Probiotic therapy

Abstract

Our current knowledge regarding the use of probiotics is limited with small studies, control drug dosing issues and delineating effects of probiotics from combination probiotic and prescription medication studies as outlined in this chapter and by others [49, 50]. That being said, specific probiotic products might have more potential for modest effect in maintenance of remission of ulcerative colitis especially for those unable to use 5-aminsalicylate products. Whether there is efficacy in active mild to moderate disease remains to be determined. Clinical practice for use in chronic relapsing pouchitis demonstrates that far fewer patients benefit from probiotics than some of the early small trials and there is a lack of evidence for their use as sole treatment in active pouchitis. There is little persuasive evidence that patients with Crohn's disease should ingest probiotics. A deleterious effect in those taking specific strains for maintenance or prevention of post-operative recurrence has not been statistically demonstrated but it seems a prudent course at the present time to discourage their use until there are further studies to ensure no trends are developing that may not be uncovered, except in large trials or meta-analysis of smaller trials. As well, at this point in time understanding what sub-groups of patients (i.e. specific genotype, specific phenotype, specific age group) do demonstrate benefit require study before advocacy of probiotics in Crohn's disease. It is important to not generalize reports of positive benefit from specific strain studies to either Genus or Species effects and it is equally as important not to generalize negative reports of a specific strain to a Genus or Species effect. Clearly there is a need for knowledge with regards to dosing, duration of therapy, delivery methods and whether blends of different strains of probiotics offer any benefit over single strains. As well, without significant regulatory controls quality control, viability and the potential for differences of microbe phenotype expression between studied probiotic products and commercially available products has led to debatable results [51, 52] and ones that make it difficult for health care providers and consumers to discern. Given the current situation of parental and self-prescribing of alternative care products including those described as probiotics for IBD, it behooves those providing care for IBD patients to know exactly all prescription and non-prescription items being administered to the children and adolescents with IBD so when problems in care are occurring comprehensive strategization of care can be co-coordinated. There are a number of clinical situations in which this could potentially be important. Among the most serious clinical scenarios to consider is that in which a patient is initiating immunosuppressive therapy. While most patients undergo the initiation of immune altering medications without incident, immunosuppression is a possibility. There is no evidence for the efficacy of probiotics in any form of severe IBD and in general, there is little clinical experience in the use of probiotics administration to severely immunocompromised IBD patients. However, in ill patients in ICU settings fungemia has developed from the use of S. boulardii as probiotic [53] and sepsis from a Lactobacillus strain has also been reported in an ulcerative colitis patient [54]. Another reason it would be good to know if patients are ingesting probiotics is related to the reported link to gastrointestinal side effects following ingestion of heat-killed probiotics. In a clinical trial evaluating the benefits of heat-killed, non-viable L. rhamnosus GG with live, viable L. rhamnosus GG for atopic dermatitis, increased gastrointestinal side effects in those administered the non-viable microbes lead to premature termination of the study [55]. Viability is affected by a number of issues that include practices of retailers (i.e. shelf time, product storage), distributors (warehouse storage, distribution) and manufacturers [56]. Poor practices at any level will lead to loss of viable microorganisms in a probiotic product with potential for problems associated with ingestion of non-viable probiotics as reported by Kirjavainen et al. [55] the symptoms of which may be mistaken for active IBD. Ingestion of S. boulardii has also been linked to worsening of diarrhea in two patients with ulcerative colitis [57]. Although the commercialization of probiotics is ahead of scientific and clinical investigation, as practitioners we should demand that the various aspects of IBD care are critically appraised before encouraging patients to ingest undocumented probiotic products as therapy in IBD. © 2008 Springer Science+Business Media, LLC. All rights reserved.