prebiotics and probiotics for irritable bowel syndreom (ibs), may 2013

7/28/2019 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


8/39Gastroenterology.2011Nov;141(5):1792-801.8


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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.


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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.


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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

39

prebiotics and probiotics for irritable bowel syndreom (ibs), may 2013

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