Are Probiotics Effective for IBD?

Evidence For and Against Taking a Probiotic for Crohn's or Ulcerative Colitis

Lactobacillus bulgaricus bacteria
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How our microbiome affects the development of inflammatory bowel disease (IBD) is a hot topic for both discussion and research. The microbiome refers to all the microorganisms (bacteria and microbes) that are living in our bodies. The microbiome of the large intestine in particular is being studied in relation to Crohn's disease and ulcerative colitis, because of the idea that either IBD is a result of a disruption in the microbiome, or that IBD causes that disruption.

Following from that is the idea that if the microbiome can be corrected, and the "right" mix of bacteria can be cultivated in the digestive tract, that IBD could be affected or even treated.

Enter probiotics, which are "friendly" bacteria that are ingested, either by eating them or by taking a supplement. Probiotics are expensive, and their popularity is growing, but are they worth the monetary investment when it comes to IBD? And even further: They are not regulated by the Food and Drug Administration, raising the question of whether or not they could cause any harm.

Important points to keep in mind about using probiotics in IBD:

  • It's not yet completely understood how the microbiome is affected by IBD.
  • Some probiotics may be effective in IBD, but more research is needed.
  • One commercially available probiotic has been shown effective for pouchitis in people with j-pouches.
  • Probiotics can be expensive and unless the "right" strain is used, might not provide any benefit.
  • Probiotics may be harmful in people who have weakened immune systems and in infants.
  • Probiotic supplements should be used on the advice of a physician.

What's the Microbiome Like in IBD Patients?

It is known already that people with IBD have a different makeup of organisms in their digestive tract than healthy people.

The microbiome is highly individualized: Every person is going to have their own version of "normal." Even so, there are trends in the microorganisms found in people with IBD that have been discovered by researchers. How this relates to symptoms and treatment is not yet known. So, it's understood that there are changes in the microbiome of a person with IBD but it's unknown how this affects the IBD and if this is even something that needs to be treated or can be effectively treated.

Are Probiotics Harmless?

There's a perception that probiotics are all good and necessary and that it's fine to "try" them and see how it works out, because there are no harms. In most cases, especially for healthy adults, probiotics are probably not harmful. Many people eat probiotics in their food every day, especially in yogurt, kombucha, or kefir. However, for other groups, such as those who are very ill, have weakened immune system, or infants, for instance, probiotic supplements might actually cause harm. It's uncommon, but adverse effects have been reported, most notably in sick infants who were given probiotics.

As we don't yet know which organisms or how much of them is needed to adjust our microbiome in a positive way, using probiotics in people who are already ill or in the elderly might not be safe.

There's not enough evidence yet to come down on this issue one way or another, but the general consensus at this point is that probiotics are not harmless, and a doctor should be consulted prior to using them.

How to Tell If a Probiotic Is Working

For some people, taking a probiotic may initially cause gas and bloating. Starting with a lower dose and increasing it steadily over time may help to lessen these types of side effects. Any discomfort or other effects should taper off in a week or two. If they don't, it's time to reevaluate that particular probiotic with a physician. It may be challenging to know if a probiotic is working.

For someone who is having loose stools, if stools firm up that might be a clue that the probiotic is effective. But if IBD is in remission, and the probiotic is being used to stay that way: it's hard to know if it's working. This is one of the many reasons why it's important to discuss probiotics with a physician and to keep a symptom diary when starting a new probiotic.

Probiotics for Crohn's Disease

Trials of probiotics in adults who have Crohn's disease in remission have shown mixed results with probiotic supplements, although it's not clear which strains would be useful. A meta-analysis (which is when researchers read the results of several studies in order to come to a conclusion) of nine such trials showed no benefit for people with Crohn's disease. There may be a benefit seen when several strains were used together, notably Saccharomyces boulardii, Lactobacillus, and VSL#3 (which is a commercial brand that contains a blend of eight bacterial strains).

There were, however, three trials included in this meta-analysis that showed a "significant advantage" for children living with Crohn's disease who supplemented with probiotics. It should be noted, however, that these were trials, which means that the children were under the care of a physician, receiving close monitoring, and that probiotics shouldn't be used in kids with IBD without discussing with a doctor.

Probiotics in Ulcerative Colitis

A meta-analysis that looked at 18 trials of probiotics for patients living with ulcerative colitis concluded that there was a "significant effect." The researchers noted that combination probiotics were shown to be more effective in people with ulcerative colitis. Supplementing with a Lactobacillus probiotic and prebiotics was effective in ulcerative colitis but not in Crohn's disease. The commercial blend VSL#3 was shown to be effective for ulcerative colitis, and when combined with Lactobacillus, was also shown to have an effect in children with IBD. Again, it should be noted, that the use of probiotics for people with IBD should be done under the supervision of a physician, especially in the case of children who have the disease.

Probiotics for J-pouches

There is one group of people with IBD for whom probiotics have been shown useful, and that is people who have a j-pouch. J-pouch surgery is a type of surgery that's done for people with ulcerative colitis, and the technical term is ileal pouch-anal anastomosis (IPAA). During this surgery, the colon is removed, along with part or all of the rectum. The last part of the small intestine is fashioned into a pouch that takes the place of the rectum and is sewn onto the anus.

One potential complication of a j-pouch is a condition called pouchitis, which brings symptoms of diarrhea, fever, urgency, and sometimes bloody stools. Pouchitis is poorly understood, but there is some evidence that regular use of probiotics may help prevent bouts of pouchitis. One strain of probiotics, which is proprietary and manufactured by only one company, has been studied and the results show that it can help prevent pouchitis or keep a patient in remission after pouchitis has been treated with antibiotics. The drawback is that probiotics are expensive and are often not covered by insurance because they are regarded as a supplement and not a medication.

Will Probiotics Be a "Cure" for IBD?

While there are some studies that show benefits for taking certain types of probiotics for certain subtypes of IBD, the effect is not going to be significant enough to be considered a cure. Probiotics may help some people with IBD, but it's important to note that they will not be effective enough that patients can stop taking IBD medications.

A Word From Verywell

The use of probiotics to treat IBD looks promising. However, there are still many questions to be answered, most notably how the microbiome is affected prior to the onset of IBD and how it changes when IBD is flaring and when it is in remission. There are so many different strains of microorganisms in the digestive tract that it is challenging to determine which bacteria should be used to alter the balance. Researchers are honing in on which strains might be useful, but there are still more unknowns than there are knowns in this area. Until there is more research data, it's not clear yet who might benefit from a probiotic supplement. Whether or not a probiotic should be used is a discussion that should happen between a doctor and a patient because it is an individual decision. Rather than "try and see," a physician can offer some guidance on which bacterial strains might be helpful.

Sources:

Celiberto LS, Bedani R, Rossi EA, Cavallini DC. "Probiotics: The scientific evidence in the context of inflammatory bowel disease." Crit Rev Food Sci Nutr. 2017 Jun 13;57:1759-1768.

Gionchetti P, Calabrese C, Lauri A, Rizzello F. "The therapeutic potential of antibiotics and probiotics in the treatment of pouchitis." Expert Rev Gastroenterol Hepatol. 2015;9:1175-1181.

Singh S, Stroud AM, Holubar SD, Sandborn WJ, Pardi DS. "Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis." Cochrane Database Syst Rev. 2015 Nov 23;(11):CD001176.

Ursell LK, Metcalf JL, Parfrey LW, Knight R. "Defining the Human Microbiome." Nutrition reviews. 2012;70(Suppl 1):S38-S44.

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