Efficacy Of Bovine Colostrum In The Treatment Of Severe Alcohol-Associated Hepatitis: A Randomized Controlled Trial

INTRODUCTION Background and Rationale Severe alcoholic hepatitis (AH) imposes a significant global burden, markedly contributing to liver-related illness and death. The worldwide impact is driven by increasing alcohol consumption and the lack of effective treatments for severe cases. Chronic alcohol intake disrupts normal gut microbiome balance, leading to dysbiosis. This imbalance involves an increase in harmful bacteria and a decrease in beneficial ones, affecting overall gut health. Alcohol also damages the intestinal barrier, making it more permeable. This increased permeability allows bacteria and their harmful byproducts, such as lipopolysaccharides (LPS), to leak into the bloodstream. The leaked bacteria and LPS (pathogen-associated molecular patterns-PAMPs) reach the liver via the portal vein. In the liver, LPS activates toll-like receptor 4 (TLR4) on immune cells, triggering a pro-inflammatory response and hepatocyte necrosis. These PAMPs also contribute to systemic endotoxemia and septicaemia. Despite optimal medical therapy, often including prednisolone, severe alcohol-associated hepatitis has a 28-day mortality rate of 30-40%. The gut-liver axis has emerged as a promising target for treatment in sAH. Interventions such as antibiotics, nonabsorbable disaccharides, probiotics, and fecal microbiota transplantation have shown variable benefits in modulating intestinal permeability and microbial imbalance in cirrhosis. However, none are currently standard treatments for sAH. Furthermore, corticosteroids, while somewhat improving short-term survival, do not address the gut-driven inflammatory cascade and may increase the risk of infections. Bovine colostrum, the first milk produced after birth, is naturally rich in immunoglobulin G (IgG), lactoferrin, antimicrobial peptides, and short-chain fatty acids. Preclinical studies show that oral bovine colostrum can neutralize lipopolysaccharides, promote epithelial regeneration transforming the leaky gut into a healthy mucosal barrier, and modify the intestinal microbiota. These properties are highly relevant to reducing the pathogenic factors of sAH. Therefore, we conducted a multicenter, double-blind, placebo-controlled Phase 3 trial to determine whether adding oral IgG-enriched bovine colostrum to standard medical treatment could enhance survival and liver function in patients with sAH. Our hypothesis was that targeting the gut-liver axis with a safe, enterally delivered biologic would decrease systemic and hepatic inflammation, mitigate hepatocyte necrosis, lower infection rates, and improve clinical outcomes. Natural History of Severe Alcohol-Associated Hepatitis in the West: In the STOPAH study, 60% - 67% patients were males; baseline Maddrey's Discriminant Function was 61.9 + 25.7 and the Model For End-Stage Liver Disease was 20.7 + 5.5 in the Placebo arm. Out of the total 418 deaths, 168(40%) occurred before day 29, 28% occurred between days 28 and 90 , 32% occurred between day 91 and 1 year. Background cirrhosis was in 86.2-93.7% patients with Severe Alcohol Associated Hepatitis treated with prednisone who had undergone liver biopsies Natural History of Severe Alcohol-Associated Hepatitis in India: In all Indian studies patients had a very severe disease as evidenced by the high Maddrey's Discriminant Function scores and Model For End-Stage Liver Disease scores. The majority of deaths occurred within the first month, with only a few deaths in the second and third months. The vast majority of these patients had underlying cirrhosis and were males. Corticosteroids could be offered in only 12%, due to contraindications in the rest of the patients - Acute Kidney Injury (37%) , infection (45%), Gastrointestinal bleed in (18%), patient's refusal in 17%. Treatment Abstinence from alcohol This is the most important factor in predicting the outcome after surviving the acute Alcohol-Associated hepatitis (AH) episode. Nutrition A careful evaluation of nutritional status and energy intake is done, with the aim to deliver 35-40 kcal/kg of body weight and a daily protein intake of 1.2-1.5 g/kg of body weight orally. Small frequent meals and a bedtime snack is advised. Supplementation of Thiamine, other B vitamins, Vitamin D, and trace elements, including Zinc, should be done. Pharmacotherapy of Severe Alcohol-Associated Hepatitis Corticosteroids All recent Western studies have concluded that corticosteroid use decreases the 30-day, but not 90- or 180-day mortality rate in patients with Severe Alcohol-Associated Hepatitis. A more durable treatment of severe alcohol-associated hepatitis is needed. The Maddrey's Discriminant Function in the Western studies ranged from \[Median (Inter Quartile Range)\] 54.4 (39.2 - 76.1) to 69.7(53.7 - 89.4). The Model For End-Stage Liver Disease score ranged from \[median (Inter Quartile Range)\] 21.49 (19.95 - 22.89) to 25(22 - 27). The 90- day mortality rate was 30% in the STOPAH trial, 30% in the DASH trial and 26% in the AntiBiocor trial compared to 10% in the Gawrieh S, et al study due to younger patients in the last study. The pooled 90-day survival was 73.61% (95% CI: 68.18%-78.69%) in placebo-treated patients in above studies. Combining four contemporary Indian studies on Severe Alcohol-Associated Hepatitis, the median Maddrey's Discriminant Function scores ranged from 70 (32 - 320) to 84 (56 - 185) and the median Model For End-Stage Liver Disease scores ranged from 26 (15 - 40) to 27.5 (19 - 41). The 90-day survival ranged from 22% - 56% on standard medical treatment. The inference is that Severe Alcohol-Associated Hepatitis in Indian patients is more severe than in Western patients. Hence, in light of the National Institute on Alcohol Abuse and Alcoholism recommendations, it is clear that Corticosteroids are not a therapeutic option for Indian patients as Maddrey's Discriminant Function and Model For End-Stage Liver Disease scores are very high. Although our pilot study conducted in 2015 had shown that treatment with a combination of Bovine Colostrum and Corticosteroids had improved the Maddrey's Discriminant Function level and survival rate at 3 months significantly, we would only use Bovine Colostrum as a therapeutic option versus standard medical treatment, rather than use corticosteroids as a active comparator arm which has no impact on the 90-day mortality and is often contraindicated in sAH patients with sepsis, acute kidney failure, upper gastrointestinal bleeding Larsucosterol Larsucosterol, an endogenous oxysterol, is an epigenetic inhibitor of DNA methyltransferases, mitigating apoptosis. In a recent study (Model of End-Stage Liver Disease score-24, Maddrey's discriminant function scores 57.2 - 63), Larsucosterol was associated with non-significant improvement in 90-day mortality: 15.2 % (30 mg/day) and 16.8 % (90 mg/day) versus 24.5% on Methylprednisolone. However, the severity of hepatitis was milder compared to Indian our studies. Failed Treatments Pentoxifylline was ineffective, and Interleukin-1-based therapies - Anakinra and Canakinumab have not improved survival rates. The granulocyte colony-stimulating factor has shown mixed results. Indian studies improved 90-day survival, while Western studies on Pegfilgrastim have been negative. Bovine colostrum Composition and Rationale for its Treatment Potential in Severe Alcohol-Associated Hepatitis The Bovine Colostrum has the following components: fat, protein, peptides, lactose ,immunoglobins, lactoferrin, lysozyme, lactoperoxidase, insulin growth factor-I . Colostrum contains elevated levels of IgG, IgA, and IgM, which make up 70-80% of the total protein in colostrum. Short-Chain Fatty Acids in Colostrum improve the integrity of the intestinal inner cell membrane. The lactoferrin concentration in colostrum is 30 - 100 fold higher than that in milk. Lactoferrin binds to lipid A of Lipopolysaccharide (LPS) to neutralize it. IgG and lactoferrin synergistically neutralize LPS. IgG and lactoferrin interact with mucosa-associated lymphoid tissue of leaky mucosal barrier to convert into healthy mucosal barrier. It increases the growth and proliferation of enterocytes. Additionally, lactoferrin has an impact on the levels of cytokines and chemokines that are produced by Gut-Associated Lymphoid Tissue and creates an environment for the growth of beneficial bacteria in the gut. Fewer bacteria and LPS /Endotoxin, - pathogen-associated molecular particles enter the Portal vein resulting in decreased trafficking and interaction of bacteria and LPS with Toll-like receptors-4 of the macrophages and Kupffer Cells in the liver. The production of pro-inflammatory cytokines such as interleukin-1 beta,6,8,10, (IL-1 beta,6,8,10), Reactive Oxygen Species (ROS) and Tumour necrosis factor-alpha (TNF-alpha) are decreased and hepatocellular necrosis is mitigated. Thermal processing of colostrum In studies conducted by Donahue and Godden et al., heating colostrum at 60 °C for 60 min decreased total plate counts, coliform counts and other pathogens, but did not affect native IgG concentration. Derivation of Dose of Bovine Colostrum Oral bovine colostrum preparation (Lactobin®) 56g/day was given prophylactically to 20 patients for 3 days preoperatively who underwent abdominal surgeries, and (Placebo) standard milk 56 g/day was given for 3 days to 20 similar patients. The course of the plasma endotoxin / LPS levels and the endotoxin neutralization capacity were measured daily up to the 10th postoperative day. The results showed that the LPS levels in the Lactobin group, were significantly lower than those in the control group (p \< 0.05). The difference between the two groups was apparent on the day of the operation and the day after. There was a significantly greater increase in endotoxin-neutralizing capacity in the patients treated with lactobin than in the control group (p\<0.006). Thus, Bovine Colostrum has been successfully used to decrease the level of Endotoxemi…