Best probiotics for crohns: Which probiotics are best for IBD?
Which probiotics are best for IBD?
Nutritional Therapist DipION
Before we start to look at the evidence behind the use of probiotics in Inflammatory Bowel Disease (IBD), it is important to understand the two different types of IBD, and their clinical presentations. Both Crohn’s Disease (CD) and Ulcerative Colitis (UC) share some similarities in symptoms, such as diarrhoea, blood* or mucus in the stools and inflammation and damage to the intestinal wall. However, the defining difference between the two conditions is the location of the ulceration and/or tissue damage. Typically, ulceration in Ulcerative Colitis is limited to the colon, whereas in Crohn’s Disease the damage can occur at any point in the GI tract, from the mouth to the anus. Crohn’s Disease is therefore divided in to 5 sub-types, dependent on the exact location in the GI tract that the damage is located.
• Ileocolitis: affects the ileum and the colon
• Ileitis: solely affects the ileum
• Gastroduodenal Crohn’s disease: affects the stomach and duodenum
• Jejunoileitis: affects the jejunum
• Crohn’s colitis: affects only the colon
It is estimated that IBD affects 1 person in every 250 in the UK
The different site of damage in the various forms of IBD is important when considering probiotic administration, as different bacteria live in different areas of the intestinal tract, and have different mechanisms of action. For this reason, most clinical trials looking at the potential for probiotic supplementation in Inflammatory Bowel Disease, focus on either Ulcerative Colitis or Crohn’s Disease, rather than grouping them both together.
Additionally, there are many other conditions affecting the GI tract that have an inflammatory component to them, however they are not typically classified as IBD. Such conditions would include Coeliac Disease, and Diverticula Disease.
Intestinal flora of IBD patients
It has been hypothesised for many years that alterations to the intestinal bacterial flora may contribute to the onset and progression of IBD. This is a theory that is now supported by clinical evidence, as several different research studies have found the composition of gut flora to be very different in IBD patients to healthy control patients. Three separate trials1,2,3all found greater numbers of anaerobic bacteria in faecal samples taken from Crohn’s disease patients than in healthy controls, with particularly elevated levels of Bacteroides.
Contrary to these studies, Giaffer et al4 found no difference in total anaerobes between active CD patients, inactive CD patients and healthy controls, but they did find more aerobes and Enterobacteria in active CD, and fewer Lactobacilli in CD patients than healthy controls.
Other research groups have focused their studies into the presence of possible pathogens in IBD, such as bacteria from the Mycobacteria and Listeria genus.
To date, the results from many of these studies are difficult to interpret and often contradictory. Imbalances in gut flora are generally found, supporting the theory that intestinal flora contributes to the pathogenesis of IBD, but the bacterial species involved often differs.
Understanding however, that dysbiosis is almost always observed in IBD patients is a step forward, even if the exact mechanics are not yet fully understood. As a logical progression from this finding, researchers have started to review the clinical outcomes of using different strains of probiotic bacteria and/or yeast in IBD patients and animal models of IBD.
So we have already looked at the increased prevalence of disruption to the GI flora in Crohn’s Disease and Ulcerative Colitis patients, as compared to healthy individuals, now let’s consider whether probiotics may help to support gut health for your clients.
Probiotics and Crohn’s disease
A non-pathogenic strain of E.coli (E. Coli Nissle 1917) has been one of the most clinically trialled probiotics with regard to Crohn’s disease. In a 1997 double-blind study by Malchow5 E.Coli Nissle 1917 or placebo was taken daily for twelve months by 32 patients with active Crohn’s disease. Both groups also received standard steroid treatment at the same time. The results showed that whilst remission rates were similar for both groups (suggesting no additional benefit to adding the probiotic to standard steroid treatment) the subsequent relapse rates were lower in the E.coli treated group (33% relapse versus 64%). This means that once remission had been achieved less of the probiotic group re-developed symptoms. Whilst this particular strain of E. coli has shown probiotic potential, we would suggest practitioners wait for more research before seeking out any E. coli supplements, as of course other strains of this bacteria are well documented and widely known for their pathogenic effect on the human body. E. coli does not appear on the European Food Safety Authority’s Qualified Presumption of Safety (QPS) list.
Saccharomyces boulardii strain
The well researched probiotic yeast Saccharomyces boulardii has also been extensively trialled in Crohn’s disease sufferers. In 2000, Guslandi et al6 divided 32 CD patients into two groups, and gave one group 1g of an anti-inflammatory drug used to treat IBD three times daily, and the other group 1g of the same drug twice daily in combination with S. boulardii probiotic, at a daily dose of 20 Billion CFU (split between 4 capsules). Over the course of 6 months, only one of the 16 patients taking 4 capsules of S. boulardii a day suffered a flare-up of their symptoms. Of the 16 patients from the control group, that were solely given the anti-inflammatory drug, 6 patients experienced a flare-up.
The fact that the relapse rate was significantly lower in patients treated with the drug in combination with S. boulardii, suggests a protective effect from the probiotic.
Probiotics and Ulcerative Colitis
The same strain of non-pathogenic E.coli (E.coli Nissle1917) as was trialled in Crohn’s Disease has also been extensively trialled in Ulcerative Colitis. This strain of bacteria has been compared with an anti-inflammatory drug used to treat IBD in three separate studies of UC patients. Perhaps the most conclusive of them, by Kruis et al7, showed that out of the 327 study participants, that were treated with either E.Coli Nissle1917 or 500mg of the drug three times daily, the relapse rates were similar in both groups, indicating that E.Coli Nissle1917 may be as effective as anti-inflammatory drugs in preventing relapse in UC patients.
A multi-strain probiotic formulation has also been studied for UC. The combination product that was researched, contained three strains of Bifidobacteria, four of Lactobacilli and one of Streptococcus salivarius sp. thermophilus. In this study by Venturi et al8 twenty patients with inactive Ulcerative Colitis were given the probiotic formulation daily for a twelve month period, during which time remission was maintained in 15 out of the 20 study participants. Whilst a 75% success rate appears significant, this trial was not placebo-controlled, so it is difficult to draw any true conclusions.
Saccharomyces boulardii has also been studied in a small pilot study involving 25 Ulcerative Colitis patients that were experiencing a flare up of their condition. Ordinarily steroid treatment would be given in such a situation, however all 25 of these UC patients had had negative reactions to steroids in the past. In this study by Guslandi et al9 all 25 patients were given 250mg S. boulardii three times per day for four weeks, alongside their regular anti-inflammatory drug treatment. 17 out of the 25 patients achieved clinical remission in this time, as confirmed by endoscopic examination. Whilst this study lacked a control group, and was quite small in number, the results definitely warrant further study, and look promising at this stage.
In 2021 the probiotic strain Lactobacillus plantarum HNU082 (Lp082) was investigated and found to play a protective role in Ulcerative Colitis in mice10. At present no human trials have been undertaken using Lactobacillus plantarum HNU082 (Lp082).
Key takeaways of probiotics and IBD
I often seem to write this line, but rarely is it more true than here, that more research is needed to determine the best strains of probiotic to use in this group of patients. Some promising findings have been uncovered already, and I personally am particularly excited about the potential role of Saccharomyces boulardii in helping to support gut health in both Ulcerative Colitis and Crohn’s Disease. Saccharomyces boulardii is my absolute favourite probiotic, as it has so many varied clinical applications.
I eagerly await further research in to this field, and in the interim I think that healthcare professionals can feel excited about the potential for probiotics in IBD management.
To add more targeted support and to benefit from potent anti-inflammatory effects, Saccharomyces boulardii can be used as maintenance for IBD patients. Some clinical trials into the use of this supplement suggest that patients are less likely to suffer a flare up of their symptoms if they add Saccharomyces boulardii to their existing plan. Additionally, many IBD sufferers experience frequent bouts of diarrhoea as a symptom of their disease, and Saccharomyces boulardii has been especially clinically trialled and shown to support bowel health in those with occasional diarrhoea.
You can find Saccharomyces boulardii in Optibac Probiotics Saccharomyces Boulardii.
For any practitioners working with Crohn’s Disease patients, you may be interested to read fellow Nutritional Therapist Kerry’s article, about the effect of pharmaceutical Crohn’s treatments on the gut flora: New study explores effects of Crohn’s treatments on gut flora.
* NB: We do not recommend probiotics be taken by patients with blood in the stool without first consulting their doctor. More information on safety here, in the Probiotics Learning Lab.
You can read more about the studies on Saccharomyces boulardii over on the Probiotics Database.
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- Kruis W, Fric P, Stolte M. Maintenance of remission in ulcerative colitis is equally effective with Escherichia coli Nissle 1917. Gastroenterology 2001;120(suppl 1): A127
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- Guslandi, M. et al. (2003) A pilot trial of Saccharomyces boulardii in ulcerative colitis. European Journal of Gastroenterology & Hepatology. Vol. 15 pp. 697 – 698.
- Yuqing Wu et al. , (2022) Probiotics (Lactobacillus plantarum HNU082) Supplementation Relieves Ulcerative Colitis by Affecting Intestinal Barrier Functions, Immunity-Related Gene Expression, Gut Microbiota, and Metabolic Pathways in Mice. Microbiology Spectrum, Dec 21;10(6):e0165122.
Article Updated: 11 May 2023
Originally Published: 14 Oct 2018
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.