The Evidence for Probiotics in IBD
In the last blog I discussed probiotic use in IBD and three considerations to consider before purchasing a probiotic. If you haven’t already- check it out. It will help break down the reasons why this topic can be so polarizing.
In this blog I’ll provide an overview of some (but definitely not all) of the research on probiotics in IBD.
In our practice there are many considerations we have before advising on which probiotic is best for someone- so be sure to check in with your health care team and IBD dietitian to get guidance on how to best use this information.
Probiotics for UC
There are a variety of probiotics that can be used to help induce remission and reduce symptoms in UC patients. We have narrowed the list down to our most commonly recommended probiotics below.
A Meta-analysis found Visbiome (formerly VSL #3) to be effective in inducing remission in active ulcerative colitis. It was found that Visbiome may be effective in inducing remission in active UC. Visbiome probiotics in this meta-analysis study were found to be as effective in preventing a relapse of UC as 5 Aminosacylates– the common drugs used to treat IBD. 
The LGG strain was found to be equally effective as mesalamine in maintaining clinical remission and significantly more effective than mesalamine in prolonging the relapse-free time. 
Biome Restore is one of our top recommendations because of its use with both UC and IBS symptom reduction (see below). In mild to moderate Ulcerative Colitis patients the L.plantarum 299v strain in a drink form has also shown some use with helping to reduce symptoms like bloating, stool frequency, abdominal pain and helping to induce remission . The L.plantarum 299v strain can also help with reducing antibiotic associated diarrhea, and reduce risk of C.diff infection in critically ill patients .
For those of you less familiar with this type of colitis- microscopic colitis is a less common type of inflammatory bowel disease that affects the large intestine. The two types of microscopic colitis are lymphocytic and collagenous colitis.
The most common symptom is persistent watery diarrhea. Microscopic colitis got its name from the fact that tissue typically appears normal in a colonoscopy and requires a microscope to diagnose.
I’ve listed two strain combinations that we know of so far that have evidence for microscopic colitis.
Lactobacillus acidophilus La5 and Bifidobacterium lactis Bb12
In a study looking at using probiotic strains Lactobacillus acidophilus La5 and Bifidobacterium lactis Bb12- compared to baseline- there was a reduction in weekly bowel frequency and a reduction in number of days with liquid stools per week- from 6 to only 1. 
Patients with active microscopic colitis who received Visbiome (VSL#3) at a dose of 900 billion CFU’s when compared to patients receiving mesalamine at 1.6 g/day, had a clinical remission rate of 46% of patients compared to 8% in the mesalamine group, and less stool mucus after 8 weeks of supplementation. 
Probiotics for Crohn’s
With Crohn’s Disease there are less options for evidence based probiotics than with Ulcerative Colitis. In fact, there are studies showing negative results with strains Lactobacillus rhamnosus GG and Lactobacillus johnsonii LAI (13, 11).
In our practice we take a variety of different approaches with Crohn’s when it comes to evaluating which supplementation will yield the best and fastest results. Oftentimes rather than probiotics, we use prebiotics to reduce symptoms.
If there are more IBS symptoms present we might also consider using a probiotic with evidence for reducing symptoms. When it comes to reducing Crohn’s activity and symptoms specifically, there is only one strain to date with evidence.
In CD patients with mild-moderate activity, co-administration of this strain supplemented led to a significant reduction in stool frequency and improvements in CDAI index (8). In combination with mesalamine, using the biocodex strain led to reduced relapse rate compared to mesalamine alone- 6% vs 38% (link).
It’s important to also acknowledge that there have been some studies that show some reaction to saccharomyces cerevisiae, but this is not true for the biocodex strain. FloraStor is the only brand currently that I’m aware of that carries this strain.
Pouchitis can occur after surgery to treat ulcerative colitis or certain other diseases. Many people with ulcerative colitis need to have their colon removed and the bowel reconnected with a procedure called J-pouch surgery.
Pouchitis is inflammation that occurs in the lining of a pouch created during surgery to treat ulcerative colitis or certain other diseases. Although it’s not an extensive list, there are a few strains of probiotics that can be both helpful in the treatment and prevention of pouchitis.
In patients who underwent surgery ulcerative colitis, 1-year supplementation with Visbiome (VSL#3) at 900 billion CFU’s a day immediately after ileostomy closure, significantly reduced episodes of acute pouchitis and improved quality of life. 
In those patients that already had pouchitis and were treated with Visbiome- 69% of subjects achieved remission after treatment; significant reductions in mean pouchitis disease activity index scores from baseline 
Significantly delayed first onset of pouchitis compared to no-treatment controls. The risk for pouchitis increases by year 3, while those on the LGG strain were able to prolong the onset up to 7 years. 
Probiotics for IBS
Approximately, half of those with Inflammatory Bowel Disease also have IBS or irritation symptoms despite being in clinical remission without inflammation . In addition, compared to the general population, those of us with IBD have a three fold greater chance of having IBS symptoms .
While inflammation reduction and reduced risk of flare is the priority for IBD patients, helping support symptom reduction can greatly improve quality of life. There are many probiotics I wanted to include here for IBS- both food based and supplement versions.
To keep things brief- I kept the list to my all time favorite strain that we have seen the most positive results in using.
Biome Restore is my most commonly used probiotic because it’s one I’ve had the highest success rate with for those that suffer with painful abdominal pain and bloating . The strain found in Biome Restore was shown in a 4 week treatment period to reduce painful IBS symptoms like bloating and abdominal pain in 78% of the individuals that took it .
Probiotics, Mental Health & IBD
Often when we discuss IBD symptoms, we only talk about gut symptoms. However, many IBD patients also deal with depression, anxiety and medical trauma. This can significantly impact quality of life and even impact our ability to recover and respond to treatment interventions.
While I’ll be covering this in more depth in my next post, I did want to call out two probiotic strains with promising early evidence to support mental health especially when combined with other layers of support.
Lactobacillus helveticus R0052 & Bifidobacterium longum R0175
In a randomized, placebo controlled human study of 55 volunteers (age- 33-60) with mild depression or anxiety, some took a placebo while others took a mixture of 3 billion CFU’s of the probiotic and they found :
- 50% improvement in depression scores
- 36% improvement in hospital anxiety and depression scale
- 49% improvement in global severity index (measures stress)
- 60% improvement in anger-hostility scores
- 13% decrease in urinary cortisol (measure of stress)
- Improvements also in self blame and problem solving
- Three weeks after, probiotic group had 7.6 times the reduction in abdominal pain compared to placebo, 2.1 times less stress induced nausea and vomiting, 2.9 times less gas and bloating
A Final Note on Probiotics
You might be wondering- how do you know if probiotics are working? It isn’t easy to determine this based on symptoms alone. As I’ve mentioned in other articles on the types of remission, symptoms alone aren’t always the best indicator of inflammation and our IBD.
We can be symptom free and have ongoing disease activity and inflammation AND we can also have irritation symptoms like gas, bloating, diarrhea (etc) and have no inflammation present.
The research on probiotics and IBD can vary quite a bit on how long it takes to see results with some studies showing symptoms improving 6 months to a year after taking probiotics.
It’s important to realize that most of the time it’s not one thing that makes a difference for IBD- it’s a layered approach of bringing in many evidence based strategies with probiotics having the potential to be one of them.
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