Typical Pre-Clinical Steps in Development

1. FMT Trial Design: How Do We Design Meaningful Studies in Inflammatory Bowel Disease?Alan C. Moss MD, FEBG, FACG, AGAFAssociate Professor of Medicine

2. Typical Pre-Clinical Steps in Development

3. Elements of Clinical Trial Design in IBD • Patient Selection • Intervention • Outcomes

4. Patient Selection

5. Populations in Prior FMT Trials in IBD

6. “Ideal” Populations to Study • Early after diagnosis, prior to immunosuppresive therapy • Early after Crohn’s resection to prevent endoscopic recurrence • Genotype-specific • Patients in remission to reduce risk of relapse • Proctitis (UC) – mode of administration • Pouchitis (UC) • Active ileal Crohn’s - ?more dysbiosis driven

7. 100 90 80 70 60 Penetrating 50 Cumulative Probability (%) Inflammatory 40 30 Stricturing 20 10 0 0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180 192 204 216 228 240 Months Rationale for Earlier Intervention - Window of Inflammation Cosnes J, et al. Inflamm Bowel Dis. 2002;8:244-250.

8. Rational for Early Intervention - Dysbiosis is Established Early Gevers D et al Cell Host Microbe. 2014 Mar 12;15(3):382-92

9. Rationale for Genotype Enrichment Frank DN, Inflamm Bowel Dis. 2011 Jan;17(1):179-84

10. Who to Exclude • Food allergies • Pregnant • Cancer • Immunocompromised • Cirrhosis • History of valvular heart disease

11. Variables to Control for in Enrolled Population Sommer F, Nat Rev Microbiol. 2013 Apr;11(4):227-38

12. Interventions

13. Variables to Consider for Intervention 1. Dose 2. Delivery 3. Duration • Stool weight • Solution concentration • Microbial consituents • Aerobe / Anerobic prep • Naso-jejnual • Enema • Colonoscopy • Capsule • Fresh / Frozen • Loading & Maintenance • Frequency of administration

14. Scenarios for Intervention – Parallel Design 100g Freeze-Thaw FMT 50g Freeze-Thaw FMT Study Population Randomize Sham FMT 100g Fresh FMT 100g Freeze-Thaw FMT Study Population Randomize Probiotics

15. Scenarios for Intervention – Cross-Over Sham FMT 100g Freeze-Thaw FMT Randomize Sham FMT 100g Freeze-Thaw FMT

16. Solutions to Uncertainties in Intervention • Tailor administration to site of inflammation • Standard concentration (fecal slurry by donor weight and re-constitution solution) • Frozen pre-screened aliquots • Regular administration - colonization alone does not guarantee efficacy

17. Frozen Donor Stool Retains its Diversity Carroll I, PLoS One. 2012; 7(10): e46953

18. Single FMT Not Sufficient – Data in Crohn’s R1001 20 R1002 R1003 15 R1004 I R1005 B H 10 R1006 R1007 R1008 5 R1009 R101 1 0 e 1 2 4 8 T 2 4 n 1 2 M k k k k R1012 i l e e e e k k F e e e e e e e s e e a W W W W W W B Vaughn B, DDW 2014

19. Outcomes

20. Clinical Efficacy Outcomes • Measure of Response / Remission - endoscopic measure important - Patient Reported Outcomes (PROs) - CDAI, SCCAI no longer convincing alone - Quality of Life • Timing of Outcome Assessment - 4 & 8 weeks for response - week 8 and 26 for remission (endoscopic)

21. Safety • Reporting of Adverse Events has been inadequate to date • Use of industry-standards for attribution and severity important • Long-term surveillance critical (storage of archival donor samples for testing)

22. Physiological Outcomes • Paired diversity assessments (pre- & post-) • Metabolomics • Inflammatory markers – CRP, Fecal Calprotectin • T-cell phenotypes

23. FMT Clinical / Safety Assessment LP T-cell phenotypes PB T-cell phenotypes Microbiome Sequencing 4 8 Weeks 0 12 24 “Impact of Fecal Biotherapy (FBT) on Microbial Diversity in Patients Inflammatory Bowel Disease” ClinicalTrials.gov Identifier:NCT01847170

24. Conclusions • FMT should be studied in similar manner to drug therapy to test its efficacy & safety - risk:benefit, cost-effectiveness • Challenges – regulatory, funding, standardization • Initial promise tempered by variable open-label study outcomes • Need for tailored intervention in targeted sub-groups of patients with IBD