Choose bugs not drugs

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What are the correct probiotics to advise your ill patients to take? Should your well patients be on probiotic supplements? What doses are appropriate? Can they cause harm?
Do you know how to choose and use a probiotic properly?
Marketing has gotten out of hand, and gastroenterology professionals need to understand the oftentimes scanty data that exists on probiotic usage. Join us and learn to use this age old tool made new again.

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Choose bugs not drugs

  1. 1. Choose Bugs notDrugs:On Choosing and Using theProper ProbioticPatricia L Raymond MD FACGRx For Sanity, Norfolk VA
  2. 2. 10,000,000,000,000,000,000
  3. 3. Alter the world within• Antibiotics• Prebiotics > dietary components that promote the growth and metabolic activity of beneficial bacteria• Probiotics > beneficial bacteria• Synbiotics > Combination of these methods
  4. 4. Probiotics are not all the same• What disease or outcome• What bacteria or yeast• What dosage• No ―One size fits all‖• Data is spotty; will stick with what is known and avoid the hype.
  5. 5. Probiotic to ‗maintain intestinal health‘
  6. 6. IPAA in Ulcerative Colitis • proctocolectomy with ileal pouch- anal anastomosis (IPAA) • Many develop ‗pouchitis‘ > acute or chronic inflammation of the ileal reservoir Image from http://knol.google.com/k/an-overview-of-rectal-surgery#
  7. 7. Pouchitis in Ulcerative Colitis• Increased stool frequency, urgency, hematochezia, abdominal pain, fever > 20 % of UC patients in the first year > 50 % of UC patients after five years > < 1 % with colectomies to treat familial polyposis Image: doi: 10.2214/AJR.05.1019 AJR October 2006 vol. 187 no. 4 W386-W391
  8. 8. Pouchitis is an infectious disease• Unique flora patterns > persistence of Fusobacteria and enteric species, increased Clostridium perfringens, and the absence of Streptococcus species in the inflamed pouch > responds to antibiotic therapy > VSL#3 effective in prevention of recurrent pouchitis after antibiotic induction of remission
  9. 9. VSL#3 and pouchitis• 40 patients with chronic, relapsing pouchitis• Abx for clinical and endoscopic remission• randomized to VSL#3 6 g/day or placebo• At 9 months: 15% VSL#3 and 100% placebo relapsed• Treatment stopped: 3 months later all VSL#3 relapsed
  10. 10. Ulcerative Colitis:Prevention of relapse• E. coli 1917 Nissle was as effective as low dose 5-ASA in preventing relapse of ulcerative colitis in adults• Lactobacillus GG appeared to be more effective than standard treatment involving mesalazine in prolonging relapse-free time• The combination of VSL#3 plus balsalazide was slightly more effective than balsalazide or mesalazine alone in a randomized trial of patients with acute mild-to-moderate ulcerative colitis• A randomized trial involving 29 children with ulcerative colitis found that VSL#3 was more effective than placebo in maintaining remission (73 versus 21 percent at one year) when given in conjunction with steroid induction and mesalamine maintenance treatment
  11. 11. VSL#3 induction of UC remission• Randomized trial of 77 • Randomized trial of 144 patients patients who were• UCDAI reduction by 50 % receiving a 5-ASA, at six weeks (33 % VSL#3 azathioprine, and/or versus 10% placebo) methotrexate• inducing remission at 12 • UCDAI reduction by 50 % weeks (43% VSL#3 at six weeks (63 % VSL#3 versus 16 % placebo) versus 41% placebo) • Induction of remission (48% VSL#3 versus 32 % placebo) • Histologic scores were not significantly improved with VSL#3 therapy
  12. 12. CD: Lacking what should be there?• Faecalibacterium prausnitzii > secretes yet to be defined products — suppress experimental colitis and proinflammatory cytokines > decreased in Crohn‘s disease — human Crohn‘s patients who underwent bowel surgery were more likely to recur if they had reduced numbers of F. prausnitzii http://blog.crohn.org.es/archivos/2008/10/30/ faecalibacterium-prausnitzii-posible-causa-de-la-ec/
  13. 13. ―…the available data do not support clinical effectiveness of probiotic therapy for either induction or maintenance of remission in patients with Crohns disease…‖CROHN’S DISEASE: NOTTHERE YET.
  14. 14. Acute diarrhea & probiotics• 52 % reduction in antibiotic-associated diarrhea (95% CI 35 to 65 percent).• 8 % reduction in travelers diarrhea (95% CI -6 to 21 percent).• 57 % reduction in risk of acute diarrhea of various causes in children (95% CI 37 to 51 percent) > 26 % reduction in adults (95% CI 7 to 49 percent).• Metanalysis: protective effects did not vary significantly among the probiotics strains Saccharomyces boulardii, Lactobacillus rhamnosus GG, Lactobacillus acidophilus, Lactobacillus bulgaricus and other strains used alone or in combination of two or more strains.
  15. 15. Antibiotic associated diarrhea• reviews suggest that probiotics (including various bacterial species and the yeast S. boulardii) are effective in reducing the incidence of diarrhea in patients who are taking antibiotics• little detailed information regarding the optimal dose or timing• probiotics may shorten the period of AAD diarrhea in patients who have already developed it
  16. 16. Too many choices
  17. 17. Recurrent C difficile colitis• 124 patients with CDAD • 32 patients recurrent CDAD > 64 initial episode of CDD • treated with oral vancomycin +/- > 60 with history of at least one prior S. boulardii CDD • Less recurrent CDAD was• 4 weeks of S. boulardii or observed among those placebo (+ treatment with receiving probiotics (16.7 vanco or metronidazole) versus 50 %)• Recurrent CDAD > Recurrence rate 34.6% on S boulardii compared with 64.7% on placebo• Initial episode of CDAD: > recurrence rate (about 20%) was the same in both groups. http://emedicine.medscape.com/article/186458-overview
  18. 18. H. Pylori & probiotics• S. boulardii improves HP regimen‘s diarrhea, epigastric discomfort, and treatment tolerability• decreased post- treatment dyspepsia symptoms independent of H. pylori status• no significant affect on the rate of H. pylori eradication
  19. 19. Necrotizing enterocolitis (NEC)• one in 2,000 to 4,000 births, between 1% and 5% of NICU admissions• 10% of premature infants, rare in full term infants.• ischemic necrosis of the intestinal mucosa, invasion of enteric gas forming organisms, and dissection of gas into the portal venous system• high morbidity & mortality, especially in premies http://www.chla.org/site/c.ipINKTOAJsG/b.4356869/k.7128/ Necrotizing_Enterocolitis.htm
  20. 20. Necrotizing enterocolitis (NEC)Review 2176 patients from 11trials:• Probiotics versus controls were less likely to develop NEC (2.4% versus 6.6%)• Infants who received probiotics had a lower mortality rate (RR 0.42, 95% CI 0.29 -0.62)• No differences in the rates of nosocomial sepsis, days to full feeds, or length of stay between infants who received probiotics and controls.• Optimal strain(s) and dosing regimen remain uncertain http://www.radswiki.net/main/index.php?title= Necrotizing_enterocolitis
  21. 21. The world of probiotics (outside the GI tract)
  22. 22. Urinary system• > 50% of women will • Lactobacillus have at least one UTI rhamnosus GR-1 and during their lifetime L. reuteri for > 30 - 40% of UTIs recur prevention and within 6 months after treatment of recurrent the initial episode UTI • Mutaflor (E coli Nissle) • Lactobacillus crispatus > vaginal • VSL#3 & oxalate kidney stones
  23. 23. Atopic dermatitis & probiotics• inflammatory, chronically relapsing, non- contagious and pruritic skin disorder• Various probiotics, http://www.dermafoto.com/diseases/atopic-dermatitis/ live and heat treated
  24. 24. Childhood eczema• risk reduction for atopic eczema in children aged 2-7 years by the administration of lactobacilli to mother during pregnancy (reduction 5·7 %; P = 0·022). http://latwanasstephens.com/could-you-be- suffering-from-atopic-eczema.php
  25. 25. Aging & probiotics• Lactobacillus johnsonii & sun damaged skin• Lactococcus lactis subsp. cremoris H61 (strain H61) to accelerated aging mice > reduced bone density loss > suppression of skin ulcers > reduced hair loss
  26. 26. Fatty liver in obese children• L. rhamnosus strain GG & pediatric obesity related NASH
  27. 27. ―While it may be premature toconclude which specific groups ofbacteria are prominent in the intestinaltract of overweight and obese subjects,it appears clear that microbescontribute to weight gain and relatedhealth issues…‖ OBESITY & PROBIOTICS
  28. 28. Probiotics: Yes or NoYes NO• Pouchitis • Crohn‘s disease• Ulcerative colitis • Radiation enteritis• Infectious diarrhea • Pancreatitis–• NEC in newborn Nooooooooo!
  29. 29. Probiotics: Murky businessMaybe: Not clear:• Antibiotic • Lactose intolerance associated diarrhea • Hepatic• H pylori encephalopathy• Recurrent UTI • Allergy• Diverticulitis • SIBO• Collagenous colitis• IBS
  30. 30. Probiotics: Big business too
  31. 31. OTC medicinal probiotics• VSL#3® (5 X 1011 per gram of four Lactobacillus species, three Bifidobacterium species, and one strain of Streptococcus salivarius subspecies thermophilus)• Align® (B. infantis)• Culturelle® (L. rhamnosus GG)• Mutaflor® (E. coli Nissle 1917)• Florastor® (Saccharomyces boulardii)
  32. 32. OTC probiotic supplements• Phillips‘ Colon Health • Trunature Digestive Probiotic > Lactobacillus gasseri, > Lactobacillus acidophilus, Bifidobacterium bifidum, Bifidobacterium lactis Bifidobacterium longum • Digestive Advantage• Ganaden Sustenex Daily > Bacillus coagulans — 4 versions: Probiotic > Intensive Bowel Support > Bacillus coagulans — B coagulans + lysine > Lactose Defense• Shaklee Optiflora® — B coagulans + lactase Probiotic Complex > Gas Defense — B coagulans + various > Bifidobacterium longum, cellulases, invertases, Lactobacillus acidophilus, galactosidase prebiotics FOS and inulin > Daily Constipation — B coagulans + fiber
  33. 33. Natural Probiotics• Fermented milk • Fermented soy > Yogurt > Natto — Dannon Activia > Miso — Stoneyfield Farms > Tempeh — Dan Active (L. casei) • Fermented > Kefir grains cabbage > Kimche > Sauerkraut
  34. 34. Medicinal Foods• Kefir grains (KAH-fear) > traditional kefir was made in skin bags that were hung near a doorway > fermented milk drink > jostled by anyone passing > shepherds of the North through the doorway to help keep the milk and kefir Caucasus region grains well mixed — discovered that fresh milk carried in leather pouches would occasionally ferment into an effervescent beverage > prepared by inoculating cow, goat, or sheeps milk with kefir grains.
  35. 35. Medicinal Foods• Kefir grains > contain a water soluble > a combination of bacteria and polysaccharide known as yeasts in a matrix of proteins, kefiran, which imparts a rope- lipids, and sugars, and this like texture and feeling in the symbiotic matrix forms "grains" mouth; appear in hues ranging that resemble cauliflower. For from white to yellow; and this reason, a complex and usually grow to the size of highly variable community of walnuts (although rice-grain- lactic acid bacteria and yeasts sized grains have been known can be found in these grains. to develop).
  36. 36. Medicinal Foods > lactobacillus kefiranofaciens and lactobacillus delbrueckii subspecies > bulgaricus produce what is known as kefiran — experiments on animals  kefiran was found to exhibit anti-tumor and anti-inflammatory properties  reduced blood pressure, blood glucose and cholesterol levels in rats.
  37. 37. Natto• fermented soybean from the • rich in vitamin K which is Japanese essential for healthy blood clotting as well as protection• bacterial strain bacillus against bone fractures and subtilis osteoporosis • Also contains an enzyme called nattokinase which has been observed to dissolve blood clots in animal tests • works by breaking down fibrin, a protein which can lead to heart attack, stroke, poor circulation and slow tissue repair when present in excess.
  38. 38. Kimchi• Korean cabbage with a • lactobacillus kimchii as host of other seasonings well as other lactic acid and ingredients, like hot bacteria pepper flakes, radish, • ? beneficial to GI and carrot, garlic, ginger, immune systems. onion, salt and fish sauce. • typical kimchi with• left to ferment from a few Chinese cabbage, carrot, days to a couple of weeks garlic, ginger, onion and pepper is also high in vitamin A, C, B1, B2, beta-carotene, calcium and iron. • animal studies suggest that kimchi may be effective against the avian flu virus.
  39. 39. Miso• produced by fermenting • miso is high in vitamin B12 soybean, barley, brown rice, or • trace minerals such as zinc, other grains with a type of copper and manganese fungus known as koji (aspergillus oryzae)• fermentation process from a few days to a couple of years• end result is a red, white or dark brown colored paste with a buttery texture• the darker the color of the miso, the saltier and stronger the flavor
  40. 40. Tempeh• Indonesian fermented soybeans• adding a tempeh starter containing the fungus rhizopus oligosporus to partially cooked soybeans and allowing the dehulled beans to ferment for about a day or two• the gaps in between the beans will be filled completely with a thin layer of white fungi which binds the soybeans tightly together into a compact piece of cake• a slight ammonia smell and flavor that can be reduced with cooking• a nutty taste that is reminiscent of meat, making tempeh a good substitute for meat.
  41. 41. Tempeh • Rhizopus oligosporus produces an antibiotic effective against certain bacteria, including staphylococcus aureus
  42. 42. Sauerkraut• allow salted cabbage to ferment on its own without the addition of any starter or vinegar for two weeks or more.• Sauerkraut is sour in taste due to the formation of lactic acid during the fermentation of cabbage.
  43. 43. Sauerkraut • Like kimchi, sauerkraut is high in vitamin C and digestive enzymes • good source of natural lactic acid bacteria such as lactobacillus and pediococcus • juice from sauerkraut is reportedly good against gastrointestinal conditions like diarrhea and constipation, and is recommended as an effective flu preventive beverage
  44. 44. A word on prebiotics• non-digestible food ingredients that stimulate the growth and/or activity of bacteria in the digestive system > Oligofructose > Inulin > Galactooligosaccharides — (aka GOS) NEW!
  45. 45. Short-chain, long-chain, and full-spectrumprebiotics• ―Short-chain" prebiotics • Full-spectrum prebiotics > Oligofructose > full range of molecular > 2-8 links per saccharide link-lengths from 2-64 molecule links per molecule > fermented more quickly in > nourish bacteria the right-side of the colon throughout the colon providing nourishment to > Oligofructose-Enriched the bacteria in that area Inulin (OEI).• Longer-chain prebiotics > Inulin > contains 9-64 links per saccharide molecule > ferments more slowly, nourishing bacteria predominantly in the left- side colon
  46. 46. RDA of prebiotics? Food to achieve 6g serving prebiotics• 4-8g/d for general digestive health support Raw Chicory Root 1/3 oz• 15g/d or more for those with active digestive Raw Jerusalem Artichoke 3/4 oz disorders. Raw Dandelion Greens < 1 oz Raw Garlic 1.2 oz Raw Leek 1.8 oz Raw Onion 2.5 oz Cooked Onion 1/4 lb Raw Asparagus 1/4 lb Raw Wheat Bran 1/4 lb Whole Wheat Flour 1/4 lb Raw Banana 1.3 lb
  47. 47. Future of probiotics• genetically engineered bacteria > secrete immunomodulators — interleukin-10 or trefoil factors
  48. 48. Probiotics & colon cancer?• Lactobacillus reuteri ATCC PTA 6475• regulates the proliferation of cancer cells and promotes cancer cell death• may lead to development of probiotic-based regimens for preventing colorectal cancer and inflammatory bowel disease.
  49. 49. Nurture your inner world • Add some prebiotic food to your diet • Add some probiotic food to your diet • Avoid antibiotics unless necessary • Avoid commercial probiotics unless for studied issue, then choose proper bacteria/yeast in proper dose.
  50. 50. Bacterial Girlby Jacqueline GaulinAdditional lyrics Ms Butt MeddlerSome bugs heal me, some bugs hurt meWhich ones are OK?Without the proper probioticMy gut goes astray
  51. 51. Bacterial Girlby Jacqueline GaulinAdditional lyrics Ms Butt MeddlerPost anti-biotic treatmentThe data‘s black and white, that‘s rightHeap healthy flora in your bowels andMake your guts work right, cause weare
  52. 52. Bacterial Girlby Jacqueline GaulinAdditional lyrics Ms Butt Meddler[Chorus:]Living in a bacterial worldAnd I am a bacterial girlYou know that we are living in abacterial worldAnd I am a bacterial girl
  53. 53. Bacterial Girlby Jacqueline GaulinAdditional lyrics Ms Butt MeddlerSaccharomyces, E. Coli NissleRhamnosis, ReuteraeOnly the precise bacteriaSteals my disease away
  54. 54. Bacterial Girlby Jacqueline GaulinAdditional lyrics Ms Butt MeddlerBugs cork me up, bugs help me goAnd thats all right you seeBe unafraid, they don‘t invade,They‘re colonizing me, causeeverybodys
  55. 55. Bacterial Girlby Jacqueline GaulinAdditional lyrics Ms Butt Meddler[Chorus:]Living in a bacterial worldAnd I am a bacterial girlYou know that we are living in abacterial worldAnd I am a bacterial girl
  56. 56. Choose Bugs notDrugs:On Choosing and Using theProper ProbioticPatricia L Raymond MD FACGRx For Sanity, Norfolk VA

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