Probiotics are live microorganisms that are beneficial to the host. Lactic acid bacteria and bifidobacteria are the most common probiotics, and probiotics are in yogurt and other fermented foods, as well as in supplements. Probiotics may help prevent ulcerative colitis flares and to maintain remission in Crohn's disease as well as pouchitis.1 Probiotics are studdied or used for diarrhea, colon cancer, lactose intollerance, immune function, inflammation, Iritable bowel syndrome, colitis and other conditions.
Dysbiosis is the overpopulation of one or more types of yeasts or bacteria. This change in the microbial environment may be the cause or result of various diseases. Supplementing with beneficial, friendly bacteria may change the gut microorganism population. Supplements of probiotics include pills, powders, yogurt, kefir, and fermented foods. The viability of the supplement depends on a number of factors. In treatment of ulcerative colitis, some bacteria may exert beneficial effects in the large intestine (colon and rectum). Certain strains of bacteria and yeast are better at this than others, and probiotic manufacturers continue to search for the best probiotic/combinations for UC.
Mechanisms of probiotics in UC
Improvement of mucosal barrier function.
Modulation of mucosal immune responses.
Displacement of pathogenic bacteria.
Studies on the best Probiotics and Ulcerative Colitis
In an 8 week study comparing VSL #3 (3,600 billion CFU/day) with placebo in a group of patients with mild to moderately active ulcerative colitis who were taking 5-ASA and/or corticosteroids who were flaring after at least 6 months of remission, of 65 patients in VSL #3 group and 66 patients in the placebo group, remission rates were 47.7% and 32.4%, respectively; the increased remission rate of VSL #3 isnt statistically significant.2 This study fails to address if VSL #3 can maintain remission in UC patients. Is a higher dose more effective in more active ulcerative colitis? The duration of the study may have been too short to realize the potential of the product. The study had a medium size number of patients in it. Also, the mechanism of action of the probiotic wasnt addressed.
In a study published in 2009 the therapeutic value of VSL #3 (3,600 billion CFU twice/day) in 77 patients, was compared to placebo in 70 patients at inducing remission. The patients had mild-to-Moderately active UC. After 6 weeks 32.5% of the VSL #3 group and 10% of the placebo group had a reduction of their disease activity index by at least 50%. In 12 weeks 42.9% of the VSL #3 patients achieved remission compared to 15.7% in the placebo group.3 Here is another study which dosnt address the efficacy of the product to maintain remission. The mechanism isnt elucidated, nor is a dose related response. The study had a medium number of participants, and the medicated group had a better response rate than many substances cause, though the results are based on a somewhat arbitrary scoring method which makes comparison to other studies difficult. Also, VSL #3 is expensive, though the prescription version is covered by some insurance companies. Also, would an increased dosage work better?
Escherichia coli Nissle 1917 (200 mg/day; two capsules of 2.5–25×109 viable bacteria per enteric coated capsule of Mutaflor 100 mg) is as effective as mesalazine (500 mg 3 times/day) at maintaining remission in UC patients over 12 months. The study was randomized, double blind and double dummy. 110 patients took Mutaflor and 112 patients took mesalazine. The safety of the probiotic E. coli Nissle 1917 was equal to that of mesalazine.4 The long term safety of E. Coli Nissle 1917 hasnt been formally evaluated. Is a higher dose of mutaflor more effective? This study dosnt address the mechanisms involved in the products effectiveness. The study was otherwise well designed, and had a medium-large number of participants compared to most UC related studies. Is a higher dosage more effective?
4 billion CFU's of Escherichia coli Nissle 1917 in a 40 ml enema caused a shorter time to remission than a placebo. Patients tested had mild to moderately active UC (proctitis/proctosigmoiditis) at the start of the trial.5 E. Coli Nissle 1917 isnt available commercially as an enema. The study didnt test patients with extensive ulcerative colitis. Perhaps a larger amount of the bacteria would be more efficacious.
Lactobacillus GG is as effective as mesalamine at maintaining remission in ulcerative colitis patients. Patients were in remission at the start of the study and had been for no longer than 12 months before the study. The patients received either 18 billion cfu of Lactobacillus GG per day (65 people), 2,400 mg of mesalamine per day (60 people), or both (62 people) and had relapse rates of 15%, 20% and 16%, respectively, after 12 months of treatment.6 This study failed to test steroid refractory patients, and 12 months is a long time to be in remission for some people. The study was further limited in that only one dosage of bacteria was tested. Also, relapse rates are low compared to those in some studies. A higher dose may have been more effective at maintaining remission.
Bifidobacterium fermented milk was found to be effective at inducing remission in ulcerative colitis.
Home made yogurt fermented for 24 hours apparently contains up to 3 billion CFU per mL.7 Such yogurt is a fundamental part of the specific carbohydrate diet. The specific carbohydrate diet is a popular diet for ulcerative colitis sufferers. Homemade kefir can have up to 10 billion cfu/ml.7 Kefir may contain more strains of organisms than yogurt, including some that may have limited health benefits.
Fecal bacteriotherapy is a treatment used by some people with UC with amazing, sometimes long term, results.
Probiotics and Cancer
Germ Free mice are less prone to some types of cancer than are regular mice.
Probiotics, prebiotics and synbiotics reduce the experimental risk of colon cancer.8 They do this through a variety of mechanisms, some of which may not be relevant to cancer development in the ulcerative colitis patient.
Aberant crypt (precancerous lesions) formation was reduced in a number of studies by about 50% when test animals were fed probiotic cultures before and after induction of aberant crypt formation.9 Formation of colon cancer in UC patients is complex and different in many cases than that in otherwise healthy people. Animal models of CRC are for the most part geared towards assessing cancer risk in the non-UC population. Short term studies on ACF dont always correlate well with long term chemopreventive effects.
Studies in humans have exhibited that markers of cancer risk decrease after administration of probiotics or fermented milks.10 Some of the markers of cancer risk in ulcerative colitis patients may be different than those in people who dont have UC.
(2) A. Tursi et al. (2010) Treatment of Relapsing Mild-to-Moderate Ulcerative Colitis With the Probiotic VSL#3 as Adjunctive to a Standard Pharmaceutical Treatment: A Double-Blind, Randomized, Placebo-Controlled Study. American Journal Of Gastroenterology. 105(10): 2218–2227.
(3) Sood A. et al. (2009). The probiotic preparation, VSL#3 induces remission in patients with mild-to-moderately active ulcerative colitis. Clin Gastroenterol Hepatol.;7(11):1202-9, 1209.e1.
(4) W Kruis et al. (2004). Maintaining remission of ulcerative colitis with the probiotic Escherichia coli Nissle 1917 is as effective as with standard mesalazine. Gut; 53(11): 1617–1623. doi: 10.1136/gut.2003.037747
(5) Harald Matthes et al. (2010). Clinical trial: probiotic treatment of acute distal ulcerative colitis with rectally administered Escherichia coli Nissle 1917 (EcN). BMC Complement Altern Med. 2010; 10: 13. Published online 2010 April 15. doi: 10.1186/1472-6882-10-13
(6) ZOCCO, M. A., DAL VERME, L. Z., CREMONINI, F., PISCAGLIA, A. C., NISTA, E. C., CANDELLI, M., NOVI, M., RIGANTE, D., CAZZATO, I. A., OJETTI, V., ARMUZZI, A., GASBARRINI, G. and GASBARRINI, A. (2006), Efficacy of Lactobacillus GG in maintaining remission of ulcerative colitis. Alimentary Pharmacology & Therapeutics, 23: 1567–1574. doi: 10.1111/j.1365-2036.2006.02927.x
(8) Cindy D. Davis et al. (2009). Gastrointestinal microflora, food components and colon cancer prevention. J Nutr Biochem. 2009 October; 20(10): 743–752.
(9) Linda J. Brady et al. (2000). The role of Probiotic Cultures in the Prevention of Colon Cancer. Journal of Nutrition. 130:4108-4148.
(10) Journana Saikali et al. (2004). Fermented Milks, Probiotic Cultures, and Colon Cancer. Nutrition and Cancer, 49(1), 14-24.