Best probiotics for crohns: Probiotics & IBD | Crohn’s disease
Probiotics & IBD | Crohn’s disease
Can probiotics help with Crohn’s disease & ulcerative colitis? We take a look at the evidence and some of the probiotic supplements available to buy.
- Intro to probiotics
- What are probiotics
- Probiotics & IBD
- Can probiotics cure IBD?
- How will I feel taking probiotics?
- Which probiotic?
- Knowing what’s in a probiotic
- Regulation of probiotics
- Probiotic food
Our gut bacteria is currently a hot topic among researchers and doctors alike. We are only just starting to understand the relationship between having a balanced microbiome (our collective gut microbes and their genes) and our health. New studies and discoveries are happening all the time and as a digestive condition inflammatory bowel disease (IBD) is frequently talked about in relation to our microbiome.
As a result of all this dozens of probiotic supplements – which when ingested may have a beneficial impact on our digestive and overall health aim to populate your gut with friendly bacteria that you might be lacking in – have come onto the market and many of them are targeting people with IBD.
In this section we examine what probiotics are available and present the current evidence available in relation to IBD and the use of probiotics.
What are probiotics?
Probiotics are supplements containing microbes that when taken in adequate amounts provide benefit to us and our health. Probiotics can help support the bacteria that live within us, especially when our bacteria are challenged, for example by antibiotics, poor diet or travelling. It is believed that many people (not just those with IBD) have unbalanced gut bacteria – which may be due to a number of reasons. Some of these reasons include:
- Overuse of antibiotics and other medication
- Illness and chronic disease
When taken – usually as a drink or capsule – probiotics may help to support our gut health. We used to think that probiotics ‘repopulated’ the gut but now we know that they do not actually take up residence, but instead they have an impact as they move through our digestive tract. You can learn more our gut microbiome in this article.
When buying probiotic products it’s important to understand that not all probiotics are the same. They do not all contain the same strains of bacteria, they have all been manufactured differently and they all deliver the bacteria to the gut in different ways.
It’s not known exactly how many different strains of bacteria live in our guts – but it’s a lot (we are talking trillions!). Manufactured probiotic supplements tend to focus their products on just one or a few strains they believe will be the most beneficial for us.
When making a probiotic the manufacturer has to grow the strains of bacteria they want in their product (or buy them from another manufacturer that does this). This can be a very complicated process. Once grown the bacteria needs to be prepared for the probiotic. In general the bacteria in capsule probiotics is freeze-dried, leaving a powder which can be encapsulated. As bacteria are delicate and sensitive to extreme conditions special steps have to be taken during this process to ensure the bacteria isn’t damaged. Steps also have to be taken to ensure the bacteria will survive once encapsulated and also survive the harsh environment of our digestive system to make it into the small intestine. Probiotic companies often do this by mixing the bacteria with digestive enzymes and soluble fibre.
For liquid probiotics the bacteria, once cultivated, is added to the liquid (usually water or dairy) rather than being encapsulated.
Do probiotics help ulcerative colitis and Crohn’s disease?
Researchers are starting to think that imbalances in our gut microbiome are linked to many diseases, ailments and even our mental health.
There is increasing evidence that suggests intestinal microbiota plays a role in initiating, maintaining and determining the characteristics and development of IBD1, 2. And, some people with IBD do report that taking probiotics can help with easing some of their symptoms.
However, studies into the effectiveness of probiotics on people with IBD are limited. There have been a few studies into specific strains of bacteria and their effect on IBD and even fewer studies specifically testing probiotic products on IBD. Generally, at the moment, the research shows that some specific probiotics may be helpful for people with ulcerative colitis but the evidence in Crohn’s Disease is less convincing.
Some of these studies include:
Probiotic product specific
VSL#3 and pouchitis. The study concluded that ‘high doses of the probiotic VSL#3 are effective in the treatment of mild pouchitis’3.
VSL#3 and ulcerative colitis. The study ‘demonstrated that VSL#3 is effective in achieving clinical responses and remissions in patients with mild-to moderately active UC’4.
Some studies have also been carried out into Crohn’s disease and microscopic colitis.
Symprove and ulcerative colitis. The study found that 76% of those with ulcerative colitis taking part in the study had significant reductions in faecal levels of calprotectin5.
Bacteria strain specific
Saccharomyces boulardii and Crohn’s disease. Results suggested that ‘Saccharomyces boulardii may represent a useful tool in the maintenance treatment of Crohn’s disease’6.
Saccharomyces boulardii and ulcerative colitis. The study’s ‘preliminary results suggest that S. boulardii can be effective in the treatment of ulcerative colitis’7.
OpticBac Probiotics have a product which just includes Saccharomyces boulardii.
Will probiotics cure my IBD?
No. Unfortunately there is currently no cure for IBD.
However, some people have found that some probiotics assist in alleviating some symptoms of their IBD. If you choose to take a probiotic it is recommended you do so alongside any other treatment you are undergoing and that you discuss taking it with your doctor before starting.
People who report success with probiotics have found a reduction in symptoms such as bloating, diarrhoea, fatigue, skin conditions (such as eczema) and constipation. Probiotics are increasingly being recognised to help people who have irritable bowel syndrome. Many people with IBD suffer from IBS too.
The success rate varies from person to person and a probiotic that may produce results for one person may not do the same for another.
Some of the probiotics available to buy
How will I feel taking probiotics?
Again, this really varies from person to person. Some people who take probiotics – whether they have IBD or not – report feeling bloated and gassy or have a short bout of diarrhoea at the beginning. This may be a reaction to the changes in bacteria in your gut. To help prevent this some probiotic companies recommend you start by taking a small dosage and build up to taking the full dose to allow your body to adjust. If you are concerned, or these symptoms persist, you should stop taking the probiotic and speak to your doctor.
Caution should be taken around taking probiotics when you are on immunosuppressant medications or are acutely unwell – always speak to your doctor before starting a probiotic to check it is safe for you to do so.
Which probiotic should I take?
Manufactured probiotics available generally fall into three types:
Unfortunately there isn’t one probiotic that works for all. It is very individual as to whether probiotics will make a difference to you, depending on your gut health.
Probiotics can be expensive and there are dozens available to buy. They are all of varying quality and some are bought from a common distributor and rebranded by the company selling them. Some brands of probiotic do have clinical research available into their finished products in relation to IBD, but most do not.
Due to the cost of probiotics it’s worth spending some time doing research into them, such as the claims they make and the clinical research behind their product, before buying them. You may also find the experiences of other people with Crohn’s disease and ulcerative colitis who use probiotics useful in making your choice.
The success (or not) you have with probiotics will be very individual and if you find that one product doesn’t work for you it doesn’t mean that none of them will. Unfortunately you may have to go through a process of trial and error to see if they are of benefit to you.
Gut health testing
Some people opt to do gut health testing to get an analysis of the bacteria in their gut before starting a probiotic. This involves sending a sample of your poo off to a lab to be analysed. At the moment comprehensive gut health testing isn’t available on the NHS so if you want to do this you will need to pay privately.
There are various companies that offer this service, including Healthpath which offers three types of gut health test*. Along with your results, many of the companies will also provide a report and some will also offer recommendations.
How do I tell what’s in a probiotic?
Probiotics must list on their labels what’s in them, including the strains and any other ingredients added.
On a product, a probiotic strain should be listed as a long name followed by a series of letters, and sometimes numbers too. For example, Lactobacillus Rhamnosus GG, or Bifidobacterium lactis HN019.
The first part of the name (for example Lactobacillus, or sometimes just referred to as L.) is the genus. The second part of the name (for example rhamnosus) is the species and the letters and numbers at the end are the strain designation.
If you know what the name of each strain in the probiotic is you can link it to any research that’s been done into the strain.
Some companies produce a Trademarked name for strains of bacteria in their products. This can be for marketing purposes and isn’t an indication of one strain being better than another. If a product contains a Trademarked strain the packaging must still list the scientific name for the strain.
If a probiotic does not list the full name of the specific bacteria in the produce or they do not state how much of the bacteria is present in the product this is a sign to be wary.
Make sure the product contains at least the level of probiotics that was used in the research. These are shown as CFU (colony forming units – the number of viable bacteria in the product) on the bottle/packaging/website. Most successful probiotic research has used more than or equal to 109 (10 with 9 zeros!) CFU per dose so this is the amount of that bacteria needed to have the beneficial outcome shown in the study.
How are probiotic products regulated?
In the UK most probiotics are governed under the same laws as foods, not medicines, and governing bodies include the European Food Safety Authority (EFSA), the Food Safety Authority (FSA) and the Advisory Committee on Borderline Substances.
These bodies issue guidelines around what probiotic companies can say in relation to their product and health claims they can make. Even if a probiotic has medical evidence to support its use for a certain condition they cannot publicise this unless they go through strict medical testing – a very expensive and lengthy process.
This is why you will often find that probiotic companies do not mention specific health conditions on their website and marketing material. Guidelines have also been issued to say that the term probiotic may no longer be used in the promotion of supplements by the companies. The Advertising Standards Authority also has oversight regarding claims made and any complaints arising. In general the industry is self-regulated so some companies choose to ‘bend’ the rules around making health claims in relation to their product.
So what about probiotic and fermented food?
Probiotic and fermented foods are foods that contain live bacteria. However, unlike commercial probiotics the exact strains and amount in the product aren’t known.
Common food sources of probiotic bacteria include:
- Sourdough bread
These can either be made at home or shop bought. Learn more about probiotic foods, including some recipes.
*Please note this is an affiliate link which means if you buy from the company we may receive a commission. You will pay the same price and any commission gained will be used to support IBDrelief’s work.
- Sartor RB. Microbial influences in inflammatory bowel diseases. Gastroenterology 2008;134:577‐594. | Article | PubMed | ISI | CAS
- Sartor RB. Genetics and environmental interactions shape the intestinal microbiome to promote inflammatory bowel disease versus mucosal homeostasis. Gastroenterology 2010;139:1816‐1819. | Article | PubMed | ISI |
- Gionchetti P, Rizzello F, Morselli C, Poggioli G, Tambasco R, Calabrese C, Brigidi P, Vitali B, Straforini G, Campieri M. High-dose probiotics for the treatment of active pouchitis. Dis Colon Rectum. 2007 Dec;50(12):2075-82; discussion 2082-4. Epub 2007 Oct 13. PMID: 17934776
- Lee JH, Moon G, Kwon HJ, Jung WJ, Seo PJ, Baec TY, Lee JH, Kim HS. Effect of a probiotic preparation (VSL#3) in patients with mild to moderate ulcerative colitis. Korean J Gastroenterol. 2012 Aug;60(2):94-101. PMID: 22926120
- Assessment of a Multi Strain Probiotic (Symprove) in IBD. Guy Sisson, Bu Hayee, Ingvar Bjarnason. Gastroenterology, April 2015 Volume 148, Issue 4, Supplement 1, Page S-531
- Guslandi, M. et al. (2000) Saccharomyces boulardii in Maintenance Treatment of Crohn’s Disease. Digestive Diseases & Sciences. Vol 45, 7, 1462 – 1464
- Guslandi M, Giollo P, Testoni PA. A pilot trial of Saccharomyces boulardii in ulcerative colitis. Eur J Gastroenterol Hepatol. 2003 Jun;15(6):697-8. PMID:12840682
Probiotics for Crohn’s disease: what have we learned?
Gut. 2006 Jun; 55(6): 757–759.
Author information Copyright and License information Disclaimer
Probiotics do not seem to be a therapeutic option for patients with Crohn’s disease, either in the acute phase or for maintenance
Keywords: Crohn’s disease, randomised controlled trial, probiotics, lactobacillus
A causative role of bacteria in Crohn’s disease (CD) has been surmised for a long time. Only in recent years however has there been a large body of evidence from genetic and bacteriological studies indicating that the intestinal flora is the essential factor in driving the Crohn’s inflammatory process in genetically susceptible individuals.1,2,3,4,5
The therapeutic arsenal for treating CD assumes the correctness of the above hypothesis. Thus immunosuppressors are used to reduce the host response and antibiotics are used to suppress the bacterial flora, with a consequent decreased activation of the gut immune system.6 Between the two strategies it should theoretically be better to remove the harmful cause instead of reducing the host defences by inducing a form of immunodeficiency that is susceptible to opportunistic infections.
If the intervention on the gut flora works, substituting antibiotics (which are heavily burdened by side effects) with probiotics is an appealing alternative. Probiotics are defined as a living microbial food ingredient with a beneficial effect on human health7; however, the concept that probiotics are a type of long life elixir useful in many pathological conditions needs to be viewed with caution.
In a world medical scenario, where new science develops new drugs and the financial cost increases, natural remedies, relatively cheap and potentially free from side effects, catch the consumer’s attention, thereby possibly biasing medical judgement.
To date, diverse probiotics, containing different strains and quantities of bacteria, are sold on the market.8 Their therapeutic effects may include a competitive action with commensal and pathogenic flora and an influence on the immune response through various mechanisms.9 Probiotics have been successfully employed in the treatment of antibiotic associated and Clostridium difficile diarrhoea,10,11 traveller’s diarrhoea,12 and rotavirus infection.13 For inflammatory bowel diseases (IBD), some researchers have reported success with different strains of probiotics in the treatment of ulcerative colitis,14,15 CD,16,17,18 and in pouchitis treatment and prevention.19,20E coli Nissle 1917, the yeast Saccharomyces boulardii, Lactobacillus rhamnosus strain GG (LGG), and VSL#3, a cocktail of eight different strains, are the various probiotics employed in these studies. Several significant flaws however limit the importance of many of the probiotic trials, such as inclusion of too few patients,16,17 too low a dose of the control drug,14 or the association of the probiotic with other medicines.15,16,17,18
Given their potentially high safety profile, the use of probiotics for maintaining CD remission induced by drugs or surgery is particularly appealing. It is suggested that luminal bacteria are the main cause of recurrent lesions after operation.3 Moreover, preventing recurrent lesions in CD after surgery has removed all of the macroscopic inflamed tracts is the best test for any type of drug.
Consequently, LGG, which has been shown to survive and colonise the human intestine by adhering to intestinal cells, has been challenged in two randomised placebo controlled trials for its efficacy in preventing recurrence after surgery21 and relapse after medically induced remission. 22
In the first study, 45 patients operated on for CD were randomly allocated to receive 12 billion LGG or identical placebo for one year.21 Clinical recurrence was ascertained in 16.6% on Lactobacillus and in 10.5% on placebo. Sixty per cent of patients in clinical remission on Lactobacillus had endoscopic recurrence in comparison with 35.3% on placebo. There were no significant differences in the severity of lesions between the two groups.
The second trial involved 75 children in medically induced remission.22 They were randomised to receive 1010 LGG bacteria or placebo for two years as an adjunct to standard maintenance treatment. The average time to relapse was 9.8 months in the LGG group and 11 months in the placebo group; 31% and 17% of children on LGG and placebo, respectively, relapsed during the study period. Neither study showed any statistically significant differences between the active and placebo groups.
In this issue of Gut, Marteau and colleagues23 have reported the results of a trial with Lactobacillus johnsonii (LA1) for prophylaxis of postoperative recurrence in CD (see page 842). Ninety eight adult patients were randomised in a double blind, placebo controlled study in which they received 4×109 LA1 or placebo for six months. At the end of this period, 64% of patients on placebo and 49% on probiotic had endoscopic recurrence. Endoscopic scores and clinical recurrences did not differ between the two groups.
Unfortunately, this study is neither decisively negative nor decisively positive. In fact, the lack of statistically significant difference between Lactobacillus and placebo might be due either to an insufficiently large sample size or to the follow up period of six months, which may have been too short to demonstrate a larger difference. However, the cumulative result of these three studies is not encouraging, and at the moment probiotics are not a therapeutic option for CD patients either in the acute phase or for maintenance.
Is it curtains, then, for probiotics in CD?
Before dropping the curtain we have to take into account some important points.
CD is a complex entity. Diverse locations and different disease behaviours may well condition the response to probiotics—for example, colonic location seems to respond better to antibiotics and, consequently, might be more susceptible to flora manipulation.
The course of CD follows different phases; probiotics might be more effective in the early ones.
There are many species of probiotic. One type might be more effective than another because strain specific properties might influence the efficacy in different cases and situations.
The quantity of bacterial content may condition the effectiveness of the probiotic.
In short, it seems advisable to wait for results from some larger controlled trials, some of which are already underway.
Setting aside the question of probiotic effectiveness however, is their use absolutely safe? In CD, antigenic stimuli contribute towards maintaining gut inflammation, and any bacteria can become a stimulus. In the two studies with LGG, recurrence rates were lower in the placebo groups than in the groups treated with probiotics.21,22
Moreover, some anecdotal reports of infections probably caused by probiotics have been published.24,25 Probiotic strains adhering to the intestinal mucosa could translocate, inducing bacteraemia and sepsis. This risk can be increased in patients with severe disease or deeply immunosuppressed.
So, in conclusion, is all news about probiotics in CD negative? A possible future scenario on probiotics use in this disease has come from data extrapolated from allergic paediatric patients. In children with atopic dermatitis, probiotics seem to stabilise intestinal barrier function and decrease gastrointestinal symptoms.26,27,28,29
In CD, enhanced mucosa permeability may play a pivotal role in causing and perpetuating intestinal inflammation.30 It is possible therefore that administration of probiotics in the very early phases of CD may limit pathological damage and aggravation of symptoms by stabilising the intestinal barrier.
We can also speculate that children with IBD familiarity, who are at risk of developing CD, could be treated by probiotics to reduce intestinal permeability and counterbalance the hypothetical “harmful” species. For this purpose, identification of subjects at risk of developing CD could be done by analysis of genetic characteristics, such as NO2 and other genes still to be identified. In this case, genetic studies in IBD could be promoted from the laboratory to practical usefulness.
Conflict of interest: None declared.
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Probiotics for the treatment of active Crohn’s disease
What is the purpose of this review?
The aim of this Cochrane Review was to investigate whether probiotics can induce remission in people with Crohn’s disease. We analyzed information from two studies to answer this question.
It is unclear whether probiotics are better than placebo. No serious adverse events occurred in any of the studies.
What was learned in this review?
Crohn’s disease is a disease that causes inflammation of the intestines and can lead to symptoms of mouth ulcers, abdominal pain, diarrhea, obstruction, fistulization (tunnels between the intestines and nearby organs), abscesses, malnutrition, low hemoglobin (blood) levels, and fatigue. There is some evidence to suggest that an imbalance of gut bacteria is the cause of the disease. Probiotics, which are live microorganisms, can affect gut bacteria and possibly reduce inflammation.
What are the main findings of this review?
We searched for randomized controlled trials (RCTs; clinical trials in which people are randomly assigned to one of two or more treatment groups) comparing probiotics to placebo. There were two RCTs, with information on 46 participants. These trials looked at adults. It is unclear whether probiotics differ from placebo in inducing remission of Crohn’s disease. It is unclear whether probiotics lead to differences in adverse events (minor and major) compared to placebo.
This review found two studies investigating and showing no benefit of probiotics in the treatment of active Crohn’s disease. Since the studies were very small, no definitive conclusions can be drawn at this time. Probiotics were generally well tolerated; there was only one side effect that led to discontinuation of probiotic treatment, but details are not known. Based on the evidence presented in these studies, we cannot draw conclusions about the effectiveness of probiotics. Carefully designed studies with large numbers of participants are needed.
How up-to-date is this review?
This overview is current as of July 6, 2020.
If you found this evidence helpful, please consider donating to Cochrane. We are a charity that produces accessible evidence to help people make health and care decisions.
Translation: Alexandrova Elvira Grigorievna. Editing: Yudina Ekaterina Viktorovna. Russian translation project coordination: Cochrane Russia – Cochrane Russia, Cochrane Geographic Group Associated to Cochrane Nordic. For questions related to this translation, please contact us at: cochranerussia@gmail. com;
Treatment of Crohn’s disease with probiotics
The causes of inflammation in the cavities of the gastrointestinal tract in Crohn’s disease are still ambiguous. However, recent studies suggest that the intestinal flora is a significant factor that stimulates inflammatory processes. This is confirmed by the fact that today antibiotics are successfully used to treat the disease, which suppress the bacterial flora of the patient. Replacing antibiotics with probiotics is an attractive alternative that is relatively safe and rivals traditional treatment in terms of effectiveness.
How to take probiotics for Crohn’s disease?
Complexes with probiotics are preparations containing live microorganisms that have a beneficial effect on the human body, normalizing the composition of the intestinal flora. They have a relatively high safety profile and, unlike antibiotics, do not have serious side effects. There are a number of things to consider before starting probiotic treatment.
- The success of the treatment depends on the location of the inflammation. For example, Crohn’s disease of the colon responds better to antibiotics, which means that this area can be said to be more susceptible to the action of probiotics.
- Crohn’s disease is best treated with probiotics in the early stages.
- One type of probiotic may be more effective depending on the specific properties of a particular strain.
- The amount of bacterial content also affects the success of the treatment.
Which probiotics to choose?
The choice of drugs for the normalization of intestinal microflora today is huge, and it is not so easy to choose the right remedy. Probiotics for Crohn’s disease should contain enough bacteria in a single dose and be resistant to the acidic environment of the stomach and intestines. Only modern probiotics meet these requirements.
fifth generation. These funds include BAK-SET forte and BAK-SET baby.