What are the most effective probiotics for Crohn’s disease. How do probiotics impact inflammatory bowel disease symptoms. Which strains show promise in clinical trials for IBD management. Can probiotics help maintain remission in Crohn’s disease patients.

Understanding Inflammatory Bowel Disease: Crohn’s vs. Ulcerative Colitis

Inflammatory Bowel Disease (IBD) is a term that encompasses two main conditions: Crohn’s Disease (CD) and Ulcerative Colitis (UC). While these conditions share some similarities, they have distinct characteristics that are crucial to understand when considering probiotic interventions.

Key Differences Between Crohn’s Disease and Ulcerative Colitis

• Location of inflammation: UC primarily affects the colon, while CD can occur anywhere in the gastrointestinal tract
• Extent of inflammation: UC affects only the innermost lining of the colon, while CD can involve all layers of the intestinal wall
• Distribution of inflammation: UC typically presents as continuous inflammation, while CD often appears in patches

Understanding these differences is essential when evaluating the potential benefits of probiotics for IBD management. The specific location and nature of inflammation can influence which probiotic strains may be most effective.

Subtypes of Crohn’s Disease

Crohn’s Disease is further categorized into five subtypes based on the affected area of the gastrointestinal tract:

1. Ileocolitis: Affects the ileum and colon
2. Ileitis: Solely affects the ileum
3. Gastroduodenal Crohn’s disease: Affects the stomach and duodenum
4. Jejunoileitis: Affects the jejunum
5. Crohn’s colitis: Affects only the colon

This classification is important when considering probiotic supplementation, as different bacterial strains may be more beneficial for specific subtypes of Crohn’s Disease.

The Role of Gut Microbiota in Inflammatory Bowel Disease

Research has increasingly pointed to the crucial role that gut microbiota plays in the development and progression of IBD. Several studies have highlighted significant differences in the intestinal bacterial composition of IBD patients compared to healthy individuals.

Dysbiosis in IBD Patients

Dysbiosis, an imbalance in the gut microbiome, is consistently observed in IBD patients. However, the specific bacterial alterations can vary between studies and individuals. Some key findings include:

• Increased levels of anaerobic bacteria, particularly Bacteroides, in Crohn’s Disease patients
• Higher numbers of aerobes and Enterobacteria in active Crohn’s Disease
• Reduced populations of beneficial bacteria such as Lactobacilli in CD patients
• Potential presence of pathogenic bacteria from genera like Mycobacteria and Listeria

These findings support the hypothesis that alterations in gut flora may contribute to the onset and progression of IBD. This understanding has led researchers to investigate the potential of probiotics in managing IBD symptoms and maintaining remission.

Probiotics and Crohn’s Disease: Current Evidence

While research on probiotics for Crohn’s Disease is ongoing, some strains have shown promising results in clinical trials. One of the most extensively studied probiotics for CD is a non-pathogenic strain of E. coli known as E. coli Nissle 1917.

E. coli Nissle 1917: A Promising Probiotic for Crohn’s Disease

A landmark study by Malchow in 1997 investigated the efficacy of E. coli Nissle 1917 in Crohn’s Disease patients. The double-blind study involved 32 patients with active CD who received either the probiotic or a placebo daily for 12 months, alongside standard steroid treatment.

Key findings from the study include:

• Similar remission rates between the probiotic and placebo groups when combined with steroid treatment
• Lower relapse rates in the E. coli Nissle 1917 group (33% vs. 64% in the placebo group)
• Potential for the probiotic to help maintain remission once achieved through standard treatment

While these results are encouraging, it’s important to note that more research is needed before specific recommendations can be made regarding E. coli-based probiotics for Crohn’s Disease management.

Evaluating Probiotic Strains for IBD Management

When considering probiotics for IBD, it’s crucial to evaluate the specific strains and their potential benefits. Different probiotic strains can have varying effects on the gut microbiome and inflammatory processes.

Factors to Consider When Choosing Probiotics for IBD

• Strain-specific effects: Not all probiotics are created equal, and their benefits can be strain-specific
• Clinical evidence: Look for strains that have been studied in well-designed clinical trials
• Safety profile: Ensure the chosen probiotic has a good safety record, especially for immunocompromised individuals
• Dosage and viability: Consider the concentration of live bacteria and their ability to survive transit through the digestive system
• Specific IBD subtype: Choose strains that have shown promise for either Crohn’s Disease or Ulcerative Colitis, depending on the patient’s diagnosis

It’s important to consult with a healthcare professional before starting any probiotic regimen, as individual responses can vary, and some strains may be contraindicated in certain situations.

Promising Probiotic Strains for IBD Management

While research is ongoing, several probiotic strains have shown potential benefits for IBD patients. Here’s an overview of some promising candidates:

Lactobacillus and Bifidobacterium Strains

These genera of bacteria are among the most commonly studied for their probiotic effects. Some specific strains that have shown promise in IBD research include:

• Lactobacillus rhamnosus GG: May help reduce inflammation and improve gut barrier function
• Bifidobacterium infantis 35624: Has shown potential in reducing inflammatory markers in IBD patients
• Lactobacillus plantarum 299v: May help alleviate symptoms in mild to moderate Ulcerative Colitis

Saccharomyces boulardii

This probiotic yeast has demonstrated potential benefits in maintaining remission in Crohn’s Disease patients. It may help by:

• Reducing inflammation in the gut
• Enhancing the intestinal barrier function
• Modulating the immune response

VSL#3: A Multi-Strain Probiotic Formulation

VSL#3 is a high-potency probiotic mixture containing multiple strains of beneficial bacteria. It has shown promise in several studies, particularly for Ulcerative Colitis patients. Potential benefits include:

• Induction and maintenance of remission in UC patients
• Reduction of inflammation in the gut
• Improvement in overall gut health and function

While these strains show promise, it’s important to note that more research is needed to establish definitive recommendations for probiotic use in IBD management.

Mechanisms of Action: How Probiotics May Benefit IBD Patients

Understanding the potential mechanisms by which probiotics may benefit IBD patients is crucial for both researchers and clinicians. While the exact pathways are still being elucidated, several key mechanisms have been proposed:

Modulation of the Gut Microbiome

Probiotics may help restore balance to the gut microbiome by:

• Competing with pathogenic bacteria for nutrients and adhesion sites
• Producing antimicrobial substances that inhibit harmful bacteria
• Promoting the growth of beneficial bacteria

Enhancement of the Intestinal Barrier Function

Probiotics may strengthen the gut barrier by:

• Increasing the production of mucus and antimicrobial peptides
• Enhancing the integrity of tight junctions between intestinal epithelial cells
• Reducing intestinal permeability (“leaky gut”)

Immunomodulation

Certain probiotic strains may help regulate the immune response in IBD by:

• Modulating the production of pro-inflammatory and anti-inflammatory cytokines
• Influencing the balance between different T cell subsets
• Enhancing the function of regulatory T cells

Production of Beneficial Metabolites

Probiotics may produce metabolites that benefit gut health, such as:

• Short-chain fatty acids (SCFAs), which serve as an energy source for colonocytes and have anti-inflammatory properties
• Vitamins and other nutrients that support overall gut health

By understanding these mechanisms, researchers can better target probiotic interventions for IBD management and develop more effective therapeutic strategies.

Challenges and Considerations in Probiotic Research for IBD

While the potential of probiotics in IBD management is promising, several challenges and considerations must be addressed to advance our understanding and develop effective treatments:

Strain-Specific Effects and Standardization

One of the main challenges in probiotic research is the strain-specific nature of their effects. Different strains, even within the same species, can have vastly different impacts on gut health and IBD symptoms. This variability makes it difficult to generalize findings across studies and develop standardized recommendations.

To address this issue, researchers and clinicians should:

• Clearly report the specific strains used in studies, including their full taxonomic designation
• Avoid generalizing results from one strain to an entire species or genus
• Work towards developing standardized protocols for probiotic research in IBD

Dosage and Duration of Treatment

Determining the optimal dosage and duration of probiotic treatment for IBD patients remains a challenge. Factors to consider include:

• The minimum effective dose for each strain or combination of strains
• The impact of long-term probiotic use on gut health and IBD symptoms
• The potential for developing tolerance or resistance to probiotic effects over time

Future research should focus on establishing clear dosage guidelines and evaluating the long-term effects of probiotic supplementation in IBD patients.

Individual Variability and Personalized Approaches

The response to probiotic interventions can vary significantly between individuals with IBD. Factors that may influence this variability include:

• The specific subtype and severity of IBD
• The individual’s existing gut microbiome composition
• Genetic factors and immune system function
• Diet and lifestyle factors

Developing personalized probiotic approaches that take these factors into account may lead to more effective treatments for IBD patients.

Safety Considerations

While probiotics are generally considered safe for most individuals, special considerations must be made for IBD patients, particularly those with compromised immune systems. Potential safety concerns include:

• The risk of bacterial translocation in patients with severely compromised gut barriers
• Possible interactions with immunosuppressive medications commonly used in IBD treatment
• The potential for adverse reactions in certain subgroups of IBD patients

Rigorous safety assessments and careful monitoring are essential when evaluating probiotic interventions for IBD patients.

Future Directions in Probiotic Research for IBD

As our understanding of the gut microbiome and its role in IBD continues to evolve, several promising avenues for future research emerge:

Microbiome-Based Personalized Probiotic Therapies

Advancements in microbiome sequencing and analysis may allow for the development of personalized probiotic therapies tailored to an individual’s specific gut microbiome profile. This approach could involve:

• Identifying microbial signatures associated with IBD subtypes and disease severity
• Developing targeted probiotic formulations to address specific microbial imbalances
• Combining probiotics with prebiotics or synbiotics for enhanced efficacy

Novel Probiotic Strains and Engineered Probiotics

Research into new probiotic strains and genetically engineered probiotics may yield more effective treatments for IBD. Potential areas of investigation include:

• Identifying and isolating novel probiotic strains from the human gut microbiome
• Developing genetically modified probiotics that produce anti-inflammatory compounds or enhance gut barrier function
• Exploring the potential of next-generation probiotics, such as Akkermansia muciniphila or Faecalibacterium prausnitzii

Combination Therapies and Integrative Approaches

Investigating the potential of combining probiotics with other therapeutic approaches may lead to more comprehensive IBD management strategies. Areas to explore include:

• Evaluating the synergistic effects of probiotics with conventional IBD medications
• Exploring the role of probiotics in supporting dietary interventions, such as the Specific Carbohydrate Diet or low FODMAP diet
• Investigating the potential of probiotics in preventing or managing IBD-related complications, such as pouchitis or small intestinal bacterial overgrowth (SIBO)

Long-Term Studies and Real-World Evidence

To better understand the long-term effects and real-world efficacy of probiotics in IBD management, future research should focus on:

• Conducting large-scale, long-term clinical trials to evaluate the safety and efficacy of probiotic interventions
• Collecting real-world evidence through patient registries and observational studies
• Investigating the potential of probiotics in preventing IBD onset in high-risk individuals

By addressing these challenges and exploring new avenues of research, the scientific community can work towards developing more effective probiotic-based strategies for IBD management, ultimately improving the quality of life for patients living with these chronic conditions.

Which probiotics are best for IBD?

Digestive Health

Kathy Wheddon


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 trials^1,2,3all 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. 

References

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9. Guslandi, M. et al. (2003) A pilot trial of Saccharomyces boulardii in ulcerative colitis. European Journal of Gastroenterology & Hepatology. Vol. 15 pp. 697 – 698.
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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.

doi: 10.1136/gut.2005.085381

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.

Key information

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.

Terminals

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.

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Translation notes:

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;

Probiotics and ulcerative colitis: what should you know?

The gastrointestinal tract contains millions of tiny bacteria that are beneficial and essential to health. However, an imbalance or change in bacteria in the gut can lead to inflammatory processes that can lead to chronic disease.

One way to change the bacterial balance of the gut is to consume probiotics.

What are probiotics?

Probiotics are bacteria. They are made from food sources, usually cultured milk, and come in the form of tablets, capsules, and powders that dissolve. Some bacteria are genetically engineered to have properties that positively influence the inflammatory response in the gut. This has been established in the course of improving the treatment of gastrointestinal inflammatory disorders such as ulcerative colitis (UC) and Crohn’s disease (CD).

Do they benefit the intestines? Which one?

Probiotics can be extremely beneficial to the gut in several ways:

• They can act as a barrier against other potentially harmful bacteria in the gut, which can trigger an immune response in the intestinal lining.
• Probiotics also increase the amount of mucus that is produced in the intestines. The thick layer of mucus helps prevent harmful bacteria from entering the intestinal lining and changes in which bacteria stick to the intestinal wall.
• Probiotics help secrete protective proteins from the intestinal immune system. These proteins help block the inflammatory response in the gut

How can probiotics help UC?

UC is an inflammatory bowel disease characterized by a chronically active inflammatory response in the lining of the colon. An underlying genetic mutation is believed to allow more aggressive bacteria to trigger this reaction in the colon. Probiotics can change the composition of bacteria in the colon into less aggressive colonies, thereby reducing inflammation. In addition, because probiotics work on the diseased portion of the lining of the colon, they can have many beneficial effects.

Which probiotics should I use?

Although several probiotics have shown benefit in patients with UC, studies are small and insufficient studies are available to support the use of probiotics to induce or maintain remission in active UC. However, the combination of certain probiotics with conventional UC medications has shown benefit in controlling the disease.

Two probiotics that have been shown to be beneficial in the treatment of UC are E. Coli Nissle (https://www.ncbi.nlm.nih.gov/pubmed/18240278)17”, not registered in Ukraine), and VSL No. 3 (https://www.ncbi.nlm.nih.gov/pubmed/15984978, approx. Probiotic mixture VSL No. 3, not registered in Ukraine). Studies have shown that VSL #3 can induce remission and reduce disease activity without any other medical treatments for mild disease. But more research is needed before this is accepted as standard practice.

Do probiotics help with Crohn’s disease?

Unfortunately, it appears that the use of probiotics in Crohn’s disease does not have the same beneficial effect on disease activity as in UC. The reason for the different effects of probiotics on CD and UC remains unclear. It is possible that different strains of bacteria are needed in BC to see any positive effects.