safety samples and the donor will be asked to come back within 15 days for a second stool donation.
The preparation will be carried out under the hood: donors’ stools will be mixed in sterile saline without preservatives using a commercial blender to obtain a final concentration of 0.5 g feces/mL. We have therefore opted for a single-use system (containing the saddle and mixing shaft), thus eliminating any risk of cross-contamination.
Materials will be filtered with sterile gauze to obtain a solution without particulate material. The suspension in the container will be prepared using pharmaceutical-grade glycerol as a bacterial cryoprotectant at a final concentration of 10%. The solution will then be placed in 30 mL syringes directly adaptable on the channel of the colonoscope and stored frozen at −80 °C for a maximum of 365 days [43–47]. All the syringes will be identical and opaque to ensure blinded conditions. The placebo will be sterile saline with pharmaceutical glycerol at a final concentration of 10% in sterile syringes directly adaptable on the channel of the colonoscope.
The investigational medicinal product (the Pharmacy will be the only one aware if it is fecal microbiota suspension or placebo) should be administered under the close supervision of an experienced physician and in an environment where full resuscitation facilities are immediately available.
The day of the transplantation, three 30 mL syringes (two syringes plus a back-up syringe, all either donor or placebo) will be left at room temperature for two hours to defrost. The contents of the two syringes will be injected 10 cm above the pouch. Finally, a 30 mL syringe of sterile saline will be administered in the pouch to push the fecal solution and avoid waste of FMT.
It should be noted that the randomized subjects will continue antibiotherapy until 48 hours prior to transplantation and will undergo a bowel cleansing (two liters of polyethylene glycol) the night before the FMT and will fast from midnight.
After transplantation, the patient will stay in the left decubitus position for two hours and then the dorsal decubitus position for two hours. Four hours after the transplantation, the patient will have a collation, and clinical surveillance will continue for six hours after transplantation to allow vital signs to be monitored (temperature, pulse, blood pressure) every two hours.
After which, patients will return for visits 2, 6, 12, 18, and 24 months after transplantation, as shown in Figure 2.
During each visit, physical examination results, adverse events and concomitant treatments will be recorded, and Pouchitis Disease Activity Index (PDAI)  and Inflammatory Bowel Disease (IBD) Disability Index  questionnaires will be filled in. The patient flowchart can be seen in SPIRIT Figure 3.
Since these visits are not part of routine care, patients will be financially compensated for each visit.
Furthermore a donor feces biocollection (fecalotheque donor) and a patient biospies (tissutheque), serum (biotheque) and feces biocollection (fecalotheque receiver) centralised at Nantes University Hospital to evaluate the correlation between donor and patient microbiota before and after FMT and, the delay of the possible patient’s microbiota resilience after FMT will be constituted.
OBJECTIVES AND STATISTICS
The main objective of this study is to compare the relapse delay after FMT versus sham transplantation for recurrent pouchitis in IPAA for ulcerative colitis.
The secondary objectives are:
- Efficacy of FMT on the relapse rate at week 24
- Efficacy of FMT on the relapse rate at week 52
- Instauration of alternative treatment within week 52
- Safety of FMT in cases of pouchitis
- Modifications of the fecal microbiota of a patient with ileal pouch for ulcerative colitis complicated of recurrent pouchitis, in remission after antibiotherapy after FMT from a healthy donor at week 8
- Evolution of healthrelated to disability
The primary endpoint is the delay between the date of transplantation and the date of the Clinical and endoscopic relapse defined by a Pouchitis Disease Activity Index superior or equal to 7 points.
The Pouchitis Disease Activity Index (PDAI) is a 19 point index of pouchitis activity based on both clinical symptoms and endoscopic and histologic findings . Active pouchitis is defined as a PDAI superior or equal 7 and remission is defined as a PDAI below 7. Clinical response to treatment can also be quantified by reduction in the PDAI (e.g. a reduction in the PDAI score ≥ 3 from baseline).
The secondary endpoints are:
- Relapse at week 24 defined as a Pouchitis Disease Activity Index (PDAI) superior or equal to 7 at week 24
- Relapse at week 52 defined as a Pouchitis Disease Activity Index (PDAI) superior or equal to 7 at week 52
- Delay within the transplantation and the instauration of an antibiotherapy or alternative treatment (immunosuppressive and/or biotherapy and/or corticotherapy)
- Registered of adverse events defined by Common Terminology Criteria for Adverse Events (4.3) during 104 weeks post-transplantation according to ANSM recommendation.
- Fecal microbiota engraftment at 8 weeks defined by :
Sorensen’s index [receiver 8 weeks after FMT vs donor] > Sorensen’s index [receiver 8 weeks after FMT vs receiver before FMT]) with Sorensen’s index [receiver 8 weeks after FMT vs donor] = 0.6. To assess this endpoint, fecal microbiota composition will be analyzed for donor sample, receiver sample before FMT and 8 weeks after FMT, using 16S sequencing (Illumina Miseq technology)
- IBD Disability Index at weeks -5, baseline, 8, 24, 52 and unscheduled visit
Sample size evaluation
This superiority study is designed to have 80% statistical power to detect a significant treatment effect on the first onset of pouchitis. We estimate a survival rate of 25% in the control group versus 60% in the treatment group at six months (Hazard ratio = 0.3685).
These figures are based on the work on probiotics of Gionchetti and Mimura [18,19].
A total of 32 events are needed to ensure 80% statistical power. For a 48-month enrollment period and 24-month follow-up period, 40 patients are needed to observe 32 events. To ensure this statistical power, a total of 42 patients will be randomized.
This sample size calculation takes into account the interim analysis planned at the first 16 observed events.
Subject disposition, demographics, and baseline characteristics will be summarized. Summary statistics for continuous variables will include the number of subjects (n), mean, median, standard deviation or standard error, minimum, and maximum. For categorical variables, the frequency and percentage will be given.
To note, if a subject is alive or lost to follow up without experiencing documented relapse at the time of the analysis, the subject will be censored at the date of last visit.
The primary endpoint is the relapse delay. This is defined in weeks as the time from transplantation to the date of the clinical and endoscopic relapse. Relapse delay will be estimated using the Kaplan–Meier method. The comparison between treatment groups will be made using the log-rank test.
Relapse rates at 24 weeks and 52 weeks will be reported for each treatment group. Delay within the transplantation and the instauration of an antibiotherapy or alternative treatment will be estimated using the Kaplan–Meier method. The comparison between treatment groups will be made using the log-rank test.
Total score on the IBD Disability Index will be estimated using a linear mixed model taking into account score at baseline (week 0), treatment, time (weeks 8 and 24), and treatment by time interaction.
A list of adverse events (AEs) (whether severe or not) will be provided. Descriptive statistics, including the frequency of subjects presenting at least one AE and the number of events, will be generated by severity and relationship to treatment. A review of the adverse events occurring during the study period will be carried out.
ADVERSE EVENT MANAGEMENT
Concerning the study treatment, the systematic review by Wang et al. (“Adverse Events of Fecal Microbiota Transplantation”)  will be used as the reference safety information. According to this review, the expected reactions for the lower gastrointestinal route are:
⇒ Gastrointestinal disorders: abdominal pain, abdominal fullness, constipation, bloating, abdominal cramp, diarrhea, nausea, transient relapse of pouchitis, irregularity of bowel movements, increase in stool frequency
⇒ Infections and infestations: bacteremia, multiorganism bacteremia, urinary tract infection, norovirus gastroenteritis
⇒ General disorders and administration site conditions: fever, chills
⇒ Investigations: temporary increase in C-reactive protein (CRP)
Most reactions reported are mild to moderate and concern abdominal pain, abdominal cramping, flatulence, increased stool frequency, constipation, fever, and a temporary increase in CRP.
An increasing intensity or frequency of these expected reactions will be viewed as unexpected. As recommended by ANSM, all medically significant infections will be treated as SUSARs (Suspected Unexpected Serious Adverse Reactions).
It has been suggested that some reactions, such as pouchitis flare, appendicitis, peripheral neuropathy, Sjogren’s disease, idiopathic thrombocytopenic purpura, and rheumatoid arthritis, might be related to FMT. In this trial, however, these events will not be viewed as expected reactions to FMT.
Any Adverse Reaction/Adverse Event, whether expected or unexpected, or serious or not, will be recorded in real time in the study eCRF.
All SAEs/SARs must be reported to the trial’s sponsor if they occur to a research participant:
- From the transplantation.
- As recommended by ANSM (the French regulatory authority), adverse events (serious and not serious) must be recorded for 104 weeks after FMT, even if the patient leaves the study (early discontinuation).
- after the end of the patient follow-up period, and without any time limit if the investigator becomes aware of a SAR possibly linked to the experimental treatment.
In case of SAE, a code-break procedure of the pharmacovigilance unit will show immediately the status of the patient.
ETHICAL, REGULATORY AND DISSEMINATION ASPECTS
The clinical study will be conducted in accordance with the relevant versions of the French Public Health Code, national and international good clinical practice (GCP) guidelines, and the Declaration of Helsinki, each in the applicable version.
The protocol was written according to 33-item SPIRIT checklist  (see Additional file 1).
It has been possible to carry out the protocol and the trial thanks to an Executive Committee which includes a Scientific Committee and a Steering Committee, created and coordinated by Dr Trang-Poisson. The Steering Committee follows the development of the trial. It is composed of the members of the Scientific Committee with the addition of the data management team, the study coordinator from the Gastroenterelogy department of CHU Nantes who coordinates assistance for patient inclusion in the other centres, and the monitoring Clinical Research Assistant (CRA).
In compliance with French law, the study protocol was submitted to the French regulatory authority (ANSM) and approved on June 8, 2018. It should be noted that in France, the pharmaceutical preparation status requires the preparation of feces for FMT to be carried out under the responsibility of the institution pharmacist. To do this, an application for authorization from a regional regulatory authority must be made. In our case, this authorization was given on May 25, 2018 by the Regional Health Agency of Pays de la Loire.
This clinical study and the donor’s and the patient’s written informed consent was submitted to and approved by the Ethical Review Board of Tours (Comité de Protection des Personnes de Tours, Région centre, Ouest-1) on June 26, 2018. Amendments, if necessary, will be sent to the ethical committee and regulatory authorities for approval. The updated protocol was at version 1.2 on June 8, 2018.
As required, the sponsor has provided an insurance policy to cover the financial consequences of its civil liability in accordance with the regulations.
All the submissions/declarations were made by the Sponsor Department of the University Hospital of Nantes.
The trial results will be published in international gastroenterological, medical and scientific journals and presented in national and international congresses. The investigators, who will share all the final trial dataset, will follow the rules and guidelines of the International Committee for Medical Journal Editors (ICMJE) . The trial’s sponsor and the French Ministry of Health, which provided the grant, have to be cited in the publication.