FOR PROFESSIONAL USE ONLY

Probiotics for Gastrointestinal Health! FOR PROFESSIONAL USE ONLY Accreditation Date: June 16, 2015 Expiry Date: April 13, 2018 CCCEP File # 1077-2015-1424-I-P CEUs 1.5 1

Presenter Disclosure Presenter: Rishma Walji ND, RAc, PhD I have the following relationships with commercial interests: Speaker/consulting fees: WN Pharmaceuticals Ltd. Speaking Fees for current program: I have received a speaker s fee from WN Pharmaceuticals Ltd. for this learning activity Commercial Disclosure This learning activity has received financial support from WN Pharmaceuticals in the form of program development fees. This learning activity has received in-kind support from WN Pharmaceuticals in the form of logistical support. 2

Disclaimer For Professional Use Only This information is provided for educational purposes only and is not intended for self-diagnosis or self-treatment of a condition that should be interpreted by a qualified health care provider. While the information in this document has been carefully reviewed and reflects current clinical and scientific knowledge, it is subject to change. Carefully watch this lesson. Instructions Complete and submit the on-line quiz. Study each question in the post-test and select the answer which you believe to be most correct. To successfully pass this lesson, a grade of 70% is required. Complete and submit the on-line Program Evaluation form. If you pass, you will receive your Statement of Attendance via email or mail for your own records. 3

Introduction Our overall health is directly linked to our gastrointestinal health. A healthy gastrointestinal system allows for proper nutrient absorption, and serves as a defense against allergens, toxins and microbes. Unfortunately, there has been a rise in gastrointestinal-related health concerns in western civilization. Changes in the human microbiota (formerly called microflora), which can be precipitated by stress, poor sleep and diet, illness, aging, antibiotics and other medications, are increasingly being identified in gastrointestinal conditions. As a result, the use and efficacy of probiotics has received great attention. Learning Objectives Goal: To educate pharmacists on the use of probiotics for gastrointestinal health. Objectives: After completing this session, the pharmacist should be able to: Describe the characteristics of probiotics. Summarize the prevalence and etiology of irritable bowel syndrome, Helicobacter pylori infection, antibiotic-associated diarrhea and inflammatory bowel disease. Describe the physical symptoms associated with these gastrointestinal conditions. Explain the safety and efficacy of probiotics in the prevention and/or treatment of these gastrointestinal conditions. 4

History of Probiotics 1857: Louis Pasteur proved the existence of microorganisms responsible for the fermentation of lactic acid (Sarowska et al, 2013). Early 1900s: Immunologist Élie Metchnikoff observed regular consumption of lactic acid bacteria in fermented dairy products was associated with enhanced health and longevity in many people living in Bulgarian villages (Martin et al, 2013). He showed some bacteria inhibit the growth of Vibrio cholerae (Sarowska et al, 2013). 1917: a strain of Escherichia coli (E. coli Nissle 1917) was isolated from the feces of a soldier who survived an outbreak of shigellosis without developing enterocolitis. The strain was successfully used to treat acute cases of infectious intestinal disease and it is still used today (Sarowska et al, 2013). Definitions The term probiotic, meaning for life in Greek, was first used in the 1960s. Today, probiotic refers to live microorganism that, when administered in adequate amounts, confer a health benefit on the host (Hungin et al, 2013). Examples include: Lactobacillus and Bifidobacterium species. Prebiotic: dietary substances, such as indigestible oligosaccharides, that provide a health benefit by selectively promoting the growth of beneficial bacteria in the gut (Hungin et al, 2013). Examples include: psyllium, inulin, lactulose and other oligosaccharides (found in onions, garlic, asparagus, leeks, artichoke, bananas, tomatoes, wheat, oats, soy beans and other plants) (Verna and Lucak, 2010). Synbiotic: products that contain a synergistic combination of probiotics and prebiotics, for example, inulin and Lactobacillus rhamnosus GG (Hungin et al, 2013; Verna and Lucak, 2010). 5

The Human Microbiota Microbiota (formerly microflora), refers to the population of microscopic organisms (bacteria, fungi, bacteriophages and viruses) that colonizes the skin, genitourinary system, respiratory system and gastrointestinal system (Scaldaferri et al, 2013). Babies are born with sterile intestines but become rapidly colonized with microorganisms during childbirth through contact with the external environment. This is mainly via the mother s vagina and gut, and the first feed (Chang, 2014; Simren et al, 2013; Scaldaferri et al, 2013). Environmental sources of bacteria are believed to be the vagina, skin and feces of the mother, providing a mix of intestinal and non-intestinal species (Morelli, 2008). Gut Microbiota, and the Intrinsic and Extrinsic Factors Affecting Distribution and Composition Legend: MMC: migrating motor complexes H+: hydrogen ions O2: partial oxygen tension siga: secretory immunoglobulin A PPI: proton pump inhibitor NSAID: non-steroidal antiinflammatory drug. (Simren et al, 2013) 6

Probiotic Species There are over 500 different bacterial species that contribute to an adult s colonic microbiota (Ciorba, 2012). Most common probiotic organisms are the lactic acid-producing bacteria, including gram-positive cocci and rod of the genera Lactobacillus, Lactococcus, Bifidobacterium, Streptococcus, and others (Sarowska et al, 2013). Resistant to low ph and tolerant to a wide range of temperatures. Probiotic Species Lactobacilli are gram-positive obligate and facultative anaerobes. More abundant in stomach and small intestine; much less abundant in the large intestine than bifidobacteria. Produce a number of antimicrobial products. Bifidobacteria are anaerobic, rod-shaped, gram-positive bacteria. Most abundant in the large intestine. Produce broad-spectrum antimicrobial activity. Saccharomyces boulardii, a yeast used in probiotic products. 7

Common Probiotic Formulations Single-organism probiotics Escherichia coli 1917 Nissle Lactobacillus salivarius UCC4331 Lactobacillus reuteri Lactobacillus casei Lactobacillus plantarus 299v Lactobacillus rhamnosus GG Bifidobacterium infantis 35624 Bifidobacterium animalis DN-173010 Bifidobacterium longum Saccharomyces boulardii Composite probiotics 1 strain of Streptococcus (Streptococcus thermophilus); 3 strains of Bifidobacterium (Bifidobacterium breve, Bifidobacterium longum, Bifidobacterium infantis); 4 strains of Lactobacillus (Lactobacillus acidophilus, Lactobacillus plantarum, Lactobacillus paracasei, Lactobacillus bulgaricus) (Verna and Lucak, 2010) Physiologic Actions of Probiotics Immunologic Effects: Immunomodulation, including enhanced phagocytic activity, production of immunoglobulin A, and alteration or regulation of inflammatory cytokine profiles. Adhere to the intestinal mucosa and act as antagonists against pathogenic species (by replacing existing pathogens or inhibiting their adherence). Inhibit harmful bacteria via the secretion of bacteriocins, which lower intestinal ph. (Chang, 2014; Corbia, 2012; Konig and Brummer, 2014; Sarowska et al, 2013; Verna and Lucak, 2010) 8

Physiologic Actions of Probiotics Gastrointestinal Effects: Modification and stabilization of the gut microflora. Enhance intestinal barrier by stabilizing tight junctions between epithelial cells, decreasing permeability of the intestinal tract, and increasing production of mucous that forms a protective barrier for the intestinal epithelium. Involved in production of nutritional factors (several B vitamins, vitamin K, folate and short chain fatty acids) and increases mineral absorption. (Chang, 2014; Corbia. 2012; Konig and Brummer, 2014; Sarowska et al, 2013; Verna and Lucak, 2010) Physiologic Actions of Probiotics Other Effects: Influence organ development such as morphogenesis of the bone and visceral organs. Detoxify carcinogens. Involved in production of daily energy needs (up to 10%). (Chang, 2014; Ciorba, 2012; Konig and Brummer, 2014; Sarowska et al, 2013; Verna and Lucak, 2010) 9

Clinical Uses of Probiotics Several proposed uses of probiotics for different medical conditions exist: Asthma and allergic diseases (atopic dermatitis, allergic rhinitis). Various infections (respiratory, urinary tract, bacterial vaginosis). Prevention of cardiovascular disease. Prevention of dental caries. Prevention of cancer. Prevention and treatment of gastrointestinal disorders (intolerance to lactose, irritable bowel syndrome, inflammatory bowel disease, infectious diarrhea, antibiotic-associated diarrhea, pouchitis, Helicobacter pylori infection, necrotizing enterocolitis). Obesity, autoimmune diseases, diabetes. (Sarowska et al, 2013; Scaldaferri et al, 2013; Verna and Lucak, 2010) Scope of Probiotic Products and Uses Legend: - AAD: antibiotic-associated diarrhea - CID: common infectious disease - IBS: irritable bowel syndrome; - NEC: necrotising enterocolitis; - RR: reduced risk; - T: treatment; - URTI: upper respiratory tract infections. (Sanders et al, 2013) 10

Criteria For Use As A Probiotic 1. The organism must be fully identified: genus, species and strain. 2. It must be safe for consumption: a. Not pathogenic or carrying antibiotic resistance genes. b. Not degrading to intestinal mucosa or conjugating for bile acids. 3. It must survive intestinal transit: acid and bile tolerant. 4. It must adhere to mucosal surface and colonize the intestine (at least briefly). 5. It must possess documented health effects: a. Produce antimicrobial substances and antagonize pathogenic bacteria. b. At least one phase 2 study documenting benefit. 6. It must be stable during processing and storage. (Verna and Lucak, 2010) Probiotic Efficacy Concerns Clinical trials have yielded inconsistent data as it is difficult to extrapolate the results of one study with one probiotic species, dose and formulation in one disease state, to other probiotics. Reasons for this include (Verna and Lucak, 2010): 1. Optimal number of colony forming units (CFUs) for each bacterial strain delivered remains unknown. 2. Very few studies have documented survival of administered probiotic as it transits the gut (through fecal recovery studies). 3. The method of delivery (e.g. yogurt vs. milk) may impact the viability and number of bacterial colonies. 4. Different probiotic species and genuses may have different immunological and physiological effects in different disease states. 5. Composition of colonic bacterial microflora appears to change with age (age > 60 years). 6. Combination probiotics may interact and have an impact on the microbiota differently than single probiotic preparations. 7. Optimal duration of probiotic treatment and durability of response are unknown. 11

Case Study 1 MK is a 29 year old female who has been struggling with IBS for 10 months. Her main symptoms include alternating diarrhea/constipation, abdominal bloating (1-2 hours after meals), pain in the lower right abdominal quadrant and flatulence. She describes her mood as anxious and her life as stressful since she works full time and is a single mom of a 4 year old. Her diet consists of whatever is quick, including bagels, coffee, take-out and frozen meals. She has a history of frequent colds and urinary tract infections. MK has been taking a proton-pump inhibitor for 2 years. There is no family history of gastrointestinal disorders. Are probiotics beneficial for the treatment of irritable bowel syndrome? Irritable Bowel Syndrome (IBS) Definition (Chang, 2014; Merck Manual, 2014): Globally accepted Rome III definition: characterized by chronic and recurrent abdominal discomfort or pain associated with disturbed defecation. Discomfort or pain is accompanied by at least two of the following: Relief by defecation Change in frequency of stool, or Change in consistency of stool Most common intestinal disorder in industrialised countries (prevalence is 10-20%), and in developing countries (Konig and Brummer, 2014; Sanders et al, 2013). The cause is unknown and pathophysiology is incompletely understood (Konig and Brummer, 2014), however changes in the interaction between intestinal microbiota and host factors (e.g. age, diet, transit, genetic factors, antibiotics), may be important (Simren et al, 2013). 12

Etiology and Pathophysiology of IBS The existence of any defects among the 3 categories (pictured at left) during early life and adolescent period may initiate biopsychosocial interactions and IBS symptoms (Chang, 2014). Dysregulation of the microbe-gutbrain axis plays a profound role in IBS pathophysiology (Konig and Brummer, 2014). Dysfunctional gut microbiota mucosal innate immune responses increased epithelial permeability, activated nociceptive sensory pathways, dysregulated enteric nervous system IBS (Chang, 2014). Probiotics for Irritable Bowel Syndrome Mechanism of Action (Chang, 2014): Anti-pathogenic ability via secretion of bacteriocins. Acidification of the colon by fermentation. Anti-inflammation to protect gut mucosa. Alteration of mucosal response to stress. Barrier enhancement. Immune-modulating effects. Inhibition of visceral hypersensitivity. 13

Evidence for Probiotics for IBS The composition of the microbiota in IBS patients is distinctly different from healthy controls (Konig and Brummer, 2014). Numerous differences in abundance of species have been found, but to date no one species has been specifically linked to IBS (Konig and Brummer, 2014). Different probiotics have distinct functional effects in the human intestine (Konig and Brummer, 2014). Some species have been shown to improve total symptom scores in IBS patients, while other species affect bloating and flatulence or stool frequency. Evidence for Probiotics for IBS Single-centre, randomized, double-blind, placebo controlled (RDBPC) trial of adult patients with symptomatic IBS (Sisson et al, 2014). Patients received 12 weeks of treatment with the probiotic (n=100) (Lactobacillus rhamnosus NCIMB 30174, Lactobacillus plantarum NCIMB 30173, Lactobacillus acidophilus NCIMB 30175 and Enterococcus faecium NCIMB 30176) or placebo (n=52). The IBS symptom severity score (IBS-SSS), which can range from 0-500, was used to monitor outcomes. Results: The mean change in IBS-SSS was -63.3 probiotic vs. -28.3 placebo. The mean difference in the IBS-SSS was statistically significant [-35.0 (95% CI; -62.03, -7.87); P = 0.01]. There was no significant improvement in the IBS quality of life (IBS-QOL). No serious adverse events were reported. 14

Evidence for Probiotics for IBS RDBPC trial of 49 IBS patients diagnosed according to Rome III criteria (Yoon et al, 2014). Patients randomly assigned to two groups: Group 1: multispecies probiotics (n=25) (a mixture of Bifidobacterium longum, B. bifidum, B. lactis, Lactobacillus acidophilus, L. rhamnosus, and Streptococcus thermophilus in equal amounts) twice daily for 4 weeks. Group 2: placebo (n=24) twice daily for 4 weeks. Results: 68.0% (17/25) of probiotic group vs. 37.5% (9/24) of placebo group (P < 0.05) had IBS symptoms substantially relieved at 4 weeks. Evidence for Probiotics for IBS DBPC, parallel-designed study of IBS subjects (n=214) randomized to receive either one capsule of L. plantarum 299v (DSM 9843) (10 billion CFU) or placebo, daily for 4 weeks (Ducrotté et al, 2012). Probiotic group showed significantly (p<0.05) greater: abdominal pain frequency at weeks 3 and 4 mean abdominal pain frequency by 51.9% vs 13.6% in placebo group at week 4 stool frequency, bloating & feeling of incomplete emptying frequency daily number of stools after week 2 severity of abdominal pain by 45.2% vs 23.3% in placebo group mean scores of severity of abdominal bloating and feeling of incomplete emptying at weeks 3 and 4 Conclusion: 4-week treatment with L. plantarum 299v (DSM 9843) provided effective symptom relief, particularly of abdominal pain and bloating, in IBS patients fulfilling the Rome III criteria. 15

Evidence for Probiotics for IBS Review of 42 trials examining the efficacy of lactic-acid bacteria in IBS found 34 trials reported beneficial effects in at least one of the endpoints or symptoms examined. However, there are numerous concerns expressed over deficits of trial design and execution relating to strain selection, optimum dosage, mode of action, safety and long-term tolerability (Clarke et al, 2012). In one small trial 13 of the 16 study participants reported unfavourable effects when using 10 10 CFU of L. plantarum MF1298 over 3 weeks. The mean number of weeks of satisfactory relief of symptoms was 1.44 weeks for placebo, but only 0.50 weeks during L. plantarum use. Symptom scores were significantly higher with probiotic use vs placebo in the following areas: abdominal pain (1.55 vs 1.14), urgency (1.54 vs 1.12) and diarrhea (6.36 vs 5.5) (Ligaarden et al, 2010). Evidence for Probiotics for IBS Meta-analysis of 10 studies found significant effect in improving: Pain scores if probiotics contained Bifidobacterium breve, B. longum and Lactobacillus acidophillus. Distension scores if probiotics contained B. breve, B. infantis, L. casei or L. plantarum. Flatulence scores if probiotics contained B. breve, B. infantis, L. casei, L. plantarum, B. longum, L. acidophilus, L. bulgaricus and S. salivarius ssp. thermophilus (Ortiz-Lucas et al, 2013). Conclusions: Some probiotics are an effective therapeutic option for IBS patients, and the effects on each IBS symptom are likely speciesspecific. 16

Evidence for Probiotics for IBS Systematic review of 16 RCTs found 11 studies showed suboptimal study design with inadequate blinding, inadequate trial length, inadequate sample size, and/or lack of intention-to-treat analysis. BUT, Bifidobacterium infantis 35624 showed significant improvement in the composite score for abdominal pain/discomfort, bloating/ distention, and/or bowel movement difficulty compared with placebo (P<0.05) in two appropriately designed studies. No other probiotic showed significant improvement in IBS symptoms in an appropriately designed study (Brenner et al, 2009). Evidence Conclusion At present, the strongest evidence is for Bifidobacterium infantis 35624 (1 x 10 8 cfu/ day taken for at least 4 weeks) and L. plantarum 299V for IBS. Benefit has also appeared for combinations of probiotics which include bifidobacteria species rather than single species lactobacillus probiotics (Ciorba, 2012). Probiotics are safe to use in IBS, however patients should be warned about the possibility of symptom aggravation (Simren et al, 2013). The primary strain that has shown aggravation of IBS symptoms is L. plantarum MF1298 Further investigation is required to determine the strains and doses that are most effective. Multi-strain combinations could provide a comprehensive treatment in order to address various concerns (Konig and Brummer, 2014). 17

Case Highlights Case Study 1 Review Patient: MK, 29 year old female Chief Complaints (CCs): IBS for 10 months, experiencing abdominal bloating (1-2 hours after meals), pain in the lower right abdominal quadrant and flatulence. Social History: stressful life - works full time, single mom, diet consists of whatever is quick, including bagels, coffee, take-out and frozen meals. Current Medications: Taking a proton-pump inhibitor for 2 years. Case Study 1 Recommendations 1. Possible discontinuation of Proton Pump Inhibitor (PPI): PPIs induce acid suppression, and may alter gut microbiota. PPI discontinuation, especially where symptoms began with PPI therapy, may be warranted (Simren et al, 2013). 2. Probiotic Recommendations: A. To address all symptoms, bifidobacterium infantis 35624 or L. plantarum 299v would be appropriate choices. 18

Case Study 1 Recommendations 2. Probiotic Recommendations cont d: B. Combination products can provide comprehensive treatment to address MK's varied concerns: To address MK's bloating/distention: combination products containing B. breve, B. infantis, L. casei and/or L. plantarum may be beneficial (Ortiz-Lucas, 2013). To address MK's flatulence: combination products containing B. breve, B. infantis, L. casei, L. plantarum, B. longum, L. acidophilus, L. bulgaricus and/or S. salivarius ssp. thermophilus (Ortiz-Lucas, 2013). To address MK's abdominal pain: combination products containing Bifidobacterium breve, B. longum and/or Lactobacillus acidophillus (Ortiz-Lucas, 2013). Case Study 2 JD is a 60 year old male with a past history of gastric ulcer. He is currently experiencing symptoms of dyspepsia, nausea, vomiting and abdominal pain. Medical testing has confirmed a diagnosis of chronic gastritis due to Helicobacter pylori infection. He has been prescribed two antibiotics and a proton pump inhibitor as part of his treatment. In the past, he has experienced diarrhea with the use of antibiotics and worries the same will happen again. Are probiotics beneficial for the treatment of Helicobacter pylori infection and antibiotic-associated diarrhea? 19

Helicobacter pylori (H. pylori) Infection H. pylori is a gram-negative pathogen that colonizes the stomach (Vale and Oleastro, 2014): Infects more than ½ of the human population worldwide. May cause chronic gastritis, peptic ulcer disease, gastric adenocarcinoma, and low-grade gastric lymphoma. Linked to diseases outside the stomach, such as cardiovascular, lung, hemotologic, and neurological diseases, and diabetes mellitus. Strains differ considerably in virulence (Baryshnikova, 2012). Infection may be asymptomatic or result in varying degrees of dyspepsia. Diagnosis is by urea breath test and testing of endoscopic biopsy samples. Conventional H. Pylori Treatment First-line treatment is standard triple therapy: a proton pump inhibitor (omeprazole 20 mg bid) plus two antibiotics (amoxicillin 1000 mg bid, clarithromycin 500 mg bid) (Merck Manual, 2014; Vale and Oleastro, 2014). Treatment failure associated with bacterial antibiotic resistance is a major problem in treatment (Vale and Oleastro, 2014). Poor patient compliance due to side-effects is also common (Ahmad et al, 2013). 20

Probiotics for H. pylori Prevent antibiotic side effects, such as diarrhea, and improve eradication rates (Vale and Oleastro, 2014). Positive effects in animal models show probiotics reduce H. pylori colonization and alleviate inflammation of the stomach (Vale and Oleastro, 2014). Human studies using combinations of antibiotics and probiotics have shown overall improvement in H. pylori gastritis, increase in H. pylori eradication, and lessening of total effects after administration of probiotics (Vale and Oleastro, 2014). Probiotics for H. pylori Mechanism of Action (Ahmad et al, 2012; Zheng et al, 2013): Bacteriocins produced by lactobacillus directly inhibit H. pylori. Production of heat stable proteinaceous compounds by bifidobacterium and enterococcus may suppress the viability of H. pylori. Metabolites (such as lactic acid produced by lactobacillus) suppress urease activity of H. pylori. Lactobacillus decreases H. pylori load through stabilization of the mucosal barrier. Immunologic response which reduces inflammatory chemokine expression and lymphocyte infiltration. 21

Evidence for Probiotics for H. pylori Meta-analysis of 9 RCTs showed lactobacillus-containing probiotic supplementation potentially elevated H. pylori eradication rates by ~10%, but might not mitigate side effects of eradication therapy (Zheng et al, 2013). Subgroup analysis: eradication rates by 17% with lactobacillus monotherapy vs. multistrain probiotics. Eradication rates in patients given lactobacillus-containing probiotics + triple regimens significantly 11% compared with control group. Conclusions: administration of lactobacillus-containing probiotics with conventional regimens seemed to be effective in the eradication therapies in both children and adults. Evidence for Probiotics for H. pylori DBRPC trial (n=70) of patients treated with standard triple therapy for 2 weeks, then randomized to receive Lactobacillus reuteri or placebo for 4 weeks (Emara et al, 2014). Results: Eradication rate: 74.3% (probiotic) vs 65.7% (placebo) (p=0.603). Gastrointestinal Symptoms Rating Scale (GSRS): 8 weeks from baseline - 4.77 ± 2.446 (probiotic) vs 9.06 ± 5.291 (placebo) (p<0.001). Less diarrhea and taste disorders reported with probiotic group vs placebo group (p=0.002). 22

Evidence for Probiotics for H. pylori Results cont d (Emara et al, 2014): Pathological Lesions (Inflammation & Activity): Evidence for Probiotics for H. pylori Conclusion: Triple therapy of H. pylori supplemented with L. reuteri increased eradication rate by 8.6%, improved the GSRS score, reduced the reported side effects and improved the histological features of H. pylori infection when compared with placebo-supplemented triple therapy (Emara et al, 2014). 23

Evidence for Probiotics for H. pylori Open label randomized observational clinical study (Dajani et al, 2013): Group A: control group of patients treated with standard triple therapy (n=106). Group B: Bifidobacterium infantis 2036 (30x10 8 CFU, twice daily) added as an adjuvant to standard triple therapy (n=100). Group C: started the probiotic for 2 weeks before initiating standard triple therapy along with the probiotic for subsequent 10 days (n=95). Group D: sequential regimen of triple therapy together with Bifidobacterium infantis 2036 (30x10 8 CFU, twice daily) for 10 days (n=76). Evidence for Probiotics for H. pylori Results (Dajani et al, 2013): Group A (n=106), Group B (n=100), Group C (n=95) and Group D (n=76) Conclusion: Adding B. infantis as an adjuvant to several therapeutic regimens commonly used for the eradication of H. pylori infection significantly improves the cure rates. 24

Antibiotic-Associated Diarrhea (AAD) Defined as unexplained diarrhea that occurs in association with the administration of antibiotics. Rise in the use of antibiotics antibiotic-associated diarrhea (AAD) and Clostridium difficile infection (CDI) (Pattani et al, 2013). Occurs in 5%-39% of patients depending on the population and type of antibiotic (Hickson, 2011). AAD can occur up to 2-3 weeks following cessation of antibiotic therapy rather than during treatment (Hickson, 2011). Clostridium difficile is a leading cause of AAD, and causes a more severe form of diarrhea. C. difficile associated diarrhea is responsible for 10-20% of all cases of AAD, and can occur up to 8 weeks after antibiotic therapy (Hickson, 2011). Antibiotic-Associated Diarrhea The fundamental problem in Clostridium difficile infection (CDI) is not the presence of the pathogenic organism per se, but the absence of healthy microbiota to keep the growth of the pathogen suppressed (Hell et al, 2013). Antibiotics disrupt normal colonic microflora alter carbohydrate metabolism and antimicrobial activity in the colon osmotic diarrhea or diarrhea caused by pathogenic bacteria. 25

Antimicrobial Activities of Probiotics Hickson et al, 2011 Evidence for Probiotics for AAD Meta-analysis of 16 trials of hospitalized patients showed significant reductions in the risks of AAD (RR 0.61, 95% CI 0.47 to 0.79, NNT to benefit 11) and CDI (RR 0.37, 95% CI 0.22 to 0.61, NNT to benefit 14) (Pattani et al, 2013). Benefit was retained regardless of study quality, type of probiotic used, and duration of follow-up. Conclusions: probiotics can be recommended for patients using antibiotics to reduce the risk for AAD and CDI, with stronger evidence available for Lactobacillus-based formulations. Large body of evidence supports the use of the yeast Saccharomyces boulardii. Meta-analysis of 10 RCTs testing efficacy of S. boulardii in preventing AAD shows an overall, pooled relative risk of 0.47 [95% confidence interval (CI)=0.35, 0.63; p<0.0001] (McFarland, 2010). 26

Evidence for Probiotics for AAD Meta-analysis of 63 RCTs (n=11,811), indicated a statistically significant association of probiotic administration with reduction in AAD (RR=0.58; 95% CI, 0.50 to 0.68; P<0.001) (Hempel et al. 2012). Systematic review and meta-analysis of 23 RCTs (n=4,213), found that probiotics significantly reduced the risk of C. difficile-associated diarrhea (CDAD) by 64% in adults (18+ years) and children (0-18 years); incidence of CDAD was 2.0% in the probiotic group compared to 5.5% in the placebo or no treatment control group (RR=0.36; 95% CI 0.26 to 0.51) (Goldenberg et al. 2013). Suggests that probiotics are both safe and effective for preventing CDAD. Evidence for Probiotics for AAD Meta-analysis of 34 RDBPC trials including patients treated with antibiotics and administered a probiotic for at least the duration of the antibiotic treatment (n=4138) (Videlock and Cremonini, 2012). Results: Pooled relative risk (RR) for AAD in the probiotic group vs. placebo was 0.53 (95% CI 0.44 0.63), corresponding to a number needed to treat (NNT) of 8 (95% CI 7 11). Preventive effect of probiotics remained significant when grouped by probiotic species, population age group, relative duration of antibiotics and probiotics, study risk of bias and probiotic administered. Pooled RR for AAD during treatment for Helicobacter pylori (H. pylori) was 0.37 (95% CI 0.20 0.69), corresponding to a NNT of 5 (95% CI 4 10). This meta-analysis confirms earlier results supporting the preventive effects of probiotics in AAD. 27

Evidence Conclusions Human studies using combinations of antibiotics and probiotics have shown overall improvement in H. pylori gastritis, increase in H. pylori eradication, and possible lessening of total adverse antibiotic effects (Vale and Oleastro, 2014). Use of lactobacillus-containing probiotic is a safe choice for improving H. pylori eradication rate (Zheng et al, 2014). Several lactobacilli and bifidobacterial strains appear to reduce the side effects of antibiotic therapies and improve patient compliance (WGO, 2011). Strong evidence of efficacy for the prevention of AAD for S. boulardii or Lactobacilluscontaining probiotics in adults or children who are receiving antibiotic therapy (WGO, 2011). Evidence for the prevention and treatment of CDAD has been suggested to be unclear (Hickson, 2011), but recent meta-analysis suggests that probiotics are both safe and effective for preventing CDAD (Goldenberg et al. 2013). Case Highlights Case Study 2 Review Patient: JD, 60 year old male. Chief Complaints (CCs): chronic gastritis due to Helicobacter pylori, symptoms of dyspepsia, nausea, vomiting and abdominal pain; concern regarding antibiotic associated diarrhea. Past Medical History: gastric ulcer, diarrhea with the use of antibiotics. Current medications: two antibiotics and a proton pump inhibitor. 28

Case Study 2 Recommendations Lactobacillus-based formulations have been found to be effective for management & treatment of both H. pylori (Zheng et al. 2013) and AAD (Pattani et al, 2013). Thus, JD may benefit from formulations dominant in lactobacilli strains. Given that JD is currently undergoing triple therapy, his treatment may be enhanced by inclusion of the following specific probiotic strains: L. reuteri: may increase eradication rate by 8.6%, improve gastrointestinal symptoms rating score, reduce reported side effects and improve histological features of H. pylori infection (Emara et al, 2014). Bifidobacterium infantis 2036: may increase eradication rate and reduce side effects (Dajani et al, 2013). Large body of evidence supports the use of the yeast Saccharomyces boulardii in preventing AAD (McFarland, 2010). Case Study 3 AJ is a 35 year old female that has recently experienced her third episode of acute, severe ulcerative colitis, with 4-days of bloody diarrhea and abdominal pain. On average she has 7 bowel movements per day. She is currently taking mesalazine 800 mg three times daily and prednisolone 20 mg daily. She is curious about what natural health products would be helpful for colitis. Are probiotics beneficial for the treatment of inflammatory bowel disease? 29

Inflammatory Bowel Disease Inflammatory bowel disease (IBD), which includes Crohn s disease (CD) and ulcerative colitis (UC), is a relapsing and remitting condition characterized by chronic inflammation at various sites in the gastrointestinal tract, which results in diarrhea and abdominal pain (Merck Manual, 2014). Chronic or recurrent pouchitis is a complication occurring in ~10-20% of UC patients after ileal anal pouch formation surgery (Ciorba, 2012). Pathogenic bacteria play a primary role in causing inflammation. Individuals with pouchitis have fewer Lactobacilli and Bifidobacterium (Ritchie and Romanuk, 2012). Clear connection between dysbiosis and IBD has been found (Martin et al, 2013). Dysbiosis: microbial imbalances on or within the body, where commensal bacteria are depleted and/or different opportunistic bacteria can grow. Etiopathogenesis of IBD Legend: NOD2: Nucleotidebinding oligomerization domain-containing protein 2 ATG16L1: Autophagy related protein 16-like 1 IL-23R: Interleukin 23 receptor. (Hold, 2014) 30

Microbiota in IBD IBD patients show amounts of dominant commensal bacteria such as Firmicutes and Bacteriodes, and Proteobacteria and Actinobacteria (Scaldaferri et al, 2013). Associated with short-chain fatty acid levels butyrate levels in IBD which is able to inhibit pro-inflammatory cytokines release to the production of mucin and antimicrobial peptides, and provide energy to colonocytes. Different gut microbiota found in patients with pouchitis: Bacteriodetes and Faecalibacterium prausnitzii (anti-inflammatory activity), and Proteobacteria (Scaldaferri et al, 2013). Evidence for Probiotics for Ulcerative Colitis Systematic review and meta-analysis of efficacy of a composite probiotic in the treatment of mild to moderately active ulcerative colitis (Mardini and Grigorian, 2014): 162 patients received 3.6 10 12 CFU/d of a composite probiotic comprised of S. thermophilus, B. breve, B. longum, B. infantis, L. acidophilus, L. plantarum, L. paracasei and L. bulgaricus, and 157 patients received placebo. 95% of patients received concomitant therapies with 5-ASA and/or immunomodulators. >50% in the Ulcerative Colitis Disease Activity Index: 44.6% of the probiotictreated patients versus 25.1% of placebo-patients (P = 0008; OR, 2.793; 95% CI, 1.375-5.676; NNT = 4-5). Response rate: 53.4% in probiotic-treated patients versus 29.3% in placebo-patients (P < 0001; OR, 3.03; 95% CI, 1.89-4.83; NNT = 3-4). Remission rate: 43.8% in probiotic-treated patients versus 24.8% in placebo-patients (P = 0007; OR, 2.4; 95% CI, 1.48-3.88; NNT = 4-5). No serious side effects were reported. Conclusion: When added to conventional therapy, the use of this composite probiotic was safe and more effective than conventional therapy alone in achieving higher response and remission rates in mild to moderately active ulcerative colitis. 31

Evidence for Probiotics for UC & CD Systematic review of 43 RCTs (Jonkers et al, 2012) found overall risk ratios: 2.70 (95% CI 0.47, 15.33) for inducing remission in active UC with Bifido-fermented milk versus placebo or no additive treatment (n = 2) 1.88 (95% CI 0.96, 3.67) for inducing remission in active UC with a composite probiotic versus placebo (n = 2) 1.08 (95% CI 0.86, 1.37) for preventing relapses in inactive UC with Escherichia coli Nissle 1917 versus standard treatment (n = 3) 0.17 (95% CI 0.09, 0.33) for preventing relapses in inactive UC/ileo-anal pouch anastomosis (IPAA) patients with a composite probiotic versus placebo 1.21 (95% CI 0.57, 2.57) for preventing endoscopic recurrences in inactive CD with Lactobacillus rhamnosus GG versus placebo (n = 2) 0.93 (95% CI 0.63, 1.38) for preventing endoscopic recurrences in inactive CD with Lactobacillus johnsonii versus placebo (n = 2) Conclusion: promising results for E. coli Nissle in inactive UC and a multispecies probiotic product in active UC and inactive pouch patients, however, no evidence is available to support the use of probiotics in CD. Evidence for Probiotics for Pouchitis RCT of 36 patients with pouchitis at least twice in the previous year or requiring antibiotics. Randomized to receive a composite probiotic comprised of S. thermophilus, B. breve, B. longum, B. infantis, L. acidophilus, L. plantarum, L. paracasei and L. bulgaricus (n=20) or placebo (n=16) (Mimura et al, 2004): Remission was maintained at one year in 17 patients (85%) on the probiotic and in one patient (6%) on placebo (p<0.0001). The inflammatory bowel disease questionnaire score remained high in the probiotic group (p = 0.3) but deteriorated in the placebo group (p = 0.0005). Conclusions: the once daily high dose of a composite probiotic is effective in maintaining remission for at least a year in patients with recurrent or refractory pouchitis. This is associated with a high level of quality of life. 32

Evidence for Probiotics for Pouchitis RCT (n=43) to assess the impact of the long-term use of composite probiotics in patients after restorative proctocolectomy (Tomasz et al, 2014). 2 groups: placebo group and treatment group with oral intake of probiotic containing Lactobacillus acidophilus, Lactobacillus delbrueckii subsp. bulgaricus, and Bifidobacterium bifidus. Results: 9 months of probiotic treatment the number of patients with pouchitis, the Pouchitis Disease Activity Index (PDAI) score, and the fecal pyruvate kinase and calprotectin (markers of inflammation). Longterm probiotics use is safe and well accepted and can be an effective method of pouchitis prevention. Evidence Conclusions The most common probiotics used in the treatment of IBD have been Lactobacillus sp, Bifidobacterium sp, Sacchromyces bouladrii,or E. coli Nissle 1917 on their own, or a composite probiotic (comprised of 3 strains of Bifidobacterium spp., 4 strains of Lactobacillus spp. and 1 strain of Streptococcus spp.) (Hold et al, 2014). Ulcerative Colitis: several published RCTs have shown benefit of probiotics in the management of ulcerative colitis (UC). Benefits have been seen for a combination of Lactobacillus, Bifidobacterium and Streptococcus probiotic species or for Escherichia coli Nissle 1917 in inducing and maintaining remission of disease activity in mild to moderately severe UC (Sanders et al, 2013). E. coli Nissle may be equivalent to mesalazine in maintaining remission of UC (WGO, 2011). 33

Evidence Conclusions Crohn s Disease: probiotic use in the management of Crohn s disease is not supported by currently available RCT data (Ciorba, 2012). No consistent effects have been noted in treating or preventing relapse of Crohn s disease (Sanders et al, 2013). Pouchitis: The strongest evidence for the use of probiotics in IBD is in the prevention and treatment of pouchitis (Verna and Lucak, 2010). E. coli Nissle 1917 and a composite probiotic (comprised of 3 strains of Bifidobacterium spp., 4 strains of Lactobacillus spp. and 1 strain of Streptococcus spp.) have been found to be effective in preventing relapse and inducing remission in this setting (Hold et al, 2014). Case Highlights Case Study 3 Review Patient: AJ, 35 year old female Chief Complaints (CCs): 3 rd episode of acute, severe ulcerative colitis, with 4-days of bloody diarrhea and abdominal pain, has 7 bowels movements per day. Current Medications: mesalazine 800 mg three times daily and prednisolone 20 mg daily. 34

Case Study 3 Recommendations AJ may experience benefits with the use of probiotics. For ulcerative colitis, the following probiotics have been shown to be helpful: A combination of Lactobacillus, Bifidobacterium and Streptococcus probiotic species which contains (Hold et al, 2014): 4 strains of lactobacilli (L. acidophilus, L. paracasei, L. bulgaricus, L. plantarum ) 3 strains of bifidobacteria (B. breve, B. infantis, and B. longum) Streptococcus thermophilus Escherichia coli Nissle 1917 (Sanders et al, 2013). Safety and Adverse Effects of Probiotics Probiotics are well-tolerated, with few side-effects that are generally gastrointestinal in nature, including bloating, diarrhea, constipation, nausea and epigastric pain. These are usually mild and self-limiting (Hoveyda et al, 2009). Caution(s) and warning(s) as outlined by the Natural and Non-prescription Health Products Directorate (NNHPD) (Health Canada, 2014): If you have fever, vomiting, bloody diarrhea or severe abdominal pain, consult a health care practitioner prior to use. If symptoms of digestive upset (e.g. diarrhea) occurs and/or persists beyond 3 days, discontinue use and consult a health care practitioner. If any bacterial/fungal strain in the product has come into contact with a priority allergen or derivative (e.g. soy, gluten, milk, fish via the culture media) that is not listed as a medicinal or nonmedicinal ingredient, one of the following risk statements must be included on the product label: If you have a XXX allergy, do not use this product; OR (May) contain(s) XXX 35

Safety and Adverse Effects of Probiotics Contraindication(s) as outlined by the NNHPD (Health Canada, 2014): If you have an immune-compromised condition (e.g. AIDS, lymphoma, patients undergoing long-term corticosteroid treatment), do not use this product. If any bacterial/fungal strain in the product possesses unexplained atypical resistance to any antibiotic/antifungal agent, the name(s) of the antibiotic(s)/ antifungal(s) agent(s) must be indicated as a contraindication on the label as follows: If you are taking XXX, do not use this product (e.g. If you are taking ampicillin, do not use this product). If you are on antibiotic(s), take the probiotic at least 2-3 hours before or after. Important Considerations When Purchasing a Probiotic Probiotic ingredients should be labelled on the product including strain, formulation and amount of the active microorganism(s), reported in colony forming units (CFUs). Recommended dosage per day should be included on the label. Expiration date and storage conditions should be provided: CFUs reported are often the number of microorganisms present at time of manufacture. This does not reflect the quantity available on the date purchased, as there may be die off that occurs during the product s shelf life. An accurate expiration or use by date should be provided in order to obtain the accurate number of CFUs expressed. The NNHPD requires that a minimum of 80% of the quantity declared on the product label is present at the end of shelf life. Supplemental probiotics are available in different forms such as capsules and powders. Its content and viability in the gastrointestinal tract is more important than the delivery form. Contact information for the manufacturer should be provided to allow the purchaser to locate additional information about the product. 36

The Probiotic Market Probiotic market was valued at $24.23 billion in 2011. Expected to grow at a compound annual growth rate (CAGR) of 6.8% from 2012 to 2017. In 2011, Asia-Pacific led the global market with share of 40.0%, followed by Europe and North America in terms of revenue. Growth is driven by consumer demand for health enhancing probiotic products such as probiotic yogurts, other probiotic dairy products, and probiotic dietary supplements (Nutraceuticals World, 2013). Practical Considerations for the Pharmacist Probiotics have been shown to have beneficial effects such as: Improving clinical outcomes for acute infectious diarrhea, antibiotic-associated diarrhea, necrotising enterocolitis, IBS, pouchitis and ulcerative colitis. Supporting healthy individuals, in cases of reducing the risk of common infectious diseases and improving intestinal function. Probiotics most likely act by altering the composition and/or activities of the colonizing microbiota and by direct interaction with the host through immune signalling mechanisms (Sanders, 2013). 37

Practical Considerations for the Pharmacist There is good evidence to support the efficacy of: B. infantis 35624 and L. plantarum 299V for IBS (Ducrotté et al, 2012, Verna and Lucak, 2010). S. boulardii and lactic acid bacteria, and the combination of the two for antibiotic-associated diarrhea (Verna and Lucak, 2010). A composite probiotic comprised of 3 strains of Bifidobacterium spp., 4 strains of Lactobacillus spp. and 1 strain of Streptococcus spp. for pouchitis (Dieleman and Hoentjen, 2012, Verna and Lucak, 2010). Practical Considerations for the Pharmacist There is good evidence to support the efficacy of: E. Coli Nissle 1917, Lactobacillus and Bifidobacterium species and a composite probiotic (comprised of 3 strains of Bifidobacterium spp., 4 strains of Lactobacillus spp. and 1 strain of Streptococcus spp.) for inducing and maintaining remission in ulcerative colitis (Verna and Lucak, 2010). There is insufficient evidence to recommend probiotics for Crohn s disease (Dieleman and Hoentjen, 2012) 38

Practical Considerations for the Pharmacist All probiotics are not created equal (Verna and Lucak, 2010). As probiotic strains do not often colonize the gut, continued consumption is likely required to sustain benefit (Ciorba, 2012) in chronic conditions. Further investigations are needed to determine the most effective strains, doses and duration of therapy for gastrointestinal conditions. Although a causal relationship is unclear, alterations in the microbiota have been associated with obesity, metabolic syndrome, atherosclerosis, type 1 diabetes, autism, allergy, asthma and celiac disease. Hence, advances in research will help to elucidate the role of probiotics in numerous health conditions for which the Pharmacist regularly provides counsel. 39