Protective Role of Pre-/ Post-biotics on Gut Inflammation, Dysbiosis, and Life Quality in Rett Syndrome (Biotics_RTT) (Biotics_RTT)

Protective Effects of Pre- and Post-biotics on Gut Inflammation, Microbiota Diversity, Epileptogenesis, and Quality of Life in Rett Syndrome

The study will examine the potential efficacy and safety of two pre- and post-biotics on markers for gut inflammation and intestinal microbiota ecology in patients with Rett syndrome. Moreover, this trial will search for possible effects on epileptogenesis and quality of life.

Study Overview

• Status: Completed
• Conditions: Epilepsy; Quality of Life; Dysbiosis; Rett Syndrome
• Intervention / Treatment: Dietary supplement: ALAC, inulin, FOS, and sodium butyrate; Dietary supplement: Sodium butyrate and zinc oxide

Detailed Description

The gastrointestinal tract is the major site of exposure to environmental molecules where 1) dietary components are chemically transformed by the microbiota, and 2) gut-derived metabolites are disseminated to all organs, including the brain. The human gut microbiota directly affects human health, and its alteration can lead to gastrointestinal abnormalities and inflammation. Indeed, accumulating clinical and experimental evidences indicate that the gut microbiota impacts behavior, modulates neurotransmitter production in the gut and brain, influences brain development and myelination patterns. Specific gut-derived metabolites, such as 4-ethylphenyl sulfate (4-EPS) and isoamylamine (IAA) are known to alter brains activity and anxiety behavior in mice and/ or promoting neural cell death leading to cognitive decline. Rett syndrome (RTT; Online Mendelian Inheritance in Man, OMIM number #312750) is a severe and progressive neurological disorder that almost exclusively affects females with an incidence of ~1:10,000 live births. Loss-of-function mutations of the X-linked methyl-CpG binding protein 2 (MeCP2) gene is the major cause (approximately 90 %) of classical cases of RTT. Although a rare disorder, RTT represents a leading cause of severe cognitive impairment in the female gender. Affected individuals commonly show a period of apparent early normal development, followed by regression of hand and/or communication skills, and subsequent development of hand stereotypies, while gait is often abnormal in those who are learning to walk.

Despite a wide phenotypic variability, RTT is commonly associated with epilepsy, sleep disturbances, and gastrointestinal dysfunction thus suggesting a link between RTT's gastrointestinal abnormalities and the gut microbiota.

RTT is associated with a dysbiosis of both the bacterial and fungal component of the gut microbiota, suggesting that MeCP2 loss-of-function can favour the establishment of a peculiar microbial community with altered production of short chain fatty acids (SCFAs) possibly contributing to the RTT gastrointestinal physiopathology.

Modulation of the systemic inflammatory response using pre- and post-biotics is advocated as a possible global therapeutic approach in neurological diseases such as Alzheimer's dementia.

Alpha-lactalbumin (ALAC), is the predominant whey protein in human milk, provides essential amino acids for protein synthesis in the developing neonates. Its supplementation in adults are associated with improved cognition, better memory and sleep. The bioactive properties of ALAC relate to antimicrobial activity, pre-biotic features and epithelial restoration via selective apoptosis activity. Moreover, the antibacterial peptides released from ALAC during digestion can exert immunostimulatory effects inducing phagocytic activity. Overall, ALAC shows reduction of inflammation and oxidative stress status as well as improvement of insulin resistance and increase in the synthesis of brain serotonin, a central nervous system neurotransmitter with well-known antiepileptic activity.

Butyrate, a bacterial metabolite and one of the main SCFAs, exhibits a broad range of pharmacological activities including microbiome modulating, anti-inflammatory, metabolic pathway regulating and anti-oxidant actions.

This body of knowledge supports testing pre- and post-biotics strategies for benefit in individuals with Rett syndrome with the goal of translating potential new treatments from experimental models to clinical practice. Results of this study could lead to the first approved pre- / post-biotics treatment for common co-morbidities in the disorder.

• Study Type: Interventional
• Enrollment (Actual): 28
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Italy
  • Siena, Italy, 53100
    • Policlinico "S. Maria alle Scotte" Azienda Ospedaliera Universitaria Senese

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 3 years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Diagnosis of classic/typical Rett syndrome (and proven loss-of-function mutation of the MeCP2 gene) with gastrointestinal dysfunction and/or positive history of epilepsy
• Female gender (age > / = 3 years old)
• Ability to obtain written informed consent from their parent(s)/legal guardian(s)
• Stable medications for at least 4 weeks prior to the baseline visit.

Exclusion Criteria:

• Diagnosis not fitting into the Rett syndrome consensus guidelines
• Nonpathogenic MECP2 mutation or mutations in non-MECP2 genes (i.e., cyclin-dependent kinase 5, CDKL5; forkhead box protein G1, FOXG1)
• Male gender
• Percutaneous endoscopic gastrostomy (PEG) tube
• Proven hypersensitivity to one or more components of the dietary supplements (X-biotics)
• Unstable concomitant medications less than 4 weeks prior to enrollment visit.
• Concomitant antibiotic therapy at the enrollment. In the case of antibiotic therapy, a 4-weeks washout period will be undertaken.
• Rejection of the informed consent form by the parents/caregivers and/or lack of compliance to the Study procedures.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Pre- and post-biotic (ALAC, inulin, FOS, and sodium butyrate); The product (ALAC+butyrate+inulin+fructo oligosaccharides FOS) is a powder for oral suspension. Dosage is dependent on weight. For participants weighing <50 kg, a 4 g dose (i.e., one 4 g sachet) is intended to be administered orally once a day after dissolving in water. For participants weighing ≥50 kg, a 4 g dose (i.e., 4 g sachets) is intended to be administered orally twice a day (12h interval) after dissolving in water.	Dietary supplement: ALAC, inulin, FOS, and sodium butyrate; Pre- and post-biotic supplementation will be administered for 3 month period (i.e. 12 weeks) given the filling out of a supplementation diary by parents/caregivers. At the scheduled visits/ phone contacts (i.e., baseline, 4 weeks and 12 weeks), systemic inflammation, intestinal inflammation, and gut microbiome characterization as well as treatment compliance, clinical and dietary intake will be assessed. A seizure diary will be provided to parents/caregivers in order to check the frequency and entity of the critical episodes. An EEG recording will be performed at enrollment (or within 6 months prior to the baseline visit).
Active Comparator: Post-biotic (sodium butyrate and zinc oxide); The product (sodium butyrate+ zinc oxide) is in the form of tablets. Dosage is dependent on weight. For participants weighing <25 kg, one 380 mg tablet is intended to be administered orally twice a day . For participants weighing 25 to 40 kg, three 380 mg tablet dose is intended to be administered orally according to the 2+1 tablets per day schedule (12h interval). For participants weighing ≥40 kg, four 380 mg tablet dose is intended to be administered orally according to the 2+2 tablets per day schedule (12h interval).	Dietary supplement: Sodium butyrate and zinc oxide; Post-biotic supplementation will be administered for 3 month period (i.e. 12 weeks) given the filling out of a supplementation diary by parents/caregivers. At the scheduled visits/ phone contacts (i.e., baseline, 4 weeks and 12 weeks), systemic inflammation, intestinal inflammation, and gut microbiome characterization, as well as treatment compliance, clinical and dietary intake will be assessed. A seizure diary will be provided to parents/caregivers in order to check the frequency and entity of the critical episodes. An EEG recording will be performed at enrollment (or within 6 months prior to the baseline visit).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Systemic inflammation	Change in circulating pro-inflammatory or change in anti-inflammatory cytokine levels	Change at 3 months from baseline of each interventional arm
Gut inflammation	Change in fecal calprotectin levels	Change at 3 months from baseline of each interventional arm
Gut dysbiosis	Change in intestinal microbiota biodiversity	Change at 3 months from baseline of each interventional arm

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Epileptogenesis	Change in frequency and/or severity of epileptic seizures (a seizure diary provided to parents/caregivers at the baseline visit)	Change at 3 months from baseline of each interventional arm

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Quality of life and gastrointestinal health	Change in well-being indices [Quality of Life Inventory-Disability Questionnaire (QI-Disability), Gastrointestinal Health Questionnaire (GHQ), Bristol Stool Chart (BSC), Rome III scoring, Sleep Disturbance Scale for Children Questionnaire (SDSC)] [QI-Disability: lower scores indicate a worse outcome, BSC: type 1-2 indicate constipation, type 3-4 normal, and type 5-7 diarrhea), Rome III scoring: higher scores indicate a worse outcome, SDSC: higher scores indicate a worse outcome]	Change at 3 months from baseline of each interventional arm
Quality of life and illness severity	Change in clinical severity [Rett Syndrome Behaviour Questionnaire (RSBQ) and Motor Behavioural Assessment Scale (MBAS)] (higher scores of RSBQ and MBAS indicate a worse outcome)	Change at 3 months from baseline of each interventional arm

Collaborators and Investigators

• Sponsor: Azienda Ospedaliera Universitaria Senese
• Collaborators: European Institute of Oncology; Kolfarma s.r.l. - Italy
• Investigators: Principal Investigator: Claudio De Felice, MD, Policlinico "S. Maria alle Scotte" Azienda Ospedaliera Universitaria Senese , 53100 Siena, Italy

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2022
• Primary Completion (Actual): February 28, 2023
• Study Completion (Actual): February 28, 2023

Study Registration Dates

• First Submitted: June 13, 2022
• First Submitted That Met QC Criteria: June 13, 2022
• First Posted (Actual): June 15, 2022

Study Record Updates

• Last Update Posted (Actual): April 18, 2023
• Last Update Submitted That Met QC Criteria: April 17, 2023
• Last Verified: April 1, 2023

More Information

Terms related to this study

• Keywords: Inflammation; Butyrate; Gut dysfunction; Alpha-lactalbumin
• Additional Relevant MeSH Terms: Pathologic Processes; Nervous System Diseases; Neurologic Manifestations; Neurobehavioral Manifestations; Disease; Genetic Diseases, Inborn; Genetic Diseases, X-Linked; Mental Retardation, X-Linked; Intellectual Disability; Heredodegenerative Disorders, Nervous System; Syndrome; Inflammation; Rett Syndrome; Dysbiosis; Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Protective Agents; Dermatologic Agents; Histamine Antagonists; Histamine Agents; Radiation-Protective Agents; Sunscreening Agents; Butyric Acid; Zinc Oxide
• Other Study ID Numbers: NCT

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No