The use of probiotics in gastrointestinal disease: INTESTINAL DISORDERS Part 3

Inflammatory bowel disease

Inflammatory bowel disease: Very recent reports have suggested that probiotics may be beneficial in the maintenance of remission of ulcerative colitis and pouchitis. In a preliminary study, 15 patients with ulcerative colitis who were intolerant to or allergic to 5-acetylsalicylic acid were treated with a new probiotic preparation (VSL#3 [VSL Pharmaceuticals, United States]) using a combination of three species of Bifidobacterium (B longum, Bifidobacterium breve and B infantis), four strains of Lactobacillus species (Lactobacillus casei, L plantarum, L acidophilus and Lactobacillus delbruekii subsp bulgaricus) and one strain of Streptococcus (Streptococcus salivarius subsp thermophilus) (5X1011 cells/g/day). In this study, 75% (12 of 15) of patients remained in remission after 12 months of treatment. This clinical response was associated with a significant increase in the fecal concentration of Lactobacillus species, Bifidobacterium species and S thermophilus from day 15 of treatment. This preparation has two main innovative characteristics compared with other probiotic compounds — a very high bacterial concentration and the presence of a mixture of different bacterial species that has the potential to have synergistic associations. Further to these studies, a double-blind, randomized trial was carried out to investigate the efficacy of the VSL#3 preparation in the maintenance treatment of chronic, relapsing pouchitis. Forty patients were randomly assigned to receive VSL#3 (6 g/day) or placebo for nine months. All patients had chronic pouchitis (defined as a history of the need for continuing medical suppressive therapy and recurrence within a few weeks of discontinuing suppression) and were in remission (Pouchitis Disease Activity Index [PDAI] score of zero after open induction of remission therapy with antibiotics). Relapse was defined as an increase of two or more points in the clinical portion of PDAI. Clinical assessment and stool culture were done monthly, while endoscopic and histological assessment were done every two months. At the end of the study period, 17 of the 20 patients treated with VSL#3 remained in remission compared with zero of 20 in the placebo arm. Fecal concentration of Lactobacillus, Bifidobacterium and S thermophilus increased only in the VSL#3 group and remained stable for the entire nine months of treatment. One month after stopping probiotic treatment, fecal concentrations of these bacterial species returned to baseline. Within four months of removing active therapy, 100% of the responding patients had relapsed. No toxicity or adverse effects of this treatment were observed. Whether all of these bacterial species are necessary for the VSL#3 effects is unknown and remains to be shown. Indeed, a small study examining the ability of Lactobacillus GG alone, albeit combined with FOS, to treat refractory pouchitis showed efficacy in reversing macroscopic endoscopic alterations.

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