1. GASTROINTESTINAL HEALTH BEYOND THE GLUTEN-FREE DIET: Probiotics and Other Therapy Jacqueline Wolf, M.D. Associate Professor of Medicine Beth Israel Deaconess Medical Center

2. I have no industry or commercial interests to declare that have any application to my presentation

3. AT THE END OF THIS PRESENTATION YOU SHOULD: Understand some of the roles of intestinal bacteria and how they are altered in irritable bowel disease(IBS) and celiac disease (CD). Understand how probiotics (healthy organisms) may be of benefit in IBS and CD Understand what other non-traditional therapies may be of benefit for gastrointestinal symptoms in IBS and possibly celiac disease

4. What is normal gut function? Bowel movements 2x/day to 2-3x/week are normal Stool form varies from person to person. In general the stool is usually well formed. Gas occurs in everyone. The amount depends on what you eat (500mL to 1500mL per day) Medications including herbs and over-the-counter medications can sometimes cause constipation, diarrhea or heartburn. Most people have rare heartburn

5. BACTERIA IN YOUR GUT 1-2 kilograms x body weight Cellular content > 10 fold higher than cells in the body (100,000,000,000,000) Bacterial microbiome (genes) 100 fold > human genome Collective metabolic activity > liver activity Likely > 1000 different bacterial species in the gut Inflamm. Bowel Dis 2004; Science 2005; 308:1635-38; Physiol Rev 2010;90:859-904; Gastroenterology 2014;146:1449-58

6. BACTERIA IN YOUR GUT What do they do? Produce carbohydrate-active enzymes that digest carbohydrates Break down protein to their component amino acids and then participate in their change to biogenic amines (compounds with another effect on the body), to immunomodulator compounds and to signaling compounds. Produce antimicrobial peptides or bacteriocins that may keep harmful organisms at bay. Make vitamins such as folate and Vitamin B12 Participate in and stimulate the development and function of the immune response Inflamm. Bowel Dis 2004; Science 2005; 308:1635-38; Physiol Rev 2010;90:859-904; Gastroenterology 2014;146:1449-58

7. BACTERIA IN YOUR GUT ESOPHAGUS (0-10 2 ) Limited in diversity Dominated by Streptococcus Increased diversity associated with chronic inflammation and dysplasia STOMACH (0-10 2 ) Limited in diversity Helicobacter pylori limits diversity Without H. pylori dominated by Streptococcus SMALL INTESTINE ( 10 2 duodenum, jejunum; 10 7 -10 8 distal ileum) Dominated by Streptococcus in duodenum and jejunum Increased number and diversity as you travel down the small bowel to the ileum Gastroenterology 2014;146:1449-1458

8. BACTERIA IN YOUR GUT LARGE INTESTINE (COLON) (10 11 -10 12 ) Dominated by phylum Firmicutes (includes Lactobacilli) and phylum Bacteroidetes Next most common Actinobacteria (includes Bifidobacteria) and Verrucomicrobia Diet can change the microbiome Ratio of Firmicutes: Bacteroidetes may determine predisposition to obesity Proteobacteria small proportion in normal individuals but may be increased in people with GI diseases Gastroenterology 2014;146:1449-1458

9. CELIAC DISEASE AND IRRITABLE BOWEL SYNDROME What is the possible connection? Symptoms of celiac disease and IBS may overlap People with celiac disease may also have IBS Studies show a 4.5% prevalence of celiac disease in people with IBS diagnosed by Rome I or II criteria Systemic review and meta-analysis showed 4 fold increase in IBS compared to non-IBS populations of celiac disease with positive serology and biopsies 3% of people with a clinical presentation of IBS subsequently diagnosed with celiac disease. Reviewed in Verdu EF et al. Am J Gastroenterol 2009. 104(6):1587-94

10. IRRITABLE BOWEL SYNDROME Can present as: 1.Diarrhea predominant (IBS-D) 2.Constipation predominant (IBS-C) 3.Mixed (alternating pattern of diarrhea and constipation)

11. IRRITABLE BOWEL SYNDROME Criteria for Diagnosis Rome IRome IIRome III Timing>3 months (continuous or recurrent) >3 months in the last 12 months (does not need to be consecutive) >3 days in the last 3 months (onset at least 6 months prior to diagnosis) CriteriaAbdominal pain (continuous or recurrent) relieved with defecation or associated with change in stool frequency with 2 of the following at least 25% of days: 1.Altered stool frequency 2.Altered stool form/passage 3.Passage of mucus 4.Bloating or feeling of abdominal distension Abdominal pain (continuous or recurrent) in the last year associated with 2 or 3 of the following: 1.Relieved with defecation 2.Onset associated with change of stool form 3.Onset associated with change of stool consistency Recurrent abdominal pain associated with 2 or more of the following: 1.Improvement with defecation 2.Onset associated with change of stool form 3.Onset associated with change of stool frequency

12. The microbiome (gut bacteria composition) is altered in IBS Bifidobacterium--decreased Lactobacillus-inconsistent findings with some studies showing a decrease and others showing an increase

13. The microbiome (gut bacteria composition) is altered in Celiac Disease (CD) Reduced concentration of Bifidobacterium spp. in the feces of untreated CD patients and in both active and nonactive CD as compared to healthy people Decreased numbers of Bifidobacterium spp. and increased numbers of Bacteroides spp. In duodenal biopsies of untreated CD Treated CD patients with persistent symptoms vs those without symptoms had higher relative abundance of Proteobacteria and lower numbers of Bacteroidetes and Firmicutes with an overall reduction in microbial richness J Clin Gastroenterol 2013:47;101-103; j Clin Pathol 2009;62:264-9; Am J Gastroenterol 2014:109;1933-1941

14. WHAT ARE PROBIOTICS Probiotics are living organisms contained in foods, such as yoghurt, and in other supplements in the form of capsules, powder or tablets, which confer a health benefit when administered in adequate amounts. Morelli L. J Clin Gastroenterol 2012;46:S1-S2

15. Some Probiotics on the Market

16. L. casei L. casei Shirota L. johnsonii Some Probiotics on the Market L. casei L. reuteri L. rhamnosus GG B. lactis Bb12

17. PROBIOTICS IN IBS Mechanisms of action Change gut bacterial composition Potentially return abnormal gut flora to normal Competitive interactions with pathogens Produce chemical products, that are toxic to pathogenic bacteria or viruses. Reinforce the mucosal barrier Inhibit the movement of bacteria across the gut wall Produce neurotransmitters that influence the motility and sensation of the gut Produce cytokines, neuroactive peptides, fatty acids, gas and other substances. Reviewed in Gastroenterology 2014; 146 (6 )

18. Probiotics Effective in IBS Probiotic Targeted Symptom relief Sample Size Weeks Bifidobacterium Reduced discomfort and bloating 274 3/6 animalis in constipation-predominant IBS Bifidobacterium Reduced abdominal pain and 362 4 infantis 35624 other IBS symptoms Bifidobacterium Alleviated global IBS, improved 122 4 bifidum MIMBb75 IBS symptoms and QOL Escherichia coli Helped in patients with altered 120 12 Nissle enteric microflora, for example, after gastroenterocolitis or use of antibiotics Lactobacillus Improved abdominal pain and 214 4 plantarum 299v bloating Reviewed in S.S Magge & J.L Wolf. Women’s Health (2013) 9(6), 1-11

19. Probiotics Effective in IBS Probiotic Targeted Symptom relief Sample SizeWeeks Saccharomyces Improved QOL, but not significantly 67 4 boulardii in individual symptoms Lactobacillus Improved bloating 60 4 Acidophilus NCFM Bifidobacterium Improved bloating 60 4 lactis Bi-07 Lactobacillus Reduced frequency and 50 6 Rhamnosus GG severity of abdominal pain in children Lactobacillus Reduced abdominal pain 40 4 acidophilus VSL#3 Reduced flatulence and retarded 48 4/8 colonic transit Reviewed in S.S Magge & J.L Wolf. Women’s Health (2013) 9(6), 1-11 S.S Magge & J.L Wolf Women’s Health (2013) 9(6), 1-11

20. PROBIOTICS IN CELIAC DISEASE VSL#3 (but not 3 other probiotics) reduced the toxicity of gluten when used in a fermentation process Bifidobacterial strains produced less toxic gliadin peptides in vitro Saccharomyces boulardii KK1 degraded part of the α- gliadin. In gluten sensitized mice KK1 decreased the IgA transporter (CD71) and improved the small bowel abnormalities and local cytokines (accelerated hair loss with DC412) Bifidobacterium infantis Natren Live Start Super Strain did not improve intestinal permeability, but did improve Gastrointestinal Symptoms and a macrophage inflammatory cytokine, but not other inflammatory markers (# 12 CD; 10 controls) Biochimica et Biophysica Acta 2006; 1762:80-93; Laboratory Investigation 2012; 92:625-635J Clin Gastroenterol 2013:47;101-103;

21. Mouse Model for Celiac Disease: Treatment with probiotics G-mice D1 D7 D37 Gluten Diet (G+) Every Day Every 3 days Sacrifice Oral delivery of KK1 or DC205 or DC412 or PBS Laboratory Investigation 2012; 92:625-635

22. Mouse Model for Celiac Disease: Treatment with probiotics  G- No gluten  G+ With gluten  KK1 Saccharomyces boulardii  DC205, DC412 Lactobacillus paracasei Villous:crypt ratio Laboratory Investigation 2012; 92:625-635 * * * * # *P<0.05 G + to G-, # P<0.05 KK1 to G+

23. Mouse Model for Celiac Disease: Treatment with probiotics Positive Cell number Laboratory Investigation 2012; 92:625-635 * * * * * * * * * * * * * * * * * * * * * * * * * * # # # *P<0.05 G + to G-, # P<0.05 KK1 to G+

24. Treatment of Celiac Disease with Bifidobacterium infantis Probiotic Arm (#) Placebo Arm (#) SyndromesBaselineFinalBaselineFinal Indigestion4.3 (3.4-5.3)2.9 (2.1-3.7)*4.0 (2.7-5.3)3.6 (2.6- 4.6) Diarrhea3.3 (2.0-4.7)2.7 (1.6-3.8)2.9 (1.7-4.0)1.6 (0.9- 2.3)* Constipation3.6 (2.2-5.0)2.5 (1.4-3.5)^2.7 (1.5-3.9)2.4 (1.0- 3.7) GERDNot SignificantNot Significant Abdominal PainNot SignificantNot Significant Composite Score Final/baseline ratioNot SignificantNot Significant *P <0.005, ^P<0.05 E. Smecuol et al. J Clin Gastroenterol 2013:47;139-147

25. Herbal medicines shown to be effective in IBS Herbal medicines use plant extracts to treat different symptoms and diseases. For effective results the herbs can be used either individually, as a mixture of different herbs or in combination with western medication. Herbal MedicineTargeted Symptom Relief Length of Study (Wks) Chinese Herbs Improved IBS global symptoms16 Padma Lax Improved constipation, abdominal pain, 12 abdominal distension and flatulence Tong Xie Yao Fang Decrease in activated mast cells present in 4 IBS STW5,STW5II,placeboReduced abdominal pain and IBS symptoms 4 STW 5/placebo (315)Decreased gastrointestinal symptom score 8 Reviewed in S.S Magge and J.L Wolf. Women’s Health (2013) 9(6), 1-11

26. The truth about gas… When carbohydrates and fat within our food aren’t broken down by the enzymes our bodies make and are not absorbed by the intestines into our bodies, bacteria found in our bowels metabolize them and form gas as a by-product. Depending on the type of bacteria residing in your gut and what food you eat, different gases and therefore different odors will be released. Gas is often a byproduct of what we eat.

27. TREATMENT OF GAS AND BLOATING Peppermint oil Simethicone-changes the surface characteristics of the gas bubbles making it easier to pass Activated charcoal-adsorbs the gas. However, it can interfere with medication absorption

28. Peppermint Oil: Treatment for Gas and Bloating A cross between watermint and spearmint Menthol is thought to be the active component causing calcium-channel blocking activity The blockage of calcium flow into smooth muscle in the intestine decreases muscle contractions thereby reducing pain Adverse effects include heartburn, skin rash, perianal burning, bradycardia and muscle tremor. Reviewed in S.S Magge and J.L Wolf.Women’s Health (2013) 9(6), 1-11

29. Peppermint Oil in IBS Study Targeted Relief Symptom Sample Size Meta-analysis of 8 Significant improvement of IBS symptoms Trials-5 dble blind Randomized, Reduced abdominal distension,, 110 Double-blind placebo stool frequency and flatulence Controlled study-4wks 2007 Double-blind study 75%PO vs 38%PL 57IBS 4 weeks >50% reduction in IBS symptoms Reviewed in S.S Magge and J.L Wolf.Women’s Health (2013) 9(6), 1-11

30. Acupuncture not shown to be effective in IBS Acupuncture is based on a life force ‘qi’ that runs through the body in channels called meridians Disruptions in qi result in disease processes, which can be corrected at the exact anatomical locations using acupuncture Study Results Sample Size/wks Real vs Sham acupuncture No significant difference 230/3 wks vs no treatment in IBS symptoms sham vs real but better than no treatment Cochran review-17 random- Many poor quality. 1806/variable Ized clinical trials Variable results.Same as Bifidobacteria, psychotherapy Reviewed in S. S Magge et al. Women’s Health 2013. 9(6):1-11

31. SUMMARY The gut contains numerous bacteria The bacteria differ in people with Irritable Bowel Syndrome (IBS) and Celiac disease (CD) from healthy individuals without those conditions. Some probiotics have been shown to improve symptoms of patients with IBS Some probiotics make gluten less toxic to patients with CD, but to date in people in contrast to animals there are no trials showing benefit. Some herbal compounds help IBS patients Peppermint oil may help bloating and gas Acupuncture has not shown benefit in IBS