Probiotics and IBS Gail A. Cresci, PhD, RD, LD, CNSC Associate Staff Gastroenterology/Nutrition Cleveland Clinic Cleveland, OH

Disclosures Scientific Advisory Board – Advocare Scientific Advisory Board - Covidien Research Funding, Speaker’s Bureau - Metagenics

Probiotic “Live microorganisms which when administered in adequate amounts confer a health benefit on the host”. Food and Agricultural Org., WHO, 2001 “Good Little Bugs”

Prebiotics Three Necessary Criteria of Ingredient Must be non-digestible by host enzymes Must be fermented in the GI tract by anaerobic endogenous bacteria in colon Must be selective in the stimulation of intestinal microbiota and of metabolic activity Demonstration of criterion is difficult A prebiotic is not available to all bacterial species that inhabit GI ecosystem Lactobacillus and Bifidobacterium considered indicator organisms Simple, naturally occurring or synthetic sugars Used as a carbon source by certain colonic bacteria for growth and metabolism Examples: Inulin, fructooligosaccharides (FOS), galactooligosaccharides (GOS), lactulose

Synbiotic Combination of probiotic and prebiotic General Aim: Meets criteria of probiotic and prebiotic The prebiotic selectively supports the growth of the probiotic component General Aim: Support the probiotic and other indigenous beneficial organisms by providing a preferred carbon and energy source to promote its growth Provide substrate for optimal or desired fermentation byproducts of probiotic

Probiotics, Prebiotics, Synbiotics Biologic Effects and Mechanisms of Action

Patel Clin Infect Dis 2015

Sept 2007-December 2013 24 Clinical Trials [15 meta-analysis; 9 systematic review] RCT, evaluating probiotic vs placebo in IBS improvement Study quality evaluated

Systematic review was performed to summarize non-eligible clinical trials for the meta-analysis that were excluded because of heterogeneity or different measurement scales for IBS symptoms All the nine studies were classified as randomized placebo-controlled trials. Four, six, and eight weeks of treatment with probiotics were reported.

1793 patients in meta-analysis RR of responders to therapies: Results 1793 patients in meta-analysis RR of responders to therapies: Abdominal pain score: two trials was 1.96 (95%CI: 1.14-3.36; P = 0.01) Global symptom score: two trials was 2.43 (95%CI: 1.13-5.21; P = 0.02) Adequate improvement of general symptoms: 7 trials (six studies) was 2.14 (95%CI: 1.08-4.26; P = 0.03) Distension, bloating, and flatulence were evaluated using an IBS severity scoring system in 3 trials (two studies) the standardized effect size of mean differences for probiotics therapy was -2.57 (95%CI: -13.05--7.92) Use of different scales to analyze mean differences of symptoms makes analysis difficult Further studies needed

Summary Probiotics reduce pain and symptom severity scores compared to placebo in IBS patients Studies inconsistent with design and outcome measurement Future studies needed with standardization Longer treatment needed (8-12 week) Ideal probiotic yet to be discovered

References Patel Clin Infect Dis 2015