The jokes about fecal transplants write themselves. The procedure, which involves taking stool from a healthy donor and transplanting it to someone else to treat a gastrointestinal condition, is ready-made for puns, and even researchers themselves can’t resist making a joke in scientific papers.
Jokes aside, fecal microbiota transplantation, or FMT, is a promising treatment for people suffering from recurrent, refractory Clostridium difficile (C. diff) infection, and possibly a host of other gastrointestinal disorders such as ulcerative colitis and Crohn’s disease that are associated with dysbiosis, or significant changes in the bacteria that live in the digestive tract. By transplanting stool—and the bacteria that come with it—from a healthy person, physicians hope to restore the normal microbiome in the gut.
New research by Stacy Kahn, MD, and her colleagues at the University of Chicago Medicine shows that patients already suffering from severe diarrhea and abdominal pain caused by these conditions are more than willing to get past the “yuck” factor of FMT. In a study published in the June issue of the journal Inflammatory Bowel Diseases, the vast majority of patients with ulcerative colitis surveyed said they were willing to consider it as a treatment, and almost half preferred whomever the doctor recommended as a donor, whether they were related or not.“When you are dealing with a sick loved one, particularly a child or a parent, you become a very strong advocate for doing whatever it takes to get them feeling better,” Kahn said.
Last year, Kahn, who is an assistant professor of pediatrics at the University of Chicago Medicine, used FMT to help an 18-month-old boy beat a C. diff infection, becoming one of the youngest children to undergo the procedure. Such success stories lead patients with other gastrointestinal conditions to wonder if it can be used to alleviate their symptoms. Kahn said her office gets 2 to 5 emails a week from patients with any number of diseases asking about the procedure.
In previous research published in April 2012, Kahn and her colleagues conducted a focus group study for adult patients with ulcerative colitis and parents of children with the disease to assess their attitudes and concerns regarding FMT. Many of them said they see it as a more “natural” option than current treatments that might require intravenous infusions, injections, or change the immune system and cause side effects such as nausea. Parents are especially keen on using FMT for children who may be facing decades of treatment with what they see as manufactured or “unnatural” chemical medications.
The new study sought to quantify these opinions with a larger group of adults with ulcerative colitis seen in the outpatient clinic at the University of Chicago Inflammatory Bowel Disease Center. Forty-six percent of these patients said they were willing to undergo FMT as a treatment for ulcerative colitis, while 43 percent said they were unsure. Only 11 percent said they had no interest in FMT. Patients who were hospitalized were more likely to be interested in FMT (55 percent) than those who hadn’t (34 percent). Their top concerns about the procedure were adequate screening of donor material for infections and cleanliness, but equal numbers said they preferred whomever the doctor recommended as a donor versus a family member or spouse (46 percent each).
As interest in FMT grows, Kahn said it’s crucial to conduct this type of research on the ethical and social issues involved with the procedure. When the National Institutes of Health launched the Human Microbiome Project to coordinate all manner of research on the bacterial environment of the body, one of the major aims was to explore such issues, although Kahn said little work has been done so far.
“I think we’re really among the leaders in this area where nobody else has really nicked the surface. People have talked broadly about ethical issues, but nobody has done any research,” she said. “We’re really doing groundbreaking work here laying the foundation, which is the really important ethical and social issues, and we’re hopeful that we’ll continue.”
Perhaps sensing the growing interest in FMT (and widespread reports of people administering the treatment themselves), last month the FDA announced that physicians must have an “investigational new drug application,” or IND, to perform FMT. The decision has caused considerable anxiety among advocates of the procedure, who fear it will slow down research and limit the flexibility of physicians to use it for patients who could benefit already.
Fortunately, Kahn and her colleagues have been working with the FDA for two years to secure IND approval for a safety and feasibility clinical trial of FMT for patients with ulcerative colitis, and received approval earlier this month. The trial will begin soon, and Kahn said she hopes it leads to more research that will refine the procedure.
“In the future we may be able to do bacterial fingerprinting so that we can identify the specific bacteria that are missing in an individual, and replenish that specific subset of healthy bacteria that that individual is missing,” she said. “Or could it be contained in a pill instead of being delivered colonoscopically. These are all ideas that right now seem very far off, but undoubtedly in reality they’re probably not so far off in the future.”
Kahn, S., Vachon, A., Rodriquez, D., Goeppinger, S., Surma, B., Marks, J., & Rubin, D. (2013). Patient Perceptions of Fecal Microbiota Transplantation for Ulcerative Colitis Inflammatory Bowel Diseases, 19 (7), 1506-1513 DOI: 10.1097/MIB.0b013e318281f520