Health care providers (HCPs) are recommending probiotic use to their patients. A telephone survey (Abe et al. 2013) of academic hospital formularies (114 of 126 responded) found that 87% carried at least one probiotic. Such use is likely driven by clinical trials demonstrating efficacy of some strains for some conditions, the excellent safety record of probiotics for the general consumer and the low cost of probiotic products relative to drug and other medical interventions. However, the probiotics recommended don’t always conform to the best scientific support. It seems that HCPs know enough about the science to suspect there is some validity to probiotic use, but not necessarily enough to recommend the most proven probiotics for a given condition. For example, Williams et al. (2010) found that ~15% of GI specialists believe that the literature supports probiotic use for Crohn’s disease, even though no such evidence exists.
A recent paper suggests an information gap on probiotic use exists among pharmacists as well (Dorval, 2015). Although several errors1 in this paper suggest that the author may not be a probiotic specialist and I don’t fully agree with the article conclusions, I sympathize with the author’s desire for clearer information regarding how pharmacists can advise consumers about probiotic efficacy and safety.
My suggestions for HCPs follow, although a concise, independently produced, evidence-based guideline for clinical use of probiotics in the United States would go far to clarify best probiotic recommendations for HCPs.
The International Scientific Association for Probiotics and Prebiotics posts a general guideline with basic considerations for choosing a probiotic. Probiotics: A Consumer Guide for Making Smart Choices. But this falls short of giving product- and condition-specific recommendations.
The closest any recommendations come to this are found in the following:
- World Gastroenterology Organisation Practice Guideline on Probiotics and Prebiotics(October 2011). Note especially Tables 8 and 9, which list strains associated with graded evidence for GI benefits for pediatric and adult use.
- Clinical Guide to Probiotic Supplements Available in Canada, PDF version.2015 Edition. An independent tool for healthcare professionals, developed by the Alliance for Education on Probiotics (AEP) and made possible through an unrestricted education grant by Danone, Ferring Pharmaceuticals, Metagenics and P&G Professional. For an interactive version, free downloaded under the name Probiotic in App Store and Google Play.
Other guidelines or recommendations:
- Probiotics for GI Health in 2012: Issues and Updates,a CME course, includes assessment of probiotics for GI benefits. The course is no longer available for CME credit, but the content is available. Note especially Table 1, which provides a list of probiotics associated with graded evidence of GI benefits. Online source. PDF.
- Probiotics for Gastrointestinal Diseases, by R Balfour Sartor, MD for UpToDate®. This is an evidence-based, physician-authored clinical decision support resource for clinicians, healthcare providers and patients. Accessing this article requires a subscription.
- Ciorba MA. A Gastroenterologist’s Guide to Probiotics.
- Use of probiotics for antibiotic associated diarrhea. [PURLs: prescribing an antibiotic? Pair it with probiotics. Rodgers et al. J Fam Pract. 2013 Mar;62(3):148-50.]
- Use of probiotics for pediatric ulcerative colitis. [Management of pediatric ulcerative colitis: joint ECCO and ESPGHAN evidence-based consensus guidelines.Turner et al; European Crohn’s and Colitis Organization; European Society for Paediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2012 Sep;55(3):340-61.]
- Use of yogurt cultures to manage symptoms of lactose intolerance [EFSA Panel on Dietetic Products, Nutrition and Allergy. Scientific Opinion on the substantiation of health claims related to live yoghurt cultures and improved lactose digestion(ID 1143, 2976) pursuant to Article 13(1) of Regulation (EC) No 1924/2006. EFSA Journal 8, 1763 (2010).]
- Use of probiotics to manage functional bowel symptoms. [Systematic review: probiotics in the management of lower gastrointestinal symptoms in clinical practice — an evidence-based international guide. Hungin et al. Aliment Pharmacol Ther. 2013 Oct;38(8):864-86.]
- Use of probiotics for acute pediataric gastroenteritis. [Review article: the management of acute gastroenteritis in children. Pieścik-Lech et al. Aliment Pharmacol Ther. 2013 Feb;37(3):289-303.]
A probiotic’s safety must be considered in the context of (1) the characteristics of the probiotic microorganism, (2) dose and delivery means for the probiotic, and (3) the vulnerability of the population using the probiotic. Although typically few or no adverse effects are observed with oral consumption of commercial food and dietary supplement forms of probiotics by the generally healthy population, this does NOT mean that all conceivable uses of all conceivable probiotic strains are safe. Probiotics marketed as foods and dietary supplements in the United States are safe for the general population (no additional safety trials are needed to establish this), but safety may not have been tested in individuals with underlying health conditions. Some associations between probiotics and septicemia or other infections have been documented for people with serious underlying health conditions. If a probiotic will be used in vulnerable populations, a pharmacist should contact the manufacturer to determine if suitable safety testing has been done on the marketed product for that population.
Take home points
- Differences in diet, colonizing microbiota and other host factors may impact a probiotic’s efficacy. Therefore, probiotic effects may vary among individuals.
- Probiotics differ with regard to strain(s), dose, storage requirements, delivery format and strength of evidence.
- Traditional probiotics (Lactobacillus, Bifidobacterium and Saccharomyces species) are typically well-tolerated by the general population
- Most probiotics in the United States are foods or dietary supplements, and are safe for the general population. Use caution when recommending for vulnerable populations.
- Paper states that probiotic dietary supplements may contain strains of Enterococcus, Bacillus, Streptococcus, and Escherichia, “which are less commonly found in the intestinal tract.” In fact, all these genera are found in the intestinal tract, especially Escherichia and Bacillus.
- Paper states that “Currently, any product containing probiotics is considered a dietary supplement”. In fact, as stated earlier in this paper, some probiotic products are foods, not dietary supplements, and as such are NOT governed by DSHEA.
- Paper states that “probiotics have been advertised for…” and a list of several diseases follows. In fact, dietary supplements cannot carry such advertisements. There are published studies on these endpoints, but not advertising.