Early ecological changes in intestinal microbiota with the long-acting GLP-2 analog apraglutide in short bowel syndrome

Background and aims Short bowel syndrome with intestinal failure (SBS-IF) is a rare, severe organ failure condition requiring long-term parenteral support. In SBS with colon-in-continuity (CiC), rapid transit and increased oxygen reshape gut and microbiota. We aimed to elucidate the effects of apraglutide, a novel long-acting glucagon-like peptide-2 (GLP-2) analog, on the gut microbiome in SBS-IF-CiC. Methods We performed a 52-week multicenter, open-label, phase 2 study in adults with SBS-IF-CiC (Leuven n = 7, Paris n = 2) receiving weekly subcutaneous apraglutide. Duodenal, distal small bowel and sigmoid colon biopsies, fecal- and plasma samples were collected over time. Analyses included mucosa-associated and fecal microbiota, fecal parameters, and fermentation metabolites. For baseline comparison, duodenal and sigmoid colonic biopsies from 20 controls (10 per region) were collected. Results Patients exhibited an altered ecosystem characterized by reduced richness, loss of colonic anaerobes and dominance of Lactobacillus and Bifidobacterium with larger inter-subject variability, lower pH, higher moisture, and lower microbial load compared to controls. Apraglutide did not change overall diversity or stool parameters, but reduced inter-subject variability in stool and sigmoid colon. Notably, Bifidobacterium decreased in both stool and sigmoid colon, whereas Prevotella increased in stool from some patients. Still, Lactobacillus remained dominant. Specific taxa correlated with fecal butyrate, propionate, and reduced distal colonic motility, indicating microbial metabolism may support boosted adaptation. Conclusions This study emphasizes that SBS-IF-CiC features an immature distal gut microbiota and apraglutide promotes early ecological maturation, suggesting that combining GLP-2 analog therapy with microbiome-targeted strategies may further enhance intestinal and ecosystem adaptation ; ClinicalTrials.gov, Number NCT04964986 https://www.clinicaltrials.gov/study/NCT04964986?term=NCT04964986&rank=1 .