SERUM-DERIVED BOVINE

IMMUNOGLOBULINS: A Major Breakthrough in Autoimmunity

Jill C. Carnahan, M.D. ABFM, ABIHM, IFMCP

Flatiron Functional Medicine, Louisville, CO

2

• Website: www.jillcarnahan.com

• Facebook: https://www.facebook.com/flatironfunctionalmedicine

• Email: DrJCarnahan@comcast.net

THE LPS STORYLipopolysaccharides are endotoxins

Lipopolysaccharide

• Lipopolysaccharides (LPS) are large molecules found in gram-

negative bacteria. They are endotoxins which if absorbed elicit a

strong immune response.

• The detection of antibodies against LPS reveals macromolecule-sized

endotoxin infiltration through the intestinal barrier into the systemic

circulation.

• Intestinal permeability can cause systemic inflammation through

translocation of LPS

In humans, the presence of LPS triggers an innate immune response,

activating the immune system and producing cytokines. Inflammation is a

reaction to those cytokines.

• Inflammatory Bowel Disease

• NSAID therapy

• Small Intestinal Bacterial

Overgrowth (SIBO)

• Celiac disease

• Protozoal infections

• Fungal Infections

• Toxic Exposure

• Food Allergies/Mast cell

disorders

• Chronic Alcoholism

• Diarrhea

• Strenuous exercise

• Increasing age

• Nutritional Depletions

Altered

Intestinal

Permeability

Poor Dietary Choices

Stress & Emotions

Infection

Lectins

Systemic Disease

Toxic Exposure

Food Allergy

Malnutrition

Dysbiosis

Toxic Overload

Elevated Total

Toxic & Antigenic

Burden

Low Stomach Acid

Systemic Disease

Examples of gram negative bacteria

• E. coli

• Campylobacter

• Salmonella

• Pseudomonas

• Enterobacteriaceae

• Helicobacter

• Neisseria gonorrhoeae

• Chlamydia

• Others, such as Borrelia may also trigger immune reaction

• Affects one third of the western population.• Increased serum LPS during the first five hours of the post-prandial period

following consumption of a meal. • Meals that are high in fat and dense in calories cause greater increase• Followed by elevated inflammation marked by measurable increases in

interleukin-6, interleukin-1-alpha, interferon-gamma, triglycerides and post-prandial insulin.

• Chronic metabolic endotoxemia has significant correlation to increases in the risk of developing many chronic diseases.

• Correlation with cardiovascular disease, diabetes, obesity, hypogonadism, autoimmunity and even mood disorders such as anxiety and depression.

AKA lipopolysaccharide (LPS)

● Inflammatory immunogens

● Component of gram-negative bacterial outer cell

wall○ Adhesin for colonization of host

○ Diversity of antigenic strains

● Circulates at low-grade levels in healthy

individuals

● Toxicity mainly mediated by the lipid-A component

Erridge, et al. Am J Clin Nutr. 2007;86:1286-1292

http://caltagmedsystems.blogspot.com/2013/05/uscn-specialist-elisa-kit-manufacturer.html

• Immune activation by LPS starts with pattern-recognition receptor called TLR4

• TLR4 is important signaling protein in innate immune system found on the surfaces

of innate immune defense cells like Macrophages and dendritic cells.

• These cells contain CD14, which binds to TLR4 to facilitate the recognition of

patterns on gram negative and gram positive bacteria.

• Circulating LPS gets bound by a phospholipid transfer protein called LBP, which

carriers LPS to the CD14-TLR complex for examination.

• Once LPS-LPB has bound to the CD14-TLR complex, it initiates an immune cascade

that leads to the activation of NFKβ

• Activation of NFKβ leads to the increased expression of pro-inflammatory mediators

TNFα, IL-1beta, IL-6 and MCP-1.

• Innate immune cells that become activated by LPS and subsequently cause the

chronic release of pro-inflammatory cytokines, in all parts of the body, including the

blood-brain barrier.

Metabolic Endotoxemia

• LPS is common trigger to of insulin resistance, obesity, and diabetes

• Endotoxemia increased during the fed and decreased during fasted

state

• LPS serum concentration 2-3X threshold defines metabolic

endotoxemia.

• High-fat diet increased the proportion of an LPS-containing microbiota

in the gut.

http://diabetes.diabetesjournals.org/content/56/7/1761.long

Metabolic Endotoxemia

• Metabolic endotoxemia was induced for 4 weeks in mice by

continuous infusion of LPS

• Increased weight gain

• Increased markers of inflammation

• Increased Triglyceride production by liver

• Increase insulin resistance

• Metabolic endotoxemia dysregulates inflammatory tone and triggers

weight gain and diabetes.

• Lowering plasma LPS concentration could be a potent strategy for the

control of metabolic diseases.

Endotoxin permeability and changes in serum endotoxin levels in the hours subsequent to the ingestion of a test meal containing

either 50ml coconut (CO), vegetable (VO) and fish oil (FO) in otherwise healthy pigs (Mani. 2013).

TYPES OF DIETARY FATS AND ENDOTOXEMIA

Saturated fat (SFA) and n-3 PUFAs have opposite effects on

LPS receptor, TLR4, and lipid rafts○ Lipid-A component of LPS is composed of SFA

○ Endotoxin toxicity is reduced when SFA in lipid-A is substituted for n-3 PUFAs

Lee, et al. J Biol Chem. 2004;279:16971-16979

Why does the type of fat matter?

How does endotoxin enter the blood?

Paracellular pathways○ Via tight junctions

Transcellular pathways○ Via lipid rafts (endocytosis)

▪ Rigid portion of membrane

▪ Composed of cholesterol, SFA

▪ Important in cell signaling

Triantafilou, et al. J Cell Sci. 2002;115:2603-2611;

ELEVATED LPS AND DISEASECONDITION MECHANISM

Leptin Resistance LPS enters and causes inflammation in the enteric nervous system leading to a

disruption in the gut-brain axis of communication.

Chronic Constipation LPS enters the enteric nervous system and causes disruption in signals for gastric

emptying and bowel motility.

Mood and Appetite Disorders LPS disrupts ghrelin function which has a direct impact on appetite and mood,

Depression LPS can migrate to the blood-brain barrier and cause inflammation along with

inhibition of dopamine receptors.

Cognitive Decline Inflammation in the blood brain barrier leads to cognitive decline

Loss of Memory and Recall LPS can get into the amygdala and hippocampus which disrupts memory function

Depression LPS can increase the turnover of serotonin in the synapse and CNS reducing the

concentration in those regions

Anorexia The reduction of serotonin in the synapse and CNS is proposed as a possible

mechanism for anorexia.

Anxiety LPS disrupts key communication between the hypothalamic-adrenal-pituitary axis

thereby increasing the expression of corticosteroid releasing hormone

Chronic Pain Elevated LPS in sensory neurons in the dorsal root stimulate nociceptors.

Parkinson’s Intra-cranially LPS causes microglial activation and neuronal loss

Hypogonadism (low testosterone) Increased circulating LPS and the subsequent chronic immune activation has

feedback inhibition of testosterone production. GELDING theory.

Autoimmunity Chronic activation of the innate immune system in various tissues leads to the by-

stander effect where self-tissues inadvertently become targeted by the immune

system.

“Chronic non-communicable diseases (NCDs) are the leading causes of work absence, disability, and mortality worldwide. Most of these diseases are associated with low-grade inflammation.”

Stress induces endotoxemia and increasing barrier permeabilityKarin de Punder* and Leo Pruimboom Frontiers in Immunology published: 15 May 2015

“In combination with modern life-style factors, the increase in bacteria/bacterial toxin translocation arising from a more permeable intestinal wall causes a low-grade inflammatory state. We support this hypothesis with numerous studies finding associations with NCDs and markers of endotoxemia, suggesting that this process plays a pivotal and perhaps even a causal role in the development of low-grade inflammation and its related diseases.”

GUT PERMEABILITY – CHRONIC INFLAMMATION

Tissue Barriers. 2015; 3(1-2): e982426. Published online 2015 Jan 15. doi: 10.4161/21688370.2014.982426

HOW DOES A HEALTHY MICROBIOME PROTECT AGINST METABOLIC ENDOTOXEMIA?

Neutralize LPS

-increase sIgA

-increase PAMP

Increase

Mucin2

production

Increase tight

junction protein

expression

Increase

regeneration of

expelled IEC

SBI (SERUM-DERIVED BOVINE IMMUNOGLOBULINS)

SBI Stats

• GRAS since 12/2008

• 43 human studies• 6 randomized, placebo-controlled trials

• 3 open-label

• 34 are retrospective case studies and series

• 57 studies total

• Over 450 peer-reviewed studies done on plasma and its sub-fractions (SBI is part of sub-fractions)

• 530 subjects have been exposed to SBI in documented clinical research for 1 day-24 months at doses ranging from 5-20g per day

• Since 2013, 4.7 million doses prescribed

• Dairy-free, sugar-free, non-GMO

Immunoglobulin history• Ehrlich rejected the idea of

inherited immunity so used mice

and switched offspring for

nursing. The mice nursed by

treated females were protected

showing antibody transfer

through milk.

• While engineering a vaccine for

cholera in the late 80s, Fasano

discovered a toxin that could

open tight junctions and that

started the search for zonulin.

• Zonulin discovered in 2000.

SBI Protect Mechanism of actionPassive immunity …

• Dysbiosis

• Abnormal microbiota

• Infections

• Intestinal Permeability

• Lifestyle-induced

• Endotoxemia results

• Dendritic cells present antigens

to T-cells who have B-cells

start antibody production

• Immune system activation

• Inflammation ensues

Why Treating Leaky Gut makes sense…

• Once we were able to see a direct correlation between the genes that regulate

zonulin and the genes associated with autoimmunity, the connection between

intestinal permeability and autoimmunity was made.

• Three Conditions must be present for autoimmunity to develop

1. Genetics,

2. Environmental Trigger

3. LEAKY GUT

• Two major stimuli that increases zonulin in everyone:

1. Gluten

2. Translocated colon bacteria in the small intestines (SIBO)

PRRs: I see you, PAMPS (pathogen-associated

molecular patterns)

“When one or more PRRs recognize a

pathogenic or dangerous molecular

pattern, a cascade of intracellular signals

is triggered. Consistent among these

signals is an upregulation of inflammatory

cytokines.”

Tom Guilliams Ph.D. in Supporting Immune Function

Roadmap (p. 25)

Inflammatory Cytokines:

• IL-1

• IL-12

• IL-18

• TNF α

SBI and PAMPs

• When Ig bind antigens, it removes PAMPS from

interacting with PRRs.

• This prevents immune activation.

• Lack of immune activation means lack of excessive

inflammation.

• Decreased inflammation means less tissue

damage.

• Less tissue damage allows enterocytes and their

junctions to be restored without assault.

• Dampens molecular mimicry.

Molecular Mimicry and Autoimmunity

• Many microbes produce structures that resemble or “mimic” the structures found in human tissues.

• Specific microbial proteins have amino acid homology with human proteins and/or homologous bacterial peptides and appear to stimulate (auto)immunity toward similar human peptides.

• Thus, when the immune system fights against the microbe, the antibodies and T-cells can “cross-react” with tissues of the human host.

• Ringrose JH. HLA-B27 associated spondyloarthropathy, an autoimmune disease based on crossreactivity between bacteria and HLA-B27? Ann Rheum Dis. 1999 Oct;58(10):598-610

• Wucherpfennig KW. Mechanisms for the induction of autoimmunity by infectious agents. J Clin Invest. 2001 Oct; 108(8):1097-104

Which patients does this affect?

• Lyme (co-infections)

• Autoimmunity (intestinal permeability, inflammation, molecular mimicry

• Crohn’s, UC, RA, Hashimoto’s, Lupus, MS

• Autism (Leaky Gut/Leaky Brain)

• Immunosuppressed

• Fibromyalgia (inflammation, infection)

• IBS/IBD

• Intestinal Permeability

• Hypersensitivities/MCAS

• Allergies, Eczema, Rashes, Chemical and Food Sensitivities

Pharma’s Not Helping the Situation

All of these medications

are common in Autoimmune

patients and have a negative

side effect for the risk of the

immune system activation

unnecessarily

LPS, Zonulin and Neuroinflammation1. Zonulin release due to gliadin

and bacteria

2. Immune Response and Inflammation

3. Zonulin, toxins, LPS, inflammatory cytokines enter circulation

4. BBB leaky due to zonulin and same products enter

5. Neuroinflammation noted in Alzheimer’s, Autism, Mood disorders, Cognitive decline, Schizophrenia

Binding capacity of SBI

Zonulin upregulated in certain conditions

• *SIBO

• Gluten intake

• Celiac

• Type 1 Diabetes

• MS

• Crohn’s

• *Ovarian cancer

• *Pancreatic cancer

• *Gliomas

• Schizophrenia

• *Autism

High index of suspicion for

endotoxemia in ALL these

patients

* indicates not ideal to give dairy.

Contraindications

• Allergy to beef

• No drug interactions

• No restrictions on duration

• No adverse events

Don’t over-complicate

Mechanism

• Leaky gut

• Dysbiosis

• GI inflammation

• Need for dairy-free

• Need for lower endotoxins

• Reduce histamine levels

Conditions

• Enteropathy (IBS, IBD)

• Autoimmunity

• Lyme

• Mold

• Autism

• *Chemotherapy

• HIV

Dosing is

simple:

2.5g-5g

twice daily

CLINICAL CASE STUDIES

Case 1

35 y/o female with ulcerative colitis

• PMHx – UC diagnosed 2 years prior to office visit

• PSHx – none

• Social – married, 3 children, high stress sales job

• Medications – mesalamine

• Diet – SCD diet

Cyrex Array 2 - Results

Assessment

Assessment

• Ulcerative Colitis

Plan

• L-glutamine butyrate enemas

• SBI 5g twice daily

• High dose Probiotic twice daily

• Anti-microbial herbal regimen x 8 weeks

• Vitamin D3 5000IU

• Omega 3’s 3g daily

Case 2

• 72 y/o women with rheumatoid arthritis and fibromyalgia

•

• PMHx

• Hypertension

• Hashimoto’s thyroiditis

• Fibromyalgia

• Rheumatoid arthritis

• Fibromyalgia

•

• PSHx

• Bilateral knee replacement

• Partial Hysterectomy at 44y/o for fibroids in uterus

• Cholecystectomy

• Tonsillectomy

Case 2

FHx – Mother’s sister died of breast cancer; sister has fibromyalgia recent diagnosis; Father died auto-accident; Mother lived to be 94y/o; Mother’s older sister had RA

Social - lives with husband of 40+ years, provided home health care for clients

Diet – gluten-free

Meds

• Methylcobalamin 2500mcg/0.4ML – use 2500mcg 2-3X weekly

• Armour thyroid 60mg daily

• Venlafaxine ER 75mg daily

• Trazadone 50mg at bedtime

• Felodipine 5mg 1 PO daily

• Methotrexate 2.5mg daily

Assessment

• Rheumatoid Arthritis

• Fibromyalgia

• Hashimoto’s

• Presumed leaky gut and endotoxemia

Plan

• Multivitamin daily

• Vitamin D3 5000IU

• Omega 3s-3g daily

• High dose probiotics twice daily

• Digestive enzymes with meals

• Curcumin daily

• Glutamine 4g twice daily

• SBI 2.5-5g twice daily

• Magnesium at bedtime

Questions?