Bovine Colostrum for Patients With Non Alcoholic Fatty Liver Disease
Bovine Colostrum for Patients With Non Alcoholic Fatty Liver Disease
Trial Synopsis: Bovine Colostrum for patients with non alcoholic fatty liver disease (NAFLD).

 Design: This is a single-arm, open-label, before-and after exploratory trial of 30 days of
 Bovine Colostrum Powder (BCP) to improve NAFLD and the metabolic syndrome.

 Duration: 8 weeks per subject.

 Sample Size: 30 subjects.

 Population: Patients with biopsy proven NASH (NAS of > 4) and an ALT level of ≥ 30 (U/L).

 Regimen Study treatment will consist of BCP, three 1.2 g oral tablets (equivalent to 600 mg
 of BCP each) for 4 weeks, from cows immunized to insulin. Patients will be followed for
 safety monitoring for an additional 4 weeks.
1. HYPOTHESIS AND STUDY OBJECTIVES

 1.1. HYPOTHESIS

 Ingestion of bovine colostrum powder (BCP) from cows immunized to insulin will improve
 non alcoholic steatohepatitis and the metabolic syndrome in patients suffering from
 these conditions

 1.2. PRIMARY OBJECTIVES

 1.2.1 To determine the efficacy of BCP in improving liver enzyme levels in patients with
 NASH.

 1.2.2 To determine the safety of the administration of oral BCP to patients with NASH.

 1.3. SECONDARY OBJECTIVES

 1.3.1. To determine whether the administration of BCP will improve the metabolic
 syndrome in patients with NASH (namely insulin resistance).

 2. INTRODUCTION

 2.1. BACKGROUND

 2.1.1. Nonalcoholic steatohepatitis.

 Nonalcoholic steatohepatitis or NASH is a common, often "silent" liver disease which
 affects about 2%-5% of Americans4-6. NASH is strongly associated with the metabolic
 syndrome, diabetes type-2 and obesity and can lead to cirrhosis, HCC, liver
 transplantation or death. The only mean for proving a diagnosis of NASH and separating
 it from simple fatty liver is liver biopsy (an invasive procedure which carries a
 certain degree of risk). Currently, there is no effective treatment for NASH7.

 2.1.2. The effect of Hyperimmune Bovine Colostrum on NASH

 Regulatory T cells (Tregs) are recognized as an important immunomodulatory component of
 the adaptive immune system. Immune dysregulation may lead to chronic inflammation,
 triggering chronic insulin insensitivity and non-alcoholic steatohepatitis (NASH). The
 role of Tregs in the adipose tissue in the regulation of NASH was not previously
 studied. Aim: To assess the effects of Tregs stimulation on hepatic injury and insulin
 resistance in NASH. Methods: Leptin deficient Ob/Ob mice were fed for 4 weeks with
 colostrum derived solutions (CDS) enriched with anti insulin specific antibodies
 (AIS-CDS, Immuron, Australia), or with purified anti insulin specific CDS (PAIS-CDS).
 The immunologic effect on the adipose tissue was determined by flow cytometry performed
 on the central adipose tissue and its stromal vasculature (SV), and compared with the
 effect on immune system of the liver and the spleen. Hepatic injury and insulin
 resistance was determined by glucose tolerance tests (GTT) and liver enzymes. Results:
 Oral administration of anti-insulin antibodies promoted the SV CD4+CD25+FoxP3+ cells
 (13.05 vs. 27.94 p=0.01). Treatment was associated with a decrease of the CD4+IL17+
 lymphocyte subset in the adipose tissue (87.89 vs. 12.93, p<0.01), the SV (61.86 vs.
 14.99, p<0.01), and in the liver (40.18 vs. 2.66, p<0.01). The liver CD8+CD25+FoxP3+
 lymphocyte subset was significantly increased (0.36 vs. 2.39, p<0.05). The CD4/CD8+
 lymphocyte ratio in the adipose tissue showed a mirror effect to that of the spleen and
 liver suggesting an opposite effect on lymphocyte trapping. Promotion Tregs in the
 adipose tissue was accompanied by a marked improvement in insulin resistance manifested
 by decreased glucose and insulin serum levels, and improved glucose tolerance test
 results (a decrease of 45%, in the area under the curve 23355 vs. 42448, in treated vs.
 controls, respectively), along with decreased liver enzymes (ALT levels decreased from
 743.4 to 379.8 IU, p<0.05; and AST from 770.5 to 299IU, in controls vs., treated
 respectively, p=0.07) without a change in body weight. Conclusions: The immune system of
 the adipose tissue plays an important role in the regulation of the metabolic syndrome.
 Decreasing TH17 in the liver, adipose tissue and SV, along with promotion of
 CD4+CD25+FoxP3+ and CD8+CD25+FoxP3+ Tregs (in the SC and liver respectively), by oral
 administration of anti insulin CDS offers a new treatment modality for NASH and insulin
 resistance, making Tregs in adipose tissue as a new therapeutic target for alleviation
 of the liver damage in NASH.

 2.1.3. BCP Has Been Shown to Be Safe and Well-tolerated in Humans

 Over 80,000 packets of Anadis tabletted BCP product with the same active component has
 been sold in Australia over 4 years. There have been no reported adverse events reports
 to Anadis. BioGard itself as a higher dose separate product was approved in 2008.

 Risk of microbiological contamination: The colostrum in the product is pasteurized;
 strict procedures minimize risk of contamination, and tablet batches are tested for
 yeast, mold, coliform bacteria, Enterobacteriaceae, staphylococci, Salmonella, and
 Listeria. The cows for colostrum production are sourced only from bovine spongiform
 encephalopathy (BSE)-free countries. Additionally, milk products are considered to have
 no detectable infectivity and are considered unlikely to present any risk if sourced
 from healthy animals under the same conditions as milk collected for human consumption.

 Lactose intolerance: Bovine colostrum extract generally contains <10% lactose, compared
 with about 50% in normal skim milk powder; therefore, lactose intolerance is unlikely to
 be a major safety problem. Clinical signs can be expected in susceptible humans given
 5-10g of lactose (Thorn et al, 1977). At a dose of bovine colostrum extract of 10g a day
 (2.8g more than the dose proposed in this study), a maximum of 1 g would be lactose.

 Side effects. No cases of death have ever been reported in studies of BCP. While the
 typical dose is 10g/day [8-10] doses as high as 10 g four times daily have been
 studied[11]. Adverse reactions have been few in number and slight in severity. In most
 clinical studies on the efficacy of bovine colostrum there have been no demonstrable
 adverse effects[9, 10, 12-15]. When they have occurred, they have mostly consisted of
 nausea, emesis, flatulence, and mild diarrhea[8, 11, 14, 16, 17]. In one study,
 transient moderate elevations in serum levels of hepatic transaminases were observed in
 volunteers who received bovine immunoglobulin concentrates prepared against E. coli
 (5/10) and rotavirus (2/10). This effect was attributed to diets high in protein
 provided at the hospital (13). More recently, bovine colostrum was well-tolerated in
 HIV-infected persons for the treatment of HIV-associated diarrhea (18).

 Colostrum administration should be avoided in person allergic to cow's milk.

 3. STUDY DESIGN

 This is a single-arm, open label, before-and-after exploratory trial to evaluate the
 effect of 4 weeks of BCP administration on serum liver enzymes and the metabolic
 syndrome in patients with NASH. Candidates will be identified from among the patients
 treated in the department of medicine and liver unit of the Hadassah Hebrew University
 Medical Center and will be asked to sign an approved informed consent from before any
 study activities are initiated. Participants will be followed on study with weekly
 visits as well as for an additional 4 weeks after concluding treatment to assess safety.

 4. SELECTION AND ENROLLMENT OF SUBJECTS

 4.1. INCLUSION CRITERIA

 4.1.1. Biopsy proven NASH (NAS score ≥ 4) 4.1.2. Serum ALT levels ≥ 30 (U/L) 4.1.3. Age 18-65
 4.1.4. Treatment of diabetes by up to 2 oral medications, with stable doses for 2 months.

 4.1.5. If participating in sexual activity that could lead to pregnancy, the study volunteer
 must agree that two reliable methods of contraception will be used simultaneously while
 receiving the protocol-specified medication and for 1 month after stopping the medication.

 NOTE: Hormonal-based methods alone are not sufficient. At least two of the following methods
 MUST be used appropriately unless documentation of menopause, sterilization, or azoospermia
 is present:

 -  Condoms (male or female) with or without a spermicidal agent. - Condoms are recommended
 because their appropriate use is the only contraception method effective for preventing
 HIV transmission

 -  Diaphragm or cervical cap with spermicide

 -  IUD

 -  Hormonal-based contraception

 Study subjects who are not of reproductive potential (girls who have not reached menarche or
 women who have been post-menopausal for at least 24 consecutive months or have undergone
 hysterectomy and/or bilateral oophorectomy are eligible without requiring the use of
 contraceptives. Written or oral documentation communicated by clinician or clinician's staff
 is required by one of the following:

 -  Physician report/letter

 -  Operative report or other source documentation in the patient record (a laboratory
 report of azoospermia is required to document successful vasectomy)

 -  Discharge summary

 -  Laboratory report of azoospermia

 -  FSH measurement elevated into the menopausal range as established by the reporting
 laboratory.

 4.1.6. Ability and willingness of subject or legal guardian/representative to provide
 informed consent.

 1. EXCLUSION CRITERIA

 i. Pregnancy or Breast-Feeding

 ii. Continuous use of the following medications for more than 3 days within 30 days of study
 entry:

 1. Immunosuppressives

 2. Immune modulators

 3. Systemic glucocorticoids

 4. Anti-neoplastic agents

 5. Insulin iii. Active drug or alcohol use or dependence that, in the opinion of the site
 investigator, would interfere with adherence to study requirements.

 iv. Serious illness requiring systemic treatment and/or hospitalization within 30 days prior
 to entry.

 v. Operation within the previous 3 months. vi. A serious infectious, cardiac, pulmonary, or
 nephrological disease vii. Allergic to cow milk or lactose intolerant.

 2. STUDY TREATMENT

 a. REGIMEN, ADMINISTRATION AND DURATION

 i. Per-protocol treatment regimen

 Subjects will receive treatment with BCP 1.8 grams (3 capsules) for 4 weeks and will then be
 monitored off study treatment for an additional 4 weeks.

 ii. Study treatment modifications

 Dose reductions will not be allowed. All study drug modifications will be documented and
 recorded.

 b. STUDY PRODUCT FORMULATION AND PREPARATION

 The study medication is supplied at tablets packaged individually in blister packs. Each 1.2
 g tablet contains 600 mg of freeze-dried BCP from cows immunized to insulin as the only
 active component, in combination with excipients including silica colloidal anhydrous,
 magnesium stearate, microcrystalline cellulose and calcium carbonate. The product can be
 stored at room temperature and has a shelf life of 5 years.

 c. PHARMACY: PRODUCT SUPPLY, DISTRIBUTION, AND ACCOUNTABILITY

 i. Study product acquisition/distribution

 BCP will be supplied by Immuron, and will be stored and dispensed by the research pharmacies
 at the Hadassah Hebrew University Medical Center.

 ii. Study product accountability

 The site pharmacist is required to maintain complete records of all study products.

 d. CONCOMITANT MEDICATIONS

 i. General guidelines

 There are no specific protocol-imposed restrictions on concomitant medications, other than
 stipulated in the inclusion/exclusion criteria. Nonetheless, whenever a concomitant
 medication or study agent is initiated or a dose changed, investigators will review the
 concomitant medications' and study agents' most recent package inserts, investigator's
 brochures, or updated information from on-line sources to obtain the most current information
 on drug interactions, contraindications, and precautions.

 ii. Prohibited medications

 Use of the following medications for more than 3 days within 30 days of study entry: Insulin,
 immunosuppressives, immune modulators, anti-neoplastic agents, glucocorticoids.

 e. ADHERENCE ASSESSMENT

 At each visit, participants will be queried about the number of doses of study medication
 missed since the last visit.
Inclusion Criteria:

 -  Biopsy proven NASH (NAS score ≥ 4)

 -  Serum ALT levels ≥ 30 (U/L)

 -  Age 18-65

 -  Treatment of diabetes by up to 2 oral medications, with stable doses for 2 months

 -  If participating in sexual activity that could lead to pregnancy, the study volunteer
 must agree that two reliable methods of contraception will be used simultaneously
 while receiving the protocol-specified medication and for 1 month after stopping the
 medication.NOTE: Hormonal-based methods alone are not sufficient. At least two of the
 following methods MUST be used appropriately unless documentation of menopause,
 sterilization, or azoospermia is present:

 -  Condoms (male or female) with or without a spermicidal agent. Condoms are
 recommended because their appropriate use is the only contraception method
 effective for preventing HIV transmission

 -  Diaphragm or cervical cap with spermicide

 -  IUD

 -  Hormonal-based contraception

 -  Study subjects who are not of reproductive potential (girls who have not reached
 menarche or women who have been post-menopausal for at least 24 consecutive months or
 have undergone hysterectomy and/or bilateral oophorectomy) are eligible without
 requiring the use of contraceptives.

 -  Written or oral documentation communicated by clinician or clinician's staff is
 required by one of the following:

 -  Physician report/letter

 -  Operative report or other source documentation in the patient record (a
 laboratory report of azoospermia is required to document successful vasectomy)

 -  Discharge summary

 -  Laboratory report of azoospermia

 -  FSH measurement elevated into the menopausal range as established by the
 reporting laboratory

 -  Ability and willingness of subject or legal guardian/representative to provide
 informed consent

 Exclusion Criteria:

 -  Pregnancy or Breast-Feeding

 -  Continuous use of the following medications for more than 3 days within 30 days of
 study entry:

 -  Immunosuppressives

 -  Immune modulators

 -  Systemic glucocorticoids

 -  Anti-neoplastic agents

 -  Active drug or alcohol use or dependence that, in the opinion of the site
 investigator, would interfere with adherence to study requirements

 -  Serious illness requiring systemic treatment and/or hospitalization within 30 days
 prior to entry

 -  Operation within the previous 3 months

 -  A serious infectious, cardiac, pulmonary, or nephrological disease

 -  Allergic to cow milk or lactose intolerant