Probiotics: The Mighty Power of the Super Bugs in Digestive and Overall Health

Pharmacy shelves are lined with a plethora of probiotic supplements, and the selection may be overwhelming for some consumers.

In the past decade, there have been countless inquiries from consumers about the potential health benefits associated with the use of probiotic supplements, also sometimes referred to as “super” microbes.

Probiotics are “live microorganisms (eg, bacteria) that are either the same as or analogous to microorganisms found naturally in the human body and when administered in sufficient amounts may be beneficial to health,” according to the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine and the World Health Organization.^1-5 Classification of probiotics is based on the genus, species, and strain, and an array of studies have explored various strains of probiotics to ascertain potential health benefits associated with their use.^2-7 Although probiotics have documented health benefits outside the gastrointestinal (GI) tract, digestive health remains the key benefit. Examples of potential protective effects associated with probiotics include alteration of epithelial cell cytokine production, enhancement of antiviral activity, GI barrier function, inhibition of the growth of potential pathogens, and regulation of T-cell induction.^1-4 Meta-analyses have indicated several ways that probiotics can exert health benefits, such as the treatment of certain types of constipation, diarrhea, and inflammatory diseases of the intestine. Continuing research has also provided compelling evidence regarding the role of probiotics in decreasing the incidence of some diarrheal illnesses, allowing those with lactose intolerance to better digest the sugar and lactose, and enhancing immune function.^1-7 Results from a study published in May 2013 showed that there was a moderate amount of evidence to conclude that probiotics are both effective and safe for preventing diarrhea associated with Clostridium difficile.⁸

Increased awareness of the importance of the microbes that live in the human gut has sparked a great deal of research on the microbiome and fueled a booming probiotics industry. Pharmacists can provide patients with pertinent information to make informed decisions about probiotic supplements.

Clinical Studies and Recent News

Results from a 2018 study published in JAMA Dermatology showed that a daily capsule of a cocktail of probiotics may reduce both the severity and symptoms of moderate atopic dermatitis and the need for topical corticosteroids to treat symptom flare-ups in pediatric patients.⁹ Results of another 2018 study suggest that probiotics can improve not only gut health but hepatic health as well.¹⁰

Furthermore, treating patients who received antibiotics with multistrain probiotics decreases the incidence of C difficile infections in hospital settings over time, according to the results of 2 studies published in Infection Control & Hospital Epidemiology.^11,12 The results of another study showed that twice the number of adults with irritable bowel syndrome (IBS) reported improvements from coexisting depression when they took a specific probiotic compared with adults with IBS who took a placebo.¹³

Probiotic Supplements

Probiotics are often present in fermented products such as dairy products (eg, buttermilk, yogurt, and yogurt drinks), some juices, and soy beverages and plants (miso and sauerkraut), as well as in dietary supplements, which are available in a variety of forms, including capsules, powders, and tablets. In both dietary supplements and probiotic foods, the bacteria may be already present or added during food preparation.^1-7 Probiotic supplements may contain 1 or more of the species of Bifidobacterium, Lactobacillus, and Saccharomyces.⁷ Within the Lactobacillus genus, reuteri is the most prevalent in the human body. However, supplements on the market may contain acidophilus, bulgaricus, fermentum, rhamnosus GG, or reuteri.^3,7 Species of Bifidobacterium found in supplements include bifidum, longum, breve, infantis, and lactis. Saccharomyces boulardii, which is yeast, is the only one of the Saccharomyces species used in dietary supplements.¹ Lactobacillus and Saccharomyces products are recommended for antibiotic-associated diarrhea, and Lactobacillus rhamnosus GG is recommended for atopy and dermatitis.⁷ Some supplements contain Bacillus coagulans.

Counseling Tips

Prior to recommending the use of any probiotic supplement, pharmacists should advise patients, especially those with medical conditions, to seek advice from their primary health care provider to ascertain appropriateness. Women who are breast-feeding or pregnant should always consult their doctors before using supplements. It is important to note that though there is limited data, there are no reports of harmful effects associated with the use of probiotics in women who are breast-feeding or in late-term pregnancies.¹ Patients should be reminded to use products from reputable companies only and to adhere to the manufacturer’s guidelines for use and dose. Concurrent administration of probiotic supplements and any antibiotics or antifungal agents is typically not recommended, and dosing intervals of these agents should be spaced at least 2 hours apart.^1,7 Although generally well tolerated, probiotics may cause mild episodes of bloating and flatulence, which tend to decrease over time.^1-7 Adverse effects can be minimized if dosing is titrated slowly in small increments. Episodes of diarrhea have been reported within the pediatric population and should be monitored.^1-7

Patients with compromised immune systems should be advised not to use probiotics because of the potential of systemic infections, and those with serious medical conditions should be monitored closely for adverse effects while taking probiotics, according to the NIH.^1-7 Research exploring the possible benefits of probiotics is ongoing.

For more information on the clinical trials investigating the use of probiotics, visit the NIH’s clinical trials website at clinicaltrials.gov/ct2/results?term=probiotics.

Examples of probiotic supplements are shown in the Table.

Yvette C. Terrie, BSPharm, RPh, is a consultant pharmacist and a medical writer based in Haymarket, Virginia.

References

• Probiotics: in depth. National Center for Complementary and Alternative Health website. nccam.nih.gov/health/probiotics/introduction.htm. Updated February 22, 2018. Accessed May 20, 2018.
• Kale-Pradhan P, Wilhelm S. Prebiotics and probiotics. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 19th ed. Washington, DC: American Pharmacists Association; 2018.
• Williams NT. Probiotics. Am J Health Syst Pharm. 2010;67(6):449-458. doi: 10.2146/ajhp090168.
• Probiotics. National Center for Complementary and Integrative Health website. nccam.nih.gov/health/probiotics. Updated September 24, 2017. Accessed May 20, 2018.
• Najm W, Lie D. Dietary supplements commonly used for prevention. Prim Care. 2008;35(4):749-767. doi: 10.1016/j.pop.2008.07.010.
• Probiotic basics. California Dairy Research Foundation website. cdrf.org/home/checkoff-investments/usprobiotics/probiotics-basics/. Accessed May 20, 2018.
• McQueen C. Nonbotanical natural medicines. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012.
• Goldenberg JZ, MA SS, Saxton JD, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev. 2013;(5):CD006095. doi: 10.1002/1465185CD006095.pub3.
• Navarro-López V, Ramírez-Boscá A, Ramón-Vidal D, et al. Effect of oral administration of a mixture of probiotic strains on SCORAD Index and use of topical steroids in young patients with moderate atopic dermatitis: a randomized clinical trial. JAMA Dermatol. 2018;154(1):37-43. doi:10.1001/jamadermatol.2017.364.
• Growing evidence that probiotics are good for your liver. ScienceDaily. sciencedaily.com/releases/2018/04/180423085445.htm. Published April 23, 2018. Updated June 18, 2018.
• Trick WE, Sokalski SJ, Johnson S, et al. Effectiveness of probiotic for primary prevention of Clostridium difficile infection: a single center before-and-after quality improvement intervention at a tertiary-care medical center [published online April 26, 2018]. Infect Control Hosp Epidemiol. doi: 10.1017/ice.2018.76.
• Johnston BC, Lytvyn L, Lo CK, et al. Microbial preparations (probiotics) for the prevention of Clostridium difficile infection in adults and children: an individual patient data meta-analysis of 6851 participants [published online April 26, 2018]. Infect Control Hosp Epidemiol. doi: 10.1017/ice.2018.84.
• Pinto-Sanchez MI, Hall GB, Ghajar K, et al. Probiotic Bifidobacterium longum NCC3001 reduces depression scores and alters brain activity: a pilot study in patients with irritable bowel syndrome. Gastroenterology. 2017;153(2):448-459.e8. doi: 10.1053/j.gastro.2017.05.003.