Probiotics for Gastrointestinal Conditions: A Summary of the Evidence

Thad Wilkins; Jacqueline Sequoia

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Aug 1, 2017 Issue

Probiotics for Gastrointestinal Conditions: A Summary of the Evidence

THAD WILKINS, MD, MBA, Medical College of Georgia at Augusta University, Augusta, Georgia

JACQUELINE SEQUOIA, MD, MPH, William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina

Am Fam Physician. 2017 Aug 1;96(3):170-178.

Patient information: See related handout on probiotics, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Article Sections

Abstract
Mechanism of Action
Regulatory Issues
Dosing, Duration, and Clinical Indications
Acute Infectious Diarrhea
Antibiotic-Associated Diarrhea, C. difficile Infection, and C. difficile–Associated Diarrhea
H. pylori Infection
Hepatic Encephalopathy, Nonalcoholic Fatty Liver Disease, and Nonalcoholic Steatohepatitis
Ulcerative Colitis
Irritable Bowel Syndrome and Functional Abdominal Pain
Constipation
Colic
Necrotizing Enterocolitis
Conditions for Which Probiotics Are Ineffective
Safety
References

Probiotics contain microorganisms, most of which are bacteria similar to the beneficial bacteria that occur naturally in the human gut. Probiotics have been widely studied in a variety of gastrointestinal diseases. The most-studied species include Lactobacillus, Bifidobacterium, and Saccharomyces. However, a lack of clear guidelines on when to use probiotics and the most effective probiotic for different gastrointestinal conditions may be confusing for family physicians and their patients. Probiotics have an important role in the maintenance of immunologic equilibrium in the gastrointestinal tract through the direct interaction with immune cells. Probiotic effectiveness can be species-, dose-, and disease-specific, and the duration of therapy depends on the clinical indication. There is high-quality evidence that probiotics are effective for acute infectious diarrhea, antibiotic-associated diarrhea, Clostridium difficile–associated diarrhea, hepatic encephalopathy, ulcerative colitis, irritable bowel syndrome, functional gastrointestinal disorders, and necrotizing enterocolitis. Conversely, there is evidence that probiotics are not effective for acute pancreatitis and Crohn disease. Probiotics are safe for infants, children, adults, and older patients, but caution is advised in immunologically vulnerable populations.

Probiotics contain microorganisms, most of which are bacteria similar to the beneficial bacteria that occur naturally in the human gut. They are available over-the-counter (OTC) or by prescription and in a variety of forms such as capsules, packets, or food supplements. Although most probiotics are available without a prescription, there may be an advantage to patients with prescription drug coverage because probiotics may be a covered benefit. Probiotics have been widely studied in a variety of gastrointestinal (GI) diseases, and one in five Americans takes probiotics for digestive problems.1 The most studied probiotics for human use belong to the Lactobacillus, Bifidobacterium, or Saccharomyces species.2 This article focuses on probiotic use in infants, children, and adults with GI conditions, and it excludes probiotics for non-GI diseases.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
Probiotic use reduces the risk of antibiotic-associated diarrhea in children and adults.	A	10, 34, 35
Probiotic use may reduce the incidence of Clostridium difficile–associated diarrhea.	B	13, 14
Probiotic use significantly reduces the risk of hepatic encephalopathy, but there is insufficient evidence regarding the effect on nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.	B	17, 38
Probiotic use increases remission rates in adults with ulcerative colitis.	A	19, 20
Probiotic use improves abdominal pain and global symptom scores in children and adults with irritable bowel syndrome.	B	21–23
Probiotic use reduces the incidence of necrotizing enterocolitis and mortality in preterm infants.	A	26, 27
Probiotic use is ineffective for acute pancreatitis and Crohn disease.	B	19, 42–45

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
Probiotic use reduces the risk of antibiotic-associated diarrhea in children and adults.	A	10, 34, 35
Probiotic use may reduce the incidence of Clostridium difficile–associated diarrhea.	B	13, 14
Probiotic use significantly reduces the risk of hepatic encephalopathy, but there is insufficient evidence regarding the effect on nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.	B	17, 38
Probiotic use increases remission rates in adults with ulcerative colitis.	A	19, 20
Probiotic use improves abdominal pain and global symptom scores in children and adults with irritable bowel syndrome.	B	21–23
Probiotic use reduces the incidence of necrotizing enterocolitis and mortality in preterm infants.	A	26, 27
Probiotic use is ineffective for acute pancreatitis and Crohn disease.	B	19, 42–45

Mechanism of Action

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Abstract
Mechanism of Action
Regulatory Issues
Dosing, Duration, and Clinical Indications
Acute Infectious Diarrhea
Antibiotic-Associated Diarrhea, C. difficile Infection, and C. difficile–Associated Diarrhea
H. pylori Infection
Hepatic Encephalopathy,

The Authors

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THAD WILKINS, MD, MBA, is director of academic development and a professor in the Department of Family Medicine at Medical College of Georgia at Augusta University....

JACQUELINE SEQUOIA, MD, MPH, is a hospitalist in the Department of Medicine at the Wm. Jennings Bryan Dorn VA Medical Center in Columbia, S.C.

Address correspondence to Thad Wilkins, MD, MBA, Medical College of Georgia at Augusta University, 1120 15th St., Augusta, GA 30912 (e-mail: jwilkins@augusta.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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