budesonide/salmeterol xinafoate) NL/H/3241/001-002/DC Date ...
55 Two New Budesonide Formulations Are Highly Efficient for Treatment of Active Eosinophilic...
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AGA Abstracts 54 Kruppel-Like Factor 5 Plays a Critical Role in β-Catenin Activation by LPA in Colon Cancer Cells Leilei Guo, Peijian He, Yi Ran No, Chris Yun Background: Lysophosphatidic acid (LPA) is a small glycerophospholipid that elicits diverse biological effects via cognate LPA receptors. Previous studies have shown that LPA acting via LPA2 receptor (LPA2R) stimulates proliferation of colon cancer cells by activation of β- catenin. In addition, a previous study by us showed that transcription factor Kruppel-like factor 5 (KLF5) plays a critical role in the LPA-mediated effects in colon cancer cells. It was reported that KLF5 physically interacts with β-catenin and enhances translocation of β- catenin into the nucleus. Aim: The current study was undertaken to elucidate the mechanism of β-catenin activation by LPA and to determine whether KLF5 plays a role in β-catenin activation. Methods: HCT116 cells were treated with 1 μM LPA or BSA as a control. Phosphorylation of glycogen synthase kinase 3β (GSK-3β) and expression levels of KLF5 and β-catenin were determined by Western blot. Role of KLF5 or LPA2R was assessed by knockdown of KLF5 or LPA2R. Nuclear translocation of β-catenin and KLF5 were determined by immunofluorescence microscopy and Western blot of nuclear fraction. The interaction of β-catenin with KLF5 and TCF4 was determined by co-immunoprecipitation. Results: We found that LPA and Wnt3 additively activated the TCF/LEF reporter activity in HCT116 cells. LPA acutely phosphorylated GSK-3β at Ser-9 and β-catenin at Ser-552 and Ser-675, which are known to facilitate β-catenin activation. LPA enhanced the interaction between β-catenin and KLF5 and increased nuclear expression of β-catenin in HCT116 cells. However, knockdown of KLF5 significantly attenuated LPA-induced, but not Wnt3-induced, activation of TCF/LEF reporter. Surprisingly, nuclear expression of β-catenin by LPA was not altered by knockdown of KLF5. We observed that LPA enhanced β-catenin interaction with KLF5 and TCF4 in HCT116 cells. Knockdown of KLF5 attenuated LPA-induced β-catenin-TCF4 association. The effects of LPA on β-catenin-KLF5 and β-catenin-TCF4 association were reproduced in LoVo and SW480 cells. Conclusion: In colon cancer cells, LPA activates β- catenin by modulating phosphorylation of GSK3β and β-catenin. LPA facilitates β-catenin interaction with TCF transcription factors. KLF5 plays an important role in LPA-induced β-catenin activation probably by enhancing the β-catenin-TCF4 interaction. 55 Two New Budesonide Formulations Are Highly Efficient for Treatment of Active Eosinophilic Esophagitis: Results From a Randomized, Double-Blind, Double-Dummy, Placebo-Controlled Multicenter Trial Stephan Miehlke, Petr Hruz, Ulrike von Arnim, Ahmed Madisch, Michael Vieth, Christian Bussmann, Monther Bajbouj, Christoph Schlag, Christiane Fibbe, Henning Wittenburg, Hans-Dieter Allescher, Max Reinshagen, Stefan Schubert, Jan F. Tack, Ralph Mueller, Karin Dilger, Roland Greinwald, Alex Straumann INTRODUCTION: Eosinophilic Esophagitis (EoE) is a rapidly emerging, chronic-inflamma- tory disease of the esophagus. So far no approved therapy is available, but swallowed topical corticosteroids have proven efficacy in the treatment of EoE. However, esophageal-adjusted formulation and optimal dosing are not yet determined. AIMS: To investigate the efficacy and safety of two different budesonide formulations (effervescent tablet [BET] and viscous suspension [BVS]) and two different doses for short-term treatment of EoE. METHODS: Adults with active EoE (n=76) randomly received 14-days treatment with either BET 2x1mg/ d (BET1, n=19) or BET 2x2mg/d (BET2, n=19), or BVS 2x2mg/d (BVS, n=19) or placebo (n=19) in a double-blind, double-dummy fashion, with a 2-week follow-up. Primary endpoint was histological remission (mean of <16 eos/mm2 hpf). Secondary endpoints included endoscopy score, dysphagia score, quality of life (modified SHS), and preference of drug formulation. RESULTS: Histological remission occurred in 100%, 93.8%, and 93.3% of budesonide (BET1, BET2, BVS, respectively) and in 0% of placebo recipients (p<0.0001). The improvement in total endoscopic intensity score was significantly higher in the 3 budesonide groups compared with placebo. Dysphagia improved in all groups at the end of treatment; however, the improvement persisted during the 2-weeks follow-up only in those treated with BET1 and BET2, with BET1 showing a significant difference to placebo (p=0.0196). There was suspected local fungal infection in 3 patients in each of the three budesonide groups, however, hypha were only found in 2 patients in each of the budesonide groups (post-hoc histopathology). Neither serious adverse events nor clinically relevant changes in plasma cortisol were observed. 80% of patients preferred the effervescent tablet. CONCLUSION: Budesonide administered as effervescent tablet or as viscous suspension was highly effective and safe for short-term treatment of EoE. The 1mg BID dose was equally effective as the 2mg BID dose. The majority of patients preferred the effervescent tablet formulation. *The first two authors contributed equally to the first authorship. 56 Cytosponge Evaluation of Eosinophilic Esophagitis in Comparison to Endoscopy: Accuracy, Safety and Tolerability David A. Katzka, Anupama Ravi, Debra M. Geno, Thomas C. Smyrk, Hirohito Kita, Pierre Lao-Sirieix, Irene Debiram -Beecham, Gail M. Kephart, Lori A. Kryzer, Jeffrey A. Alexander, Rebecca Fitzgerald Cytosponge Evaluation of Eosinophilic Esophagitis in Comparison to Endoscopy: Accuracy, Safety and Tolerability Introduction: Eosinophilic esophagitis (EoE) is an incipient and often silent allergic inflammatory disease that requires repeated esophageal mucosal sampling but lacks an easy and inexpensive means of doing so. Aim: To compare the accuracy, safety and tolerability of the CytospongeTM, a novel non-endoscopic cell sampling technique, with endoscopy for the diagnosis of EoE. Methods: Twenty patients with EoE and varying levels of esophageal eosinophilia underwent CytospongeTM cell sampling of esophageal mucosa followed by endoscopy and biopsy. A clot method to homogenize the sample and improve standard cytological smear methods was used. Samples were assessed for eos/HPF, histologic findings, and EDN staining. The CytospongeTM e procedure was assessed for acceptability, S-16 AGA Abstracts endoscopic abrasion scores, cytology sample and complications. Results: All 20 Cytos- pongeTM procedures yielded adequate specimens for analysis. 16/20 patients had active EoE (> 15 eos/HPF on biopsy). Of these, all 16 patients had at least 1 eos/HPF on Cytos- pongeTMsamples. 10 patients had > 15 eos/HPF. Other histologic features of EoE identified on the CytospongeTM derived sample included spongiosis and basal cell hyperplasia. Four patients had more eos on CytospongeTM than on biopsy with one patient having a positive cytology and negative biopsy. Overall there was good correlation between eos/HPF on histology and cytology (r=0.448, p=0.046 max, r=-0.50 (p=0.025 avg). EDN staining was robust with the correlation of peak extracellular EDN staining to eos/HPF at R=0.6482, P= 0.0036. Correlation of peak extracellular EDN staining between CytospongeTM and biopsy specimens was also significant (R=0.5980, P=0.0054). No complications occurred with the CytospongeTM. Mucosal abrasion scores were <2 in 19/20 patients. All patients preferred the CytospongeTM o endoscopy. Conclusions: In this pilot study, the CytospongeTM was safe, well tolerated and sensitive in diagnosing eosinophilic esophagitis. It also detected positive cases not found with biopsy. Larger studies are needed to better establish more precise eos/HPF cutoffs and prove continued safety and efficacy. 57 Dilate or Medicate? A Randomized, Blinded, Controlled Trial Comparing Esophageal Dilation to No Dilation Among Adult Patients With Eosinophilic Esophagitis Robert T. Kavitt, Fehmi Ates, James C. Slaughter, Tina Higginbotham, Michael F. Vaezi Introduction: The role of esophageal dilation in eosinophilic esophagitis (EoE) remains unknown. The practice of dilation is currently based on center preferences and expert opinion. Recent guidelines (ACG 2013) suggest "the role of dilation as a primary therapy of EoE is still controversial and should be individualized". Thus, the aim of this randomized, blinded, controlled trial was to determine if and to what extent dysphagia improves in response to initial esophageal dilation followed by standard medical therapies (PPI and swallowed fluticasone). Methods: Adult participating patients with newly diagnosed EoE and prior unresponsiveness to twice daily PPI from 2008-2013 were randomized to dilation or no dilation at the time of endoscopy. Patients were blinded to whether or not they received dilation. Distal and proximal esophageal biopsies were obtained (>15 eos/hpf qualified). Endoscopic features were graded as major and minor for the distal and proximal esophagus; major [rings (0-3), exudates (0-2), furrows (0-2), edema (0-2), and stricture (absent/present)] and minor [feline esophagus, narrow caliber, crepe paper appearance (absent/present for all)]. Subsequent to randomization and endoscopy all patients received fluticasone 440 mcg twice daily and dexlansoprazole 60 mg daily for 2 months. The primary outcome was reduction in overall dysphagia score, assessed at 30 and 60 days post-interven- tion. Dysphagia frequency (0-5), severity (1-4), and quality (0-4) were assessed by an investigator blinded to randomization status. Results: 80 patients were approached; 50 consented to participate; 19 did not fulfill criteria and 1 was lost to follow-up. 31 were randomized and completed the protocol; 17 randomized to dilation and 14 to no dilation. Both groups were similar with regard to gender, age, eosinophil density, endoscopic score, and baseline dysphagia score (Table). The population exhibited moderate to severe dysphagia at baseline. Overall there was a significant (p<0.001) but equal reduction in mean dysphagia score at 30 and 60 days post-randomization compared to baseline in both groups (Figure). Complete resolution of dysphagia was achieved equally in only 23% and 36%, while signifi- cant improvement occurred equally in 69% and 79% of patients undergoing dilation and no dilation respectively. However, no significant difference in dysphagia scores between treatment groups after 30 (p=0.6) or 60 (p=0.7) days post intervention was observed. Odynophagia was reported by 2 in the dilation group and 1 in the group not undergoing dilation. Conclusions: In this randomized, blinded, controlled trial among adults with a new diagnosis of EoE, esophageal dilation did not result in additional improvement in dysphagia score compared to treatment with PPI and fluticasone alone. In this group, dilation does not appear to be a necessary initial treatment strategy. Study Population Characteristics
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Kruppel-Like Factor 5 Plays a Critical Role in β-Catenin Activation by LPA inColon Cancer CellsLeilei Guo, Peijian He, Yi Ran No, Chris Yun
Background: Lysophosphatidic acid (LPA) is a small glycerophospholipid that elicits diversebiological effects via cognate LPA receptors. Previous studies have shown that LPA actingvia LPA2 receptor (LPA2R) stimulates proliferation of colon cancer cells by activation of β-catenin. In addition, a previous study by us showed that transcription factor Kruppel-likefactor 5 (KLF5) plays a critical role in the LPA-mediated effects in colon cancer cells. It wasreported that KLF5 physically interacts with β-catenin and enhances translocation of β-catenin into the nucleus. Aim: The current study was undertaken to elucidate the mechanismof β-catenin activation by LPA and to determine whether KLF5 plays a role in β-cateninactivation. Methods: HCT116 cells were treated with 1 μM LPA or BSA as a control.Phosphorylation of glycogen synthase kinase 3β (GSK-3β) and expression levels of KLF5and β-catenin were determined by Western blot. Role of KLF5 or LPA2R was assessed byknockdown of KLF5 or LPA2R. Nuclear translocation of β-catenin and KLF5 were determinedby immunofluorescence microscopy and Western blot of nuclear fraction. The interactionof β-catenin with KLF5 and TCF4 was determined by co-immunoprecipitation. Results: Wefound that LPA and Wnt3 additively activated the TCF/LEF reporter activity in HCT116cells. LPA acutely phosphorylated GSK-3β at Ser-9 and β-catenin at Ser-552 and Ser-675,which are known to facilitate β-catenin activation. LPA enhanced the interaction betweenβ-catenin and KLF5 and increased nuclear expression of β-catenin in HCT116 cells. However,knockdown of KLF5 significantly attenuated LPA-induced, but not Wnt3-induced, activationof TCF/LEF reporter. Surprisingly, nuclear expression of β-catenin by LPA was not alteredby knockdown of KLF5. We observed that LPA enhanced β-catenin interaction with KLF5and TCF4 in HCT116 cells. Knockdown of KLF5 attenuated LPA-induced β-catenin-TCF4association. The effects of LPA on β-catenin-KLF5 and β-catenin-TCF4 association werereproduced in LoVo and SW480 cells. Conclusion: In colon cancer cells, LPA activates β-catenin by modulating phosphorylation of GSK3β and β-catenin. LPA facilitates β-catenininteraction with TCF transcription factors. KLF5 plays an important role in LPA-inducedβ-catenin activation probably by enhancing the β-catenin-TCF4 interaction.
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Two New Budesonide Formulations Are Highly Efficient for Treatment ofActive Eosinophilic Esophagitis: Results From a Randomized, Double-Blind,Double-Dummy, Placebo-Controlled Multicenter TrialStephan Miehlke, Petr Hruz, Ulrike von Arnim, Ahmed Madisch, Michael Vieth, ChristianBussmann, Monther Bajbouj, Christoph Schlag, Christiane Fibbe, Henning Wittenburg,Hans-Dieter Allescher, Max Reinshagen, Stefan Schubert, Jan F. Tack, Ralph Mueller,Karin Dilger, Roland Greinwald, Alex Straumann
INTRODUCTION: Eosinophilic Esophagitis (EoE) is a rapidly emerging, chronic-inflamma-tory disease of the esophagus. So far no approved therapy is available, but swallowed topicalcorticosteroids have proven efficacy in the treatment of EoE. However, esophageal-adjustedformulation and optimal dosing are not yet determined. AIMS: To investigate the efficacyand safety of two different budesonide formulations (effervescent tablet [BET] and viscoussuspension [BVS]) and two different doses for short-term treatment of EoE. METHODS:Adults with active EoE (n=76) randomly received 14-days treatment with either BET 2x1mg/d (BET1, n=19) or BET 2x2mg/d (BET2, n=19), or BVS 2x2mg/d (BVS, n=19) or placebo(n=19) in a double-blind, double-dummy fashion, with a 2-week follow-up. Primary endpointwas histological remission (mean of <16 eos/mm2 hpf). Secondary endpoints includedendoscopy score, dysphagia score, quality of life (modified SHS), and preference of drugformulation. RESULTS: Histological remission occurred in 100%, 93.8%, and 93.3% ofbudesonide (BET1, BET2, BVS, respectively) and in 0% of placebo recipients (p<0.0001).The improvement in total endoscopic intensity score was significantly higher in the 3budesonide groups compared with placebo. Dysphagia improved in all groups at the endof treatment; however, the improvement persisted during the 2-weeks follow-up only inthose treated with BET1 and BET2, with BET1 showing a significant difference to placebo(p=0.0196). There was suspected local fungal infection in 3 patients in each of the threebudesonide groups, however, hypha were only found in 2 patients in each of the budesonidegroups (post-hoc histopathology). Neither serious adverse events nor clinically relevantchanges in plasma cortisol were observed. 80% of patients preferred the effervescent tablet.CONCLUSION: Budesonide administered as effervescent tablet or as viscous suspensionwas highly effective and safe for short-term treatment of EoE. The 1mg BID dose was equallyeffective as the 2mg BID dose. The majority of patients preferred the effervescent tabletformulation. *The first two authors contributed equally to the first authorship.
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Cytosponge Evaluation of Eosinophilic Esophagitis in Comparison toEndoscopy: Accuracy, Safety and TolerabilityDavid A. Katzka, Anupama Ravi, Debra M. Geno, Thomas C. Smyrk, Hirohito Kita,Pierre Lao-Sirieix, Irene Debiram -Beecham, Gail M. Kephart, Lori A. Kryzer, Jeffrey A.Alexander, Rebecca Fitzgerald
Cytosponge Evaluation of Eosinophilic Esophagitis in Comparison to Endoscopy: Accuracy,Safety and Tolerability Introduction: Eosinophilic esophagitis (EoE) is an incipient and oftensilent allergic inflammatory disease that requires repeated esophageal mucosal sampling butlacks an easy and inexpensive means of doing so. Aim: To compare the accuracy, safetyand tolerability of the CytospongeTM, a novel non-endoscopic cell sampling technique, withendoscopy for the diagnosis of EoE. Methods: Twenty patients with EoE and varying levelsof esophageal eosinophilia underwent CytospongeTM cell sampling of esophageal mucosafollowed by endoscopy and biopsy. A clot method to homogenize the sample and improvestandard cytological smear methods was used. Samples were assessed for eos/HPF, histologicfindings, and EDN staining. The CytospongeTM e procedure was assessed for acceptability,
S-16AGA Abstracts
endoscopic abrasion scores, cytology sample and complications. Results: All 20 Cytos-pongeTM procedures yielded adequate specimens for analysis. 16/20 patients had activeEoE (> 15 eos/HPF on biopsy). Of these, all 16 patients had at least 1 eos/HPF on Cytos-pongeTMsamples. 10 patients had > 15 eos/HPF. Other histologic features of EoE identifiedon the CytospongeTM derived sample included spongiosis and basal cell hyperplasia. Fourpatients had more eos on CytospongeTM than on biopsy with one patient having a positivecytology and negative biopsy. Overall there was good correlation between eos/HPF onhistology and cytology (r=0.448, p=0.046 max, r=-0.50 (p=0.025 avg). EDN staining wasrobust with the correlation of peak extracellular EDN staining to eos/HPF at R=0.6482, P=0.0036. Correlation of peak extracellular EDN staining between CytospongeTM and biopsyspecimens was also significant (R=0.5980, P=0.0054). No complications occurred with theCytospongeTM. Mucosal abrasion scores were <2 in 19/20 patients. All patients preferredthe CytospongeTM o endoscopy. Conclusions: In this pilot study, the CytospongeTM wassafe, well tolerated and sensitive in diagnosing eosinophilic esophagitis. It also detectedpositive cases not found with biopsy. Larger studies are needed to better establish moreprecise eos/HPF cutoffs and prove continued safety and efficacy.
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Dilate or Medicate? A Randomized, Blinded, Controlled Trial ComparingEsophageal Dilation to No Dilation Among Adult Patients With EosinophilicEsophagitisRobert T. Kavitt, Fehmi Ates, James C. Slaughter, Tina Higginbotham, Michael F. Vaezi
Introduction: The role of esophageal dilation in eosinophilic esophagitis (EoE) remainsunknown. The practice of dilation is currently based on center preferences and expertopinion. Recent guidelines (ACG 2013) suggest "the role of dilation as a primary therapyof EoE is still controversial and should be individualized". Thus, the aim of this randomized,blinded, controlled trial was to determine if and to what extent dysphagia improves inresponse to initial esophageal dilation followed by standard medical therapies (PPI andswallowed fluticasone). Methods: Adult participating patients with newly diagnosed EoEand prior unresponsiveness to twice daily PPI from 2008-2013 were randomized to dilationor no dilation at the time of endoscopy. Patients were blinded to whether or not theyreceived dilation. Distal and proximal esophageal biopsies were obtained (>15 eos/hpfqualified). Endoscopic features were graded as major and minor for the distal and proximalesophagus; major [rings (0-3), exudates (0-2), furrows (0-2), edema (0-2), and stricture(absent/present)] and minor [feline esophagus, narrow caliber, crepe paper appearance(absent/present for all)]. Subsequent to randomization and endoscopy all patients receivedfluticasone 440 mcg twice daily and dexlansoprazole 60 mg daily for 2 months. The primaryoutcome was reduction in overall dysphagia score, assessed at 30 and 60 days post-interven-tion. Dysphagia frequency (0-5), severity (1-4), and quality (0-4) were assessed by aninvestigator blinded to randomization status. Results: 80 patients were approached; 50consented to participate; 19 did not fulfill criteria and 1 was lost to follow-up. 31 wererandomized and completed the protocol; 17 randomized to dilation and 14 to no dilation.Both groups were similar with regard to gender, age, eosinophil density, endoscopic score,and baseline dysphagia score (Table). The population exhibited moderate to severe dysphagiaat baseline. Overall there was a significant (p<0.001) but equal reduction in mean dysphagiascore at 30 and 60 days post-randomization compared to baseline in both groups (Figure).Complete resolution of dysphagia was achieved equally in only 23% and 36%, while signifi-cant improvement occurred equally in 69% and 79% of patients undergoing dilation andno dilation respectively. However, no significant difference in dysphagia scores betweentreatment groups after 30 (p=0.6) or 60 (p=0.7) days post intervention was observed.Odynophagia was reported by 2 in the dilation group and 1 in the group not undergoingdilation. Conclusions: In this randomized, blinded, controlled trial among adults with anew diagnosis of EoE, esophageal dilation did not result in additional improvement indysphagia score compared to treatment with PPI and fluticasone alone. In this group, dilationdoes not appear to be a necessary initial treatment strategy.Study Population Characteristics
