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Probiotics for the Gut - A Guide for Primary Care Physicians

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Probiotics have been shown to be of benefit in several gut disorders. Today, probiotics are a multibillion dollar industry, with a myriad of options that can be confusing. This presentation introduces the fundamentals of probiotics to primary care doctors for use in their daily practice.

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Probiotics for the Gut - A Guide for Primary Care Physicians

  1. 1. Probiotics for the Gut A Guide for Primary Care Physicians Dr Jarrod Lee Gastroenterologist & Advanced Endoscopist Mt Elizabeth Novena Hospital 1
  2. 2. Ilya Metchnikov (1845 – 1916) • “The Father of Probiotics” • Russian biologist, zoologist and protozoologist • Nobel prize in 1908 for work on phagocytosis • “Prolongation of Life: Optimistic Studies” (1907) – Proposed that ingesting bacteria could have health benefits and prolong life 2
  3. 3. Human body • 10 trillion human cells; 23,000 human genes • 100 trillion bacteria; 3 million genes “If gut bacteria are making you ill, can swapping them out make you healthy?” 3Economist 2012
  4. 4. 4 Gut Microbiota
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  9. 9. How Do We Start? 9
  10. 10. Definitions • Probiotics: – Live microorganisms that confer a health benefit on the host when administered in adequate amounts • Prebiotic: – Dietary substances that nurture a selected group of micro- organisms in the gut – Favouring the growth of beneficial over harmful bacteria • Synbiotics: – Products that contain both probiotics and prebiotics 10
  11. 11. Lactic Acid Bacteria • Used for preservation of food by fermentation for thousands of years – Fermentation: process by which a microorganism transforms food into other products • Found in many yoghurts – But yoghurts not considered probiotics as not shown to have an adequate number of viable bacteria specifically shown to confer health benefits • Includes Lactobacillus, Lactococcus, Streptococcus 11
  12. 12. Lactic Acid Bacteria 12
  13. 13. Probiotic Nomenclature • Probiotic strains are identified by genus, species and an alphanumeric designation • Marketing and trade names are not regulated, e.g. LGG 13 Genus Species Strain Lactobacillus rhamnosus GG Lactobacillus casei DN-144 001
  14. 14. Legal Definition NONE!!! 2011 WGO Minimum Criteria: • Specified by genus and strain • Alive • Delivered in adequate dose through end of shelf life • Efficacious in controlled human studies • Safe for intended use 14
  15. 15. Prebiotics • Mostly used as food ingredients – E.g. biscuits, cereals, chocolates, spreads, dairy products • Common prebiotics: oligofructose, inulin, lactulose – Oligofructose found naturally in: wheat, onions, bananas, honey, garlic, leeks • Fermentation of oligofructose in colon: – Increases bifidobacteria numbers – Increases fecal weight, and shortens GI transit time • Increased colonic bifidobacteria inhibits pathogens, reduces ammonia levels, and produces vitamins 15
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  17. 17. 17 Clinical Indications
  18. 18. How Does It Work? 18
  19. 19. Infectious Diarrhea • Treatment – 2004 Cochrane review (23 RCTs, 1917 patients) showed probiotics significantly reduced diarrhea duration by a mean of 30.5 hours – 2007 meta-analysis showed similar effect in children • Prevention – 2007 meta-analysis (12 RCTs, 4709 patients) showed modest decrease in risk of travellers diarrhea with probiotics; RR 0.85 19BMJ 2007; Travel Med Infect Dis 2007
  20. 20. Antibiotic Associated Diarrhea • Antibiotics cause disturbances in gut flora which lead to reduced resistance to pathogens such as Clostridium difficile • Latest meta-analyses: 2013 Cochrane review – 23 RCTs, 4213 patients (adults and children) – Probiotics significantly reduced risk of diarrhea by 64% (2.0% vs 5.5%) – Adverse events reduced by 20% – Similar findings in earlier meta-analyses • Greatest benefit if started within 72H of antibiotics 20
  21. 21. • 19 RCTs, 1650 patients • Probiotics significantly better than placebo – RR of symptoms persisting 0.71 – NNT 4 • No difference in type of probiotic used • More useful for pain, bloating, global improvement • A meta-analysis of 3 RCTs showed similar effect in children 21Gut 2010; APT 2011
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  23. 23. Safety • Safe, few side effects – Flatulence and mild discomfort – Mild, self limited – No long term safety data • No known interactions with other medications or supplements • Rare reports of pathological infection • Avoid in: short gut syndrome, severely ill or immune compromised patients 23
  24. 24. What Probiotic Strain? • Lactobacillus and Bifidobacterium species – Have the most evidence for digestive disorders – Preferred probiotics for these conditions – Lactobacillus (especially LGG) has strongest evidence for acute infectious diarrhea – Bifidobacterium has strongest evidence for IBS • Saccharomyces boulardii – probiotic yeast strain – proven to be beneficial in diarrhoea conditions – potential advantage of resistance to most antibiotics 24
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  26. 26. What Dose? • In general, higher dosages of > 5 billion CFUs per day in children, and > 10 billion CFUs per day in adults were associated with better outcomes • Studies with Saccharomyces boulardii use a dose of 250 to 500 mg per day • No evidence that even higher dosages are unsafe, but may be more expensive and unnecessary 26
  27. 27. How Long? • Survive in the human gut and detectable in stool • Do not colonize the gut and not detectable 1-4 weeks after stopping • Sustained benefit requires continued consumption 27
  28. 28. Which One to Choose? 28
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  30. 30. Lacteol Fort • Lactobacillus acidophilus • Heat killed and freeze dried • Works by exclusion: – Adheres to brush border cells – Prevents pathogens from attaching, colonizing and drawing fluid • “Stimulates growth of acidogenic flora and IgA synthesis” 30
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  34. 34. Conclusion Probiotics are: • Well proven in studies for specific gut disorders • Safe to use, but avoid in short gut, severely ill or immune compromised patients • Symptomatic effects may be modest; may be best used as adjuncts rather than replacements for conventional therapy • Selection should consider clinical indication, strain and dosage 34
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  36. 36. Thank You Questions to drjarrodlee@gmail.com 36

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