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Background Ambitious therapeutic goals in the therapy of inflammatory bowel disease need more stringent individual endpoints. Several definitions for composite endpoints are under evaluation to describe disease control. Most commonly symptomatic (PRO2) remission is combined with endoscopic response, histology and/or biomarker remission. Here we explore the addition of fatigues as a lead problem reported by patients with IBD as part of a composite endpoint. Methods We have conducted an interim analysis of an ongoing open label study of patients with Crohn’s disease (CD) and ulcerative colitis (UC) assigned to anti-TNF therapy, vedolizumab, ustekinumab or tofacitinib. Patients are scheduled for evaluations at start of the respective therapy and at weeks 2, 6, 14, 26 and 52. Endoscopies are conducted before therapy and at weeks 14 and 52. Clinical remission (CR) was defined as CDAI < 150 and reduction of partial Mayo score (pMayo) > 50% vs. baseline at week 14. All patients who are not in CR and/or no improvement in endoscopy at week 14 are assessed for a switch in the mechanism of action and observation schedules after a switch are reset to week 0. FACIT-F scores Results Fatigue was present in 52% patients (39/75) at baseline. 54% (25/46) of the patients achieved CR at week 14 while 46% (21/46) did not meet CR criteria (non-responder). Fatigue at baseline was persistent at week 14 in 12% (3/25) of CR responders, in contrast to 43 % (9/21) of non-responders. 64% (21/33) of all patients reached a combined endpoint of CR and absence of fatigue. If fatigue was present at baseline (n = 25), fatigue response was observed in 52% (13/25) of the patients, while CR was only reached in 40% (10/25) and the combined endpoint of CR and fatigue response in 24% (6/25) of the patients at week 14. In contrast, 71% (15/21) of patients without fatigue at baseline reached CR at week 14. Absence of fatigue at baseline thus increased the chance of CR at week 14, with an OR of 3.75 [1.031 – 11.50] (p = 0.0422 in Fisher’s exact test). Conclusion Fatigue is an important complaint strongly impacting the patients’ quality of life. A composite endpoint including fatigue and clinical remission (based on pMayo and CDAI) can be reached in a significant percentage of patients treated with biological therapies. Presence of fatigue at baseline might serve as a strong marker for clinical non-response at week 14. Further evaluation and replication of this novel composite endpoint will be conducted in our ongoing trial with a particular focus on inclusion of endoscopies and long-term outcome.

Background Currently available disease activity indices for IBD (e.g., CDAI and Mayo score) focus on symptoms directly related to intestinal function, while other relevant health consequences of disease activity including quality of life, neuropsychiatric symptoms like depression, and social functionality, are not captured. With better therapies more stringent definitions of patient health have come into focus. One of the most common patient reported outcomes (PROs) in IBD is fatigue, which can be unrelated to endoscopic disease activity. We have shown earlier a strong degradation of tryptophan in active IBD (Nikolaus et al, 2017, Gastroenterology) and low tryptophan levels have been linked in various chronic disease to high fatigue levels. Here, we aim to study the relationship of fatigue with disease activity in the context of therapy response to a biological treatment. Methods Patients with Crohn’s disease and ulcerative colitis with high disease activity (Mayo score ≥ 6, CDAI ≥ 220) and planned new therapy with a biologic agent were included into a prospective observational protocol. After informed consent, clinical disease activity, inflammatory biomarkers, tryptophan levels in serum and fatigue levels were assessed longitudinally at week 0, 2, 6 and 14 after start of induction therapy. Complete assessments including week 14 were available for 38 patients for this interim analysis of the ingoing study. For fatigue assessment we used the validated German version of the fatigue subscale of the FACIT-F questionnaire. Patients were stratified into therapy responder (clinical remission (CR), reduction of partal Mayo score (pMayo) > 50%, CDAI < 150), non-responders (reduction of Mayo Results In the cross-sectional analysis of all patients (n = 76), the fatigue score strongly (inversely) correlated with pMayo and CDAI and correlated positively with tryptophan levels in serum. In receiver operating characteristic (ROC) analysis, FACIT-F score were able distinguish active vs. non-active disease (p < 0.0001, AUC = 0.7619) with specificity of 0.7103 and sensitivity of 0.7160. We did not observe significant differences in fatigue scores between males and females. In the longitudinal analysis, fatigue score only improved in the CR group (n = 25, median FACIT score 30 at baseline vs. 44 at week 14, p = 0.0221), and was significantly higher in CR vs. non-responder (n = 16, median FACIT score 44 vs. 31.5, p = 0.007). Conclusion Fatigue is strongly related but not completely overlapping with disease activity. Fatigue will be evaluated as a a patient-oriented indicator for therapeutic response. This observation will be extended by increasing the cohort size and independent validation.

Background A major drawback in diagnosis and monitoring of IBD are insufficient biomarkers that do not correlate well with tissue disease activity. Inflammation and cellular stress lead to an increased release of exosomes (Lipinski et al, 2019, EMBO J) carrying inflammatory signal proteins as cargo (Wozniak et al, 2020, J Cell Biol). Interestingly, colorectal cancer cells strongly release tumor markers after stimulation by sonography waves, probably through the disruptive energy of standard ultrasound (D’Souza et al, 2009, PNAS). We thus hypothesize that application of ultrasound waves on inflamed intestinal tissue in active IBD induces the release of tissue-specific exosomes that can be detected in the peripheral blood and used as novel biomarkers. Methods 26 patients with different degrees of disease activity and various ongoing therapies with IBD were included in a pilot trial. Serum was taken before and 30 minutes after diagnostic transabdominal ultrasound. Serum exosomes were precipitated (using ExoQuick) and exosomal (exo-)miRNA were isolated for miRNA sequencing using SeraMir protocol. Exosomal proteins were isolated for quantification of inflammatory markers (as exosomal cargo). Results We found a correlation between exo-miRNA concentration and disease severity, determined by clinical assessment scores and sonographic findings. Exo-miRNA sequencing revealed a select few miRNAs to be induced by sonography. However, the overall composition of annotated miRNA transcripts did not separate samples according to sampling timepoints. Among these “inducible” exo-miRNA, we found hsa-miR-942, which is involved in cell cycle and Wnt signaling in intestinal epithelial cells, to be significantly induced in higher grade intestinal inflammation. The exosomal protein concentrations did not correlate with disease severity at baseline, but were increased after sonography in severe intestinal inflammation. We did not find markers of the inflammasome apparatus as inducible exosomal cargos. Conclusion Sonography-induced exosomal markers, e.g., exo-miRNAs, could become novel biomarkers for intestinal inflammation in IBD. Further exploration of the functional role of inducible biomarkers and continued investigation of exosomal miRNA and protein profiling will be performed.

Background The role of nutrition in Inflammatory Bowel Disease (IBD) remains unclear. Studies about the effects of nutritional components on intestinal inflammation and the gut microbiome, as well as the concept of exclusive enteral nutrition in paediatric Crohn’s Disease (CD) are suggestive of an impact of nutrition on the pathophysiology. However, there is currently a lack of knowledge on how food components may affect IBD. Here, we investigated the T helper (Th) cell response against nutritional antigens in healthy controls and IBD patients. Methods We used a highly sensitive and specific method developed in our lab, the antigen reactive T cell enrichment (ARTE), to detect wheat and milk-reactive CD4+ T cells directly ex vivo in blood of healthy controls (n=18), CD (n=17) and Ulcerative Colitis (UC, n=15) patients. Peripheral blood mononuclear cells (PBMC) were incubated with whole antigen lysates and activated T helper cells were identified based on the up-regulation of the activation marker CD154. Magnetic enrichment of CD154 positive cells enabled to collect sufficient numbers of food-reactive T cells for their detailed characterization by multiparameter flow cytometry. Results We detected low frequencies of milk and wheat-reactive T cells in healthy individuals. Milk-reactive T cells were less frequent and expressed several markers of T cell exhaustion. In CD, but not UC patients, we identified higher frequencies of food-reactive T cells. These tended to be particularly increased in patients with disease manifestation in the upper gastrointestinal tract. In addition, we observed increased production of inflammatory cytokines of wheat-reactive T cells in CD, compared to healthy controls and UC patients. No ground-breaking differences were identified regarding the expression of exhaustion markers between IBD patients and controls. Conclusion Frequencies of food-reactive Th cells are increased in CD and show a proinflammatory cytokine pattern. The Th1-response of wheat-reactive T cells, characterized by high IFN-γ-secretion, might contribute to the perpetuation of chronic intestinal inflammation.