The Efficacy of Lactobacillous Probiotic and Trace Elements in the Management of Ulcerative Colitis Patients the Patients Will be Recruited From Outpatient Clinic of Inflammatory Bowel Disease (IBD) of the National Hepatology and Tropical Medicine Research Institute NHTMRI, Cairo, Egypt

Objectives

• To evaluate the efficacy of lactobacillus probiotics when added to UC standard of care in maintaining remission in UC patients.
• To evaluate efficacy of trace elements when added to UC standard of care in maintaining remission in UC patients.
• To compare the efficacy of adding lactobacillus probiotics versus adding trace elements to UC standard of care.
• To evaluate safety of lactobacillus probiotics and trace elements when added to UC standard of care in maintaining remission in UC patients.

Methodology Study subjects Patients will be enrolled from the outpatient clinic of IBD and gastroenterology of National Hepatology and Tropical Medicine Research Institute (NHTMRI). The recruited patients should meet the following inclusion and exclusion criteria.

Inclusion criteria

• Age 18-65 years. 2. Patients diagnosed with mild to moderate UC (according to Mayo Score (36) for Ulcerative Colitis).

• Patients are on standard of care (biological therapy e.g., infliximab ). Exclusion criteria

• Patients with neurological problems including Alzheimer disease and other dementias, multiple sclerosis, Parkinson's disease, history of large stroke, severe psychiatric disease as it may affect their ability to adhere to their medication and the clinical trial rules and their ability to perform the tests and questionnaires involved in the study (37).
• Patients with communication problems, that can affect their ability to fully understand the purpose of the trial, difficulty in communicating by phone or ability to come in scheduled visits (38).
• Patients with autoimmune diseases.
• Patients with colorectal cancer.
• Patients previously received probiotics or trace elements in the previous month before recruitment.
• Liver cirrhosis.
• Chronic kidney disease (CKD) which is defined as an estimated glomerular filtration rate (eGFR) less than 60 ml/min per 1.73 m2, persisting for 3 months or more (39).
• Pregnancy or Lactation (40)
• Patients on conventional therapy (5-amino salicylic acid treatment). Study design and study site This study will be open label, parallel, prospective interventional study which will be conducted in the outpatient clinic of IBD and gastroenterology of the National Hepatology and tropical medicine research institute (NHTMRI), Cairo, Egypt.

The recruited patients will be randomly allocated in one of three groups:

Group I. Study group 1 Forty-four patients will receive 20 billion colony forming unit (CFU) of Lactobacillus acidophilus (1 capsule of 10 billion CFU twice daily) for six months together with IBD standard of care (biological therapy e.g., infliximab in a dose of 5mg/kg ) to be given routinely to the patients according to the hospital protocol.

Group II. Study group 2 Forty-four patients will receive 1 tablet twice daily of trace elements (zinc 15 mg, chromium 15 mcg, selenium 15 mcg, copper 1000 mcg, iodine 75 mcg, iron 30 mg, magnesium 2.5 mg, molybdenum 15 mcg) as Vitayami® (41-43) together with the IBD standard of care biological therapy e.g., infliximab in a dose of 5mg/kg) to be given routinely to the patients according to the hospital protocol.

Group III. Control group Forty-four Patients will be receiving the UC standard of care (biological therapy e.g., infliximab in a dose of 5mg/kg) according to the hospital protocol without receiving lactobacillus or trace elements.

Primary outcome The decline in the inflammatory bowel disease activity index to less than 50% compared to baseline.

Secondary outcome The improvement in mucosal healing measured by colonoscopy compared to baseline.

Monitoring parameter

After signing an informed consent, all patients will be subjected to the following evaluation at baseline, and then after the recruitment as follow:

Clinical assessment: complete medical history and medication history (at the beginning of the study) and physical examination (including body weight and vital signs), physical examination will be done at the beginning of the study and every 2 weeks.

The Inflammatory bowel disease activity index (Mayo scoring (36) system for assessment of ulcerative colitis activity will be performed for all patients at the beginning and at the end of the study after 6 months.

Mayo Scoring System for Assessment of Ulcerative Colitis Activity is defined as follows:

The Mayo score for ulcerative colitis disease activity provides an assessment of disease severity and can be used to monitor patients during therapy. The score can range from 0-12 with higher scores indicating worse severity.

Biochemical evaluation: Complete blood picture with differential, serum bilirubin (total and direct), serum transaminases (AST and ALT), alkaline phosphatase, gamma-glutamyl transferase (GGT), serum albumin, prothrombin time and concentration, urea and serum creatinine will be performed. These biochemical tests will be done 3 times during the study period at baseline, week 12, and week 24 (end of treatment).

Intestinal ultrasound (44) at the beginning and at the end of the trial. Colonoscope at the beginning and at the end of the trial. Efficacy Assessment To assess the efficacy of adding lactobacillus probiotic and trace elements, the Mayo Scoring System for Assessment of Ulcerative Colitis Activity (35) will be assessed at baseline and at the end of treatment (week 24) where decline in Mayo score to less than 50% compared to baseline will be considered as the primary outcome. The secondary outcome will be the improvement in mucosal healing measured by colonoscopy at week 24 of study period compared to baseline (week 0).

Safety Assessment All the patients and/or their care givers will be requested to report any adverse events, serious adverse events. This step will be repeated every two weeks during the clinic visit of the study period and the patient will be asked about the grade of other side effect and it will be documented as follow: 0=Asked but negative response, 1=Mild (does not interfere with daily function), 2=Moderate (interferes with daily activities), 3=Severe (of medical significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated). 4= Life threatening (urgent intervention indicated). (45,46)

Adherence to the therapy will be monitored, it will be observed as follows:

The patients will be allowed to attend to the outpatient unit every 2 weeks for follow-up visit and for dispensing new strips of lactobacillus or trace elements, by reviewing the empty strips and counting the remaining tablets of administered drugs adherence will be checked.

Quality of life The Arabic validated version of Short Irritable Bowel Disease Questionnaire (SIBDQ) . The patients will be interviewed at the beginning, at week 12 of the study and at the end of the study. It comprises a total of 10 questions grouped into four different dimensions: social questions grouped into four different dimensions: social bowel, emotional, and systemic. Each question is scored by a 7-point Liker scale, ranging from 1 (a severe problem) to 7 (not a problem at all), giving an absolute SIBDQ score ranging from 10 (poor HRQoL) to 70 (Optimal HRQoL).

Food frequency questionnaire Food Frequency Questionnaires (FFQ) are a type of dietary assessment instrument that attempts to capture an individual's usual food consumption by querying the frequency at which the respondent consumed food items based on a predefined food list. Given that food lists are culturally specific, FFQs need to be adapted and validated for use in different contexts. It was adopted from the Canadian Health Measures Survey (CHMS) food questionnaire (2015) (48-50).

The registered dietitian will record the food intake of these patients, including food items of significant interest for IBD and specify food habits that patients are likely to adapt due to their reflection on disease complaints (51,52). FFQ will be done one time at the beginning of the study. Every patient will be supplied with a daily diary to document the component and amount of food intake in daily bases and it will be checked for each patient every 2 weeks by the dietitian to calculate the number of probiotics and trace elements taken with food for every patient.

Statistical analysis The sample size for this study was determined using R software (version 4.3.1). Assuming a significance level of 0.05 and a power of 80%, the calculation was based on the formula for comparing proportions in a multi-arm clinical trial. The proportion of participants achieving a reduction in the inflammatory bowel disease activity index by less than 50% from baseline was assumed to be 69% under the null hypothesis and 74% under the alternative hypothesis (53). Based on these assumptions, the required sample size was approximately 36 participants per arm, for 108 participants across three arms. To account for a 20% dropout rate, the total sample size was increased to about 44 participants per arm, resulting in a total of 132 participants for the study.

Inclusion criteria

• Age 18-65 years.
• Patients diagnosed with mild to moderate UC (according to Mayo Score (36) for Ulcerative Colitis).
• Patients are on standard of care (biological therapy e.g., infliximab ).

Exclusion criteria

• Patients with neurological problems including Alzheimer disease and other dementias, multiple sclerosis, Parkinson's disease, history of large stroke, severe psychiatric disease as it may affect their ability to adhere to their medication and the clinical trial rules and their ability to perform the tests and questionnaires involved in the study (37).
• Patients with communication problems, that can affect their ability to fully understand the purpose of the trial, difficulty in communicating by phone or ability to come in scheduled visits (38).
• Patients with autoimmune diseases.
• Patients with colorectal cancer.
• Patients previously received probiotics or trace elements in the previous month before recruitment.
• Liver cirrhosis.
• Chronic kidney disease (CKD) which is defined as an estimated glomerular filtration rate (eGFR) less than 60 ml/min per 1.73 m2, persisting for 3 months or more (39).
• Pregnancy or Lactation (40)
• Patients on conventional therapy (5-amino salicylic acid treatment).