Probiotics
safety (and efficacy) data are from trials of short duration and there is a paucity of long-term data from clinical studies of probiotics in IBS. Nevertheless, to date no specific safety concerns have been identified with the use of probiotics in IBS patients and these treatments are generally considered to be safe and tolerable. However, a ‘cautionary tale’ relating to the use of probiotics was recently highlighted in a multicenter RCT where increased mortality was observed in patients with acute pancreatitis following probiotic treatment.82
It is therefore possible
that subsets of patients, such as those with significant or acute co-morbid illness, may not be suitable for probiotic therapy. Further appropriately designed studies are therefore necessary to rigorously assess the safety of specific probiotics in IBS patients.
Conclusions and Future Directions
Because IBS is a symptom-based disorder of diverse pathogenesis, many affected patients do not obtain adequate symptomatic relief from conventional medical therapies. As such, there is a pressing need for beneficial therapies. The possibility that alterations in intestinal commensal bacteria and mucosal inflammation may contribute to the development of symptoms in some patients with IBS has led to the hypothesis that probiotics may improve these symptoms. There is preliminary evidence from RCTs that probiotics may be a promising strategy for treating a subset of IBS patients. Overall, however, many of the studies were small in size, of short duration, and had significant design flaws, making the interpretation of results more difficult. Most studies suggest that single-strain Lactobacillus-containing probiotics are of limited efficacy in IBS patients. Evidence from two RCTs suggests that B. infantis 35624 is efficacious for the treatment of IBS symptoms.
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It is possible that other probiotics will prove to be equally or perhaps more efficacious for treating IBS.
Further large and methodologically rigorous RCTs that report on the efficacy, safety, and tolerability of single-strain and combination probiotic remedies in IBS patients over the short- and long-term are clearly needed. These studies should utilize established symptom-based criteria, clinical outcomes, and study methodology as suggested by the third guidelines of the Rome Foundation83
and regulatory agencies. Studies to assess the
combination of prebiotic and probiotic (synbiotic) or the use of bacterial lysates (postbiotics) to treat IBS will also be of considerable interest. We are at the dawn of a new age in which the gut microflora may serve as the richest source of new treatment developments for a variety of medical conditions,84
so put away your hand sanitizer and enjoy the ride. n
William D Chey, MD, AGAF, FACG, FACP, is a Professor of Medicine, a Director at the GI Physiology Laboratory, and a Co-Director for the Michigan Bowel Control Program in the Division of Gastroenterology at the University of Michigan School of Medicine. Professor Chey’s research interests include the diagnosis and treatment of the functional bowel disorders, acid-related disorders, and Helicobacter pylori infection. He is a member of the Board of Trustees and Publications Committee of the American College of
Gastroenterology (ACG) and joined the Board of Directors of the Rome Foundation in 2010 and is past Chair of the Clinical Practice Section (2006–2008) of the American Gastroenterological Association (AGA). He has been elected to the roster of ‘Best Doctors’ since 2001 and ‘America’s Top Doctors’ since 2009. He has authored more than 250 manuscripts, reviews, and book chapters. Professor Chey received his medical degree and training in internal medicine at the Emory University School of Medicine.
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27. Barbara G, Stanghellini V, Brandi G, et al., Interactions between commensal bacteria and gut sensorimotor function in health and disease, Am J Gastroenterol, 2005;100:2560–8.
28. Nobaek S, Johansson ML, Molin G, et al., Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome, Am J Gastroenterol, 2000;95:1231–8.
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