Prebiotics and Probiotics for Irritable Bowel Syndreom (IBS), May 2013
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Transcript of Prebiotics and Probiotics for Irritable Bowel Syndreom (IBS), May 2013
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Probio&csandprebio&csfor
irritablebowelsyndromewithBenjaminBrown,ND
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Prac&calconsidera&ons
Efficacy:Notallprobio&csandprebio&csareeffec&veforIBS.Infactwhenyoulookbeyondmarke&ngclaimssomehaveneverbeenproven,othersarenotmuchmoreeffec&vethanplaceboandmanydonotrelievethemosttroublingsymptoms;bloa&ngandpain.
Safety:Whenprescribingprobio&csandprebio&csthedoseandproductcanhaveanimportantinfluenceonadversesymptoms.Highdoseprebio&csmaysignificantlyexacerbatesymptoms,whilesomeprobio&cproductsmayalsomakesymptomsworse.
Cost:Probio&csinpar&cularcanbeexpensive.Thedifferenceincostpermonthtothepa&entcanbeasmuchas40.00foraproductthatmaybelesseffec&vethanthecheaper
alterna&ve. 2
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Thegutfloraandirritablebowelsyndrome
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Thegutfloraandirritablebowelsyndrome
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Gut microbiota composition in African children living in rural areas with a polysaccharide-
rich diet when compared with Italian city children.
Simrn M et al. Gut 2013;62:159-176
Copyright BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.5
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Relevanceofstudiesshowingchanges
inthegutmicrobiotainIBS
Therelevanceofsmallintes&nalbacterialovergrowthinirritablebowelsyndrome(IBS)remainsunclearduetomethodologicalproblems,influenceofconfoundingfactorsandlargedifferencesbetweenstudies.
HeterogeneityofIBSandvaria&oninmethodsusedto
studythefaecalmicrobiotahaveresultedinconflic&ngreportsofdifferencesfromhealthycontrols.
ThemicrobiomemaycontributetoIBSsymptomsbyalteringgutneuromotor-sensoryfunc&on,barrierfunc&onand/orthebraingutaxis.
Gut.2013Jan;62(1):159-76.6
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Globalanddeepmolecularanalysisoffecal
samplesindicatesthatpa&entswithIBShavea
differentcomposi&onofmicrobiota.This
informa&onmightbeusedtodevelopbe]er
diagnos&csandul&matelytreatmentsforIBS.
Gastroenterology.2011Nov;141(5):1792-801.7
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Gastroenterology
2011Nov;141(5):
1555-99
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Pa&entswithdiarrhea-predominantIBSdisplay
enhancedproinflammatorycytokinerelease,
andthismaybeassociatedwithsymptomsand
anxiety.
Gastroenterology.2007Mar;132(3):913-20.
Inouropinion,diarrhea-predominantIBS
shouldnolongerbeclassifiedasafunc&onaldisorder.
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Plot chart of currently available strategies for modifying gut microbiota aiming to
demonstrate the relationship between the effectiveness and invasiveness/safety of the
proposed approach.
Simrn M et al. Gut 2013;62:159-176
Copyright BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.11
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Probio?csforIBS
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Areallprobio?cseffec?ve
Severalorganisms,suchasLactobacillusGG,Lactobacillusplantarum,Lactobacillusacidophilus,Lactobacilluscasei,theprobio&ccocktailVSL#3,andBifidobacteriumanimalis/lac&s,havebeen
foundtoalleviateindividualIBSsymptoms,suchasbloa&ng,flatulenceandcons&pa&on.
OnlyafewproductshavebeenfoundtoaffectpainandglobalsymptomsinIBS.
Resultsofotherstudieshavebeennega&ve.
GastroenterolClinNorthAm.2012Dec;41(4):805-19. 13
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Theevidencefromclinicaltrialsandsystema&c
reviewsarelargelysuppor&veoftheuseofprobio&csinIBS,butonlyforspecificstrains.
CurrOpinGastroenterol.2013Mar;29(2):184-9.14
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Someprobio&csalleviateindividualsymptoms.
Study
Probio?c Outcome
O'SullivanandO'Morain
2000
L.caseiGG Noeffectofprobio&con
globalsymptomsbuta
trendforimprovementin
thediarrheasubgroup.Kimetal.2003 Mixtureof8strains Significantreduc&onin
bloa&ngbutnoother
symptoms;colontransit
wasreduced.
BaussermanandMichail2005 L.rhamnosusGG Wasnotsuperiortoplacebototreatabdominal
painbutmayhelprelieve
bloa&ng.
Ringel-KulkaT,etal.2011 L.acidophilusNCFMB.
lac&sBi-07
Significantlyrelieved
bloa&ng,butnoother
symptoms. 16
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Someprobio&csmayalleviateglobalsymptoms.
Study
Probio?c Outcome
O'Mahony,etal.2005
B.infan2s3562
Abdominalpain/
discomfort,bloa&ng/
disten&on,andbowelmovementdifficultywere
significantlylowerthanfor
placebo.
Whorwelletal.2006 B.infan2s3562 Improvementinabdominal
pain,bloa&ng,boweldysfunc&on,incomplete
evacua&on,straining,
passageofgas.
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Study
Probio?c Outcome
NobaekS,etal.2000 L.plantarum299V Resultsindicatedecreased
painandflatulencein
pa&entswithIBS.
Niedzielinetal.2001 L.plantarum299V Significantreduc&onin
paininallpa&ents,and
tendencytoimprovement
incons&pa&onand
bloa&ng.
Ducro]P,etal.2012 L.plantarum299V Significantlyreducedpain
severity,dailyfrequency
andbloa&ng.
Someprobio&csmayalleviateglobalsymptoms.
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Study
Probio?c Outcome
Encketal.2008 E.coliDSM17252and
EnterococcusfaecalisDSM
16440mixture
Significantimprovementin
globalsymptomscoreand
inpainscore.
Encketal.2009 E.coliDSM17252 Significantimprovementin
globalsymptomscoreand
inpainscore.
Williamsetal.2008 LAB4(mix):L.acidphilusCUL60CUL21,B.lac2s
CUL34,B.bifidusCUL20
Significantimprovementinthesymptomseverity
scoreandinscoresfor
qualityoflife,dayswith
pain,andsa&sfac&onwith
bowelhabit.
Someprobio&csmayalleviateglobalsymptoms.
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Study Probio?c Outcome
KabirMA,etal.2011 S.boulardii Treatmentfor30daysin
diarrhoeapredominantIBS
pa&entsdidnotresultinanyimprovement.
SndergaardB,etal.2011 L.ParacaseiF19,L.
acidophilusLa5B.lac&s
Bb12
Therewasnodifference
betweentheprobio&c
treatmentorplacebo.
NivE,etal.2005 L.reuteriATCC55730
IBSsymptomsdidnot
improvewithtreatment.
Someprobio&csmayhavenobeneficialeffects.
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Someprobio&csmayhaveadverseeffects.
Study Probio?c Outcome
LigaardenSC,etal.2011 L.plantarumMF1298 TheIBSsumscoreandthe
scorefordiarrhoeawere
significantlyhigherwithtreatmentthanwith
placebo.
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Exampleproduct
Descrip&on:
SuperProbio&cisahighstrength
supplementdesignedtohelpkeepyourdiges&vesysteminbalancewith
premiumqualityprobio&cbacteria.
PerCapsule:
LACTOBACILLUSACIDOPHILUS
4billioncfu
LACTOBACILLUSRHAMNOSUS
4billioncfu
SACCHAROMYCESBOULARDII
4billioncfu
S.Boulardiinot
effec&veforIBS.
Strainsnotspecified.
Genericstatement.
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Ques?onstoaskwhenselec?ngaprobio?c.
1. Whatstrain(s)ofbacteriaareintheproduct?2. Hasthisstrain(s)beenstudiedinhumanclinicaltrials?3. Ifamul&-strainproduct,hasthecombina&onbeenstudied?(bacteriamayhaveunknowninterac&ons).4. Ifso,whatwastheoutcome?(e.g.bloa&ng,pain,bowel
movements,qualityoflife).
5. Andwastheeffectsuperiortoplacebo?6. Whatdosewasused?(concentra&on,dura&on).
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Costcomparisonofavailableprobio?cs
Product Strains Dayssupply Costperday
A LAB4(mix):L.acidphilus
CUL60CUL21,B.lac2s
CUL34,B.bifidusCUL20
30 0.98
B L.rhamnosus,L.
acidophilus,L.plantarum,
andE.faecium(strainsnot
specified).
6 3.65
C Mixtureof8strains
10 1.49
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Clinicalconsidera?ons
Notallprobio&csarethesame,andnotallprobio&csarelikelytobeeffec&ve.Strainselec&onisimportant.
Someprobio&csmaybebenefitcertainsymptomswhileothersmayprovideglobalrelief.
Thereispoten&alforsomestrainstoproduceadverseeffects.
Un-testedproductsdonothaveproofofefficacyorsafety.Costdifferencesvaryconsiderably.Productswithevidence
ofbenefitmaybecheaperthanunprovenproducts.
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Prebio?csforIBS
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Prebio&csareanalterna&vestrategyfor
alteringthegutmicrobiotabyprovidingregular
dosesofaspecificsubstrateengineeredtobereadilymetabolizedbyspecificdesirable
bacteriatherebyencouragingtheirgrowth.
AlimentPharmacolTher.2008Aug15;28(4):385-96.
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Theprebio&cconceptinIBS
Amongthemodifica&onsofthegutmicrobiota,adecreaseofbifidobacteriaandmorespecificallyBifidobacteriumcatenulatumhasbeenobservedinIBS
pa&entsincomparisontohealthysubjects.
compoundsshowingsuch[prebio&ceffectsareknowntomodulatethediges&vemicrobiotaand
par&cularlytos&mulatethegrowthofbifidobacteriaespeciallywhentheini&allevelislow.
BrJNutr.2010Aug;104Suppl2:S1-63. 28
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Prebio&csmayexacerbatesymptoms
Study Interven?on Outcome
OlesenGudmand-Hoyer.
2000.
20gfructooligosaccharides
over12weeks.
Aer46weekson
treatment,
IBSsymptomsworsened
thenweresameas
placebo.
Hunteretal.1999 6gfructooligosaccharides
(2gthree&mesdaily).
Noeffectagainstplacebo.
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Treatmentwithshort-chain
fructooligosaccharidesat5g/dfor6weeks
reducedincidenceandintensityofsymptomsascomparedtoplacebo.Prebio&ctreatmentalso
improvedfunc&onaldiges&vedisordersrelated
qualityoflife
BrJNutr99,31131830
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Treatmentwith3.5gor7gperdayoftrans-
galactooligosaccharidesfor6weekssignificantly
improvedflatulence,bloa&ngandcompositescoreofsymptomsaswell-subjec&veglobal
assessment.Italsoincreasedthepropor&onof
bifidobacteriainfaecalsamples.
AlimentPharmacolTher.2009Mar1;29(5):508-18.
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Prac&calsummary
1. Highdoses(about20gramsdaily)canmakesymptomsworseandalthoughsymptomsimproveaer&metheycanbeworseforafewmonths.
2. Smalldoses(about5gramsdaily)howeverdonttendmakesymptomsworseandhaveshownthemostlikelihoodofbenefit.
3.
Short-chainfructo-oligosaccharideesandtrans-galacto-oligosaccharideshavedemonstratedbenefit.
4. Prebio&csarerela&velycheape.g.a30daysupplyofsachetscontaining2.8ggalactooligosaccharidesper
dose=0.29perday. 32
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KeypointsandResources
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Keypointsummary
1. Somepa&entswithIBSmayrespondtopre/orprobio&cs.
2. Probio&csneedtobecarefullyselectedinastrain-specificmanner.
3. Prebio&cchoiceanddoseshouldreflectposi&veclinicalstudies.
4. Itsiss&llunclearwhetherpre/orprobio&csareane&ologicalapproach.IBSisaheterogeneousdisorderandmayhaveseveralpossiblecauses.
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McKenzieYA,etal;GastroenterologySpecialist
GroupoftheBri&shDiete&cAssocia&on.Bri?sh
Diete?cAssocia?onevidence-basedguidelinesfor
thedietarymanagementofirritablebowel
syndromeinadults.JHumNutrDiet.2012Jun;
25(3):260-74..
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JHumNutrDiet.2012Jun;25(3):260-74.36
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GrundmannO,YoonSL.Irritablebowel
syndrome:epidemiology,diagnosisand
treatment:anupdateforhealth-careprac??oners.JGastroenterolHepatol.2010
Apr;25(4):691-9.
JGastroenterolHepatol.2010Apr;25(4):691-9.37
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JGastroenterolHepatol.2010Apr;25(4):691-9.38
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Probio&csandprebio&csfor
irritablebowelsyndrome
withBenjaminBrown,ND
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