By Dr. Brian Bressler, MD, MS, FRCPC (biography and disclosures)
What I Did Before
The approach to patients with irritable bowel syndrome has changed significantly as we continue to understand the cause behind patients’ symptoms. Traditionally, the approach to symptoms related to irritable bowel syndrome has focused on altering the stool consistency to allow easier handling of it through the colon. The traditional example of such intervention would be supplementing a patient’s diet with fibre, often with Metamucil or a similar product. Clinical studies have not supported this approach. Another focus in therapy has been altering the enteric nervous system, as it has been known now for a long time that a large component to the pathophysiology of irritable bowel syndrome is centred around the dysfunction of the nerves controlling the bowel. Typical medical approaches to this have included Dicetel and Zelnorm (this medication has been removed from the market due to cardiovascular concerns).
What Changed My Practice
We are beginning to understand the complex nature and interaction the bacterial flora has in our body, specifically our GI tract. On average, 100-200 grams of feces is excreted by a person each day. Approximately 50% of this mass is bacteria. Ninety percent of the total cells in the human body are bacteria. For every gram of stool, it is estimated that there are one trillion bacteria. We are far from understanding the role each bacteria have in our bowels, and we are unable to permanently manipulate our bacterial flora. The definition of a probiotic is live micro-organisms which, when administered in adequate amounts, confers a health benefit on the host. A good probiotic must have certain critical characteristics. First and foremost, it must be safe for the consumer, it must be delivered alive to the gut in the correct concentration. This last point is critical when evaluating a probiotic because the design of it must allow the bacteria to stay alive despite the gastric acids and bile salts that it is exposed to, as well as it must be able to resist other microbes in the intestines. Finally, a good probiotic must have proven efficacy. Recently there has been clinical evidence for using probiotic therapy for various medical conditions, including treatment of acute gastroenteritis, prevention of antibiotic-associated diarrhea and irritable bowel syndrome. Recent studies using probiotic therapy have proven that altering intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome. A controlled double-blinded randomized study on the efficacy of Lactobacillus plantarum 299v (a probiotic available in Canada) in patients with irritable bowel syndrome revealed significant improvement in the active group compared to the control group in treating symptoms associated with irritable bowel syndrome.
What I Do Now
For the most part, patients are interested in exploring non-pharmacological approaches to treating irritable bowel syndrome. With the clinical evidence that is now available for certain probiotics, I have begun to use probiotics in treating patients’ irritable bowel syndrome.
A probiotic is like an antibiotic and one cannot use any probiotic for any medical condition.
I emphasize to patients that the appropriate probiotic which has been studied for the medical condition that one wants to treat should be tried and many others which are commonly used, such as Lactobacillus acidophilus has no proven clinical efficacy in GI conditions such as irritable bowel syndrome. Tuzen and Activa yogurt are two examples of probiotics I use for treating IBS. VSL3 I use for treatment of pouchitis and to a lesser extent ulcerative colitis. Florastor I use in patients with recurrent C diff, or in some circumstances to treat antibiotic induced diarrhea.
The major drawback to probiotic therapy is the expense and to date I am not aware of third-party coverage of these supplements. I have had many patients use probiotic therapy to treat their irritable bowel syndrome to minimize the impact this syndrome has on the quality of their life. As we go forward, my hope is that we learn further the role that microflora has on our health and, with that knowledge, we can isolate and use specific bacteria to treat more effectively irritable bowel syndrome as well as many other conditions relating to our gastrointestinal tract.
References for the data regarding Lactobacillus Plantarum: (Note: Direct article downloads and article requests require a login ID with the BC College of Physicians website)
[1.] Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome. Nobaek S, Johansson ML, Molin G, Ahrné S, Jeppsson B. Am J Gastroenterol. 2000 May;95(5):1231-8.PMID: 10811333 [View PubMed – indexed for MEDLINE]
[2.] A controlled, double-blind, randomized study on the efficacy of Lactobacillus plantarum 299V in patients with irritable bowel syndrome. Niedzielin K, Kordecki H, Birkenfeld B. Eur J Gastroenterol Hepatol. 2001 Oct;13(10):1143-7.PMID: 11711768 [View PubMed – indexed for MEDLINE] [View Article]
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Thanks! Do probiotics treat infant colic as well?
I looked quickly at the PubMed links for the articles cited … amongst related articles at PubMed are at least 2 more recent trials, which appear to be double blind, which suggest no benefit from this treatment.
Cochrane systematic reviews:
a) apparently found no benefit in children from a few studies:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003019/frame.html
b) protocol for adults with diarrhea-predominant IBS:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005985/frame.html
The abstracts of studies cited suggest that many people improve with an “intervention”, but it didn’t look to me as if these studies suggest that the intervention has been proven to work, compared with the control.
Thomas L. Perry, M.D.
Thank you for this. But why use a yogurt like Activa which contains cornstarch instead of just plain yogurt?
1. I am not aware of strong clinical evidence that probiotics treat infant colic (but that doesn’t mean the evidence does not exist)
2. Systematic reviews or other combined anaylsis such as meta-analysis would only be valid ways to critique the data if they were only dealing with one strain of a probiotic (which I don’t believe is the case in these reviews). An important concept to appreciate is that all probiotics differ in there potential ways to treat disease. An analogy I use is to compare them to antibiotics in that we would only use certain antibiotics to treat certain conditions, and obviously reviewing all types of antibiotics to treat one condition would not make sense. As we further our knowledge in understanding the way we can use probiotics we are learning which strains and which dose are optimal to treat disease.
When evaluating therapies to treat functional disease such as IBS, placebo control is critical as there is a significant placebo response to any intervention in a clinical study. The cited studies were placebo controlled and the active group was superioir to the placebo group in certain critical endpoints reported.
3. A great point. Until we have good data that probiotic enhanced yogurt is superior to plain yogurt I would not have a strong preference for one over the other as we know regular yogurt has bacteria in it as well (in fact this is why lactose intolerant pts can tolerate yogurt because the bacteria digest the lactose).
the ayurvedics have been doing this for millenia. Not a new or startling discovery…
As someone who has IBS I found this article very interesting. However since I have IBS very much under control with a low fat high soluble fibre diet I wonder if there would be much in the way of benefit for me.
I would also add while a Soluble fiber supplement is a excellent way to treat IBS I wouldn’t recommend a psyllium based product like Metamucil as it’s more likely to cause bloating than other types of fiber. Not a good thing if your already prone to painful bloating because of IBS. A fibre supplement is also only part of a diet based approach to IBS. In my experience keeping your diet low in fat and free from caffeine will also help.
Is there any evidence that iberogast works for IBS?
What is the name of a soluble fiber supplement?
Great article. Few comments :
1. Lactobacillus reuteri in infantile colic: Savino et al in Paediatrics (2008)
2. NICE guidelines do suggest only soluble fibre in IBS , not the insoluble or combination. Examples of soluble fibre supplements: Benefibre; Mixed fibre:Metamucil
3. Iberogast – some evidence, see Cocgrane review
4. Enteric coated peppermint oil capsules (formerly Colpermin, now available as Pepogest and others)
Hope this helps
[…] Probiotic therapy has changed my approach to treating patients 26 Jul 2010. Tuzen and Activa yogurt are two examples of probiotics I use for. for one over the other as we know regular yogurt has bacteria in it as. – Probiotic therapy has changed my approach to treating patients […]
There remain many challenges in managing IBS, largely due to its heterogeneity. There is much variability in regard to many parameters, including the following:
1. pathophysiology (“afferent” vs “efferent” signalling in the Enteric Nervous System);
2. predominant symptom(s);
3. precipitating and/or aggravating factors (post-infectious, “stress”, diet-related, deeper emotional trauma, etc);
4. overlap with upper GI and non-GI symptoms (dyspepsia, somatic pain, abnormal sleep, fatigue, etc);
5. severity and life impact;
6. response to various treatments, including placebo;
7. clinical trial evidence.
Perhaps more than with any other type of agent, clinical trial reports on effectiveness of various probiotics for IBS have varied tremendously, probably due to the heterogeneity of not only IBS, but of different probiotics.
Dr. Bressler has emphasized that not all probiotics are the same. There are differences in the literature in regard to treating various conidtions (GI and otherwise). There are also differences in concentrations and viability of different organisms. Moreover, while there are a number of putative mechanisms by which probiotics may effect biologic response in the host (patient), these have remained theoretical for the most part.
We still need more information. However, due to the variables described above, we must be cautious in interpreting individual study results.
Have you considered the role of SIBO in IBS? Dr. Pimentel at Cedars Sinai suggests that in a majority of IBS cases addressing SIBO has had great success. He also believes that supplementing with probiotics may only serve to reduce symptoms or in some cases exacerbate rather than eliminating the originating problem.
Can you comment on the use of rifaximin as a protocol against SIBO and potentially IBS?
in my opinion, IBS is a terribly difficult disease to treat and thus any novel evidenced-based therapies are certainly welcome
I’d just gone thru a recent “rush” of newly diagnosed IBS patients – you know, as a GP sometimes you have unrelated people with similar conditions come to you in waves. This is very helpful. i never thought to view probiotics as a heterogeneous group – “just like antibiotics”! but yeah, why not! It’s a really enlightening point, that when we’re evaluating studies and evidence, and recommending therapeutic options, that we keep in mind which specific condition we’re treating and which agent – not which “group” of agents – just like not all BP meds are created equal for all kinds of hypertensive patients etc. This is practice-changing for me in the context of recommending probiotics, which I already do regularly.
Kefir is far better than Yogurt. Also if you combine Cooked Oats with the regular consumption of Kefir you have a mix that just can’t be beat! You can also add in S. Boullardi for the treatment of diahrrea if you want or add in other good bacteria known to help in certain ways and also onions which like Oatmeal feed the good bacteria.
Note: Some varieties of Kefir are superior to other types. A patient needs to try 2-3 different types to see which ones provide the desired effect. Kefir needs to also be consumed regularly and for more than a couple of weeks which means your patient needs to commit themselves to trying it. Bacteria need to take hold and become established before any results are noticed.