Vagus Nerve Stimulation a New Approach in the Treatment of Crohn's Disease (VNS)

The Anti-inflammatory Effect of Vagus Nerve Stimulation (VNS): a New Approach in the Treatment of Crohn's Disease

The purpose of this study is to determine whether (VNS) Vagus Nerve Stimulation , is effective in the treatment of Crohn's disease.

Study Overview

• Status: Terminated
• Conditions: Crohn's Disease
• Intervention / Treatment: Device: vagus nerve stimulation (VNS)

Detailed Description

Inflammatory bowel diseases or IBD (Crohn's disease and ulcerative colitis) are chronic inflammatory diseases involving the digestive tract, in particular the small bowel and/or the recto-colon. IBD represent a public health problem in Gastroenterology. The etiopathogeny of IBD is multifactorial involving immunological, genetic, infectious and environmental factors. An overarching hypothesis is that an unbalance of the autonomic nervous system, represented by the sympathetic and parasympathetic nervous system (e.g. the vagus nerve) is part of the mechanisms underlying the pathophysiology of IBD. A dysautonomia has been observed in IBD patients and we have recently demonstrated that this dysautonomia was linked to psychological coping, in particular in Crohn's disease. Classically, the vagus nerve, a mixed nerve, has an anti-inflammatory role through its central afferents which secondarily stimulate the hypothalamic-pituitary adrenal axis. Recent data have shown that the anti-inflammatory properties of the vagus nerve also involve peripheral efferents via an interaction of acetylcholine with nicotinic receptors leading to an inhibition of TNF release by macrophages. Vagus nerve stimulation (VNS) is currently used for the treatment of some forms of epilepsy in Human via a stimulation of vagal afferents. We have recently validated a model of chronic VNS (3h/d for 5 days) in freely moving rats by stimulating vagal efferents and we have studied the anti-inflammatory properties of VNS in an experimental model of colitis in rats. VNS significantly decreased body weight loss due to colitis and had an anti-inflammatory effect by decreasing a multivariate index of inflammation. To date, medical treatment of IBD (e.g. 5-aminosalicylates, corticosteroids, immunosuppressives or biotherapies i.e. anti-TNF) is only suspensive. The aim of our project is to propose another type of anti-inflammatory treatment based on neurostimulation of vagal efferents. For this purpose, we aim to perform a pilot study in 10 patients with moderate to severe Crohn's disease despite a reference treatment (corticosteroids and/or immunosuppressives) using the anti-inflammatory properties of VNS as an alternative to anti-TNF therapy. Central and peripheral effect of VNS will be also evaluated by electroencephalographic and sympatho-vagal (heart rate variability) recordings. The finality, at term, is to use VNS as an alternative to the conventional anti-TNF therapy not devoid of side effects, in particular infectious, with the advantage to use an intrinsic anti-inflammatory (anti-TNF) system and to take cover of problems of adherence to treatment which are frequently observed in the medical treatment of IBD.

• Study Type: Interventional
• Enrollment (Actual): 9
• Phase: Phase 3

Contacts and Locations

Study Locations

• France
  • Isere
    • Grenoble, Isere, France, 38043
      • Grenoble University Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 63 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients with CD involving the ileo-colon, diagnosed for at least 3 months prior to screening in flare (220<CDAI<450) of their disease despite a treatment reference (corticosteroids and/or immunosuppressives) with a stable dose will be included
• CRP>5mg/l and/or fecal calprotectin <100µg/l
• CDEIS > 7 (Crohn's disease endoscopic index of severity)
• Consenting patient

Exclusion Criteria:

• Known cardiac pathology
• VNS contraindication
• Anoperineal CD only or associated with ileocolic lesion
• Diagnosis of indeterminate colitis, positive stool culture for enteric pathogens
• CD Surgery within 3 months before screening
• Short small intestine (<1m)
• Koenig syndrome
• Intra-abdominal abscess
• Fistula with clinical or radiological abscess evidence
• Anoperineal CD with or without rectal involvement
• Ileostomy, colostomy, enteral or parenteral feeding
• Clinical condition medically or surgically unstable that, at the discretion of the investigator would not be compatible with the patient's participation in the study
• Any recent neoplasia, in the year prior to screening

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: VSN; VNS therapy

Device: vagus nerve stimulation (VNS); VNS therapy consists of an implanted pacemaker-like device that delivers mild, intermittently pulsed signals to the patient's left vagus nerve. Roughly the size of a small pocket-watch and weighing less than one ounce, the pulse generator is implanted in the patient's left chest area. A thin thread-like wire, attached to the generator, runs under the skin to the left vagus nerve in the neck

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Clinical remission 12 months after initiation of VNS	Clinical remission at 12 months : Patient without corticoids or a dose of 20mg without dose adjustment (stable treatment) and without anti-TNF,; CDAI <150 or CDAI has dropped by at least 70 or 100 points (Δ70, Δ100) compared with the baseline CDAI; Stable immunosuppressive therapy.	12 months after initiation of VNS

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Clinical remission 6 months after initiation of VNS	Clinical remission at 6 months : Patient without corticoids or a dose of 20mg without dose adjustment (stable treatment) and without anti-TNF,; CDAI <150 or CDAI has dropped by at least 70 or 100 points (Δ70, Δ100) compared with the baseline CDAI; Stable immunosuppressive therapy	6 months after initiation of VNS
VNS tolerance	Description and frequency of adverse events	12 months
Assessment of VNS effectiveness with biological markers	Assessment of VNS effectiveness with biological markers of the pro-and anti-inflammatory status	12 months
Endoscopic and ultrasound Assessment of VNS effectiveness	Endoscopy : CDEIS (Crohn's Disease Endoscopic Index of Severity) Ultrasound : score Migaleddu V. and al, 2009	12 months
Assessment of the central effects of VNS	Evolution of : Sleep cycle : duration of sleep stages, sleep latency, latency between the different sleep stages.; High-resolution Electroencephalogram (EEG): Spatiotemporal evolution of the spectral density of EEG power in the different frequency bands; Correlation between high-resolution EEG markers of autonomic nervous system	At 6 weeks, at 6 months, at 12 months
Evaluation of peripheral effects of VNS on sympatho-vagal balance	Evolution of cardiac variability markers using time and frequency analysis of electrocardiogram : Frequency Analysis : LH, HF, LF/HF; Time analysis : RMS-SD, pNN50, NN50, average cardiac rhythm	6 weeks, 6 months, 12 months

Collaborators and Investigators

• Sponsor: University Hospital, Grenoble
• Collaborators: Institut National de la Santé Et de la Recherche Médicale, France; Université Joseph Fourier; CRSSA : Centre Recherche Service Santé Armée
• Investigators: Principal Investigator: Bruno BONAZ, MD, PHD, Grenoble university hsopital

Publications and helpful links

General Publications

• Borovikova LV, Ivanova S, Zhang M, Yang H, Botchkina GI, Watkins LR, Wang H, Abumrad N, Eaton JW, Tracey KJ. Vagus nerve stimulation attenuates the systemic inflammatory response to endotoxin. Nature. 2000 May 25;405(6785):458-62. doi: 10.1038/35013070.
• Meregnani J, Clarencon D, Vivier M, Peinnequin A, Mouret C, Sinniger V, Picq C, Job A, Canini F, Jacquier-Sarlin M, Bonaz B. Anti-inflammatory effect of vagus nerve stimulation in a rat model of inflammatory bowel disease. Auton Neurosci. 2011 Feb 24;160(1-2):82-9. doi: 10.1016/j.autneu.2010.10.007. Epub 2010 Nov 11.

Study record dates

Study Major Dates

• Study Start (Actual): March 1, 2012
• Primary Completion (Actual): March 30, 2017
• Study Completion (Actual): May 30, 2017

Study Registration Dates

• First Submitted: March 30, 2012
• First Submitted That Met QC Criteria: April 2, 2012
• First Posted (Estimate): April 3, 2012

Study Record Updates

• Last Update Posted (Actual): May 3, 2018
• Last Update Submitted That Met QC Criteria: May 2, 2018
• Last Verified: August 1, 2017

More Information

Terms related to this study

• Keywords: inflammation; Crohn's Disease; Inflammatory bowel diseases; TNF; vagus nerve stimulation; VNS
• Additional Relevant MeSH Terms: Digestive System Diseases; Gastrointestinal Diseases; Gastroenteritis; Intestinal Diseases; Inflammatory Bowel Diseases; Crohn Disease
• Other Study ID Numbers: DCIC11/12