Not all probiotics are created equal

Consider the evidence base and recommend probiotics on a case-by-case basis.

Not all probiotics are created equal
Not all probiotics are created equal

Nashville – When recommending probiotics to patients, clinicians must evaluate products on a case-by- case basis and consider the evidence base for specific conditions, according to Candace Sandal, NDP, ARNP, a professor at Wilmington University in Delaware.

“Use of a probiotic should be based on research studies – using a specific probiotic for a specific disease process. One probiotic should not be considered the same as another,” Sandal said at the American Association of Nurse Practitioners 2014 meeting.

As many as 81% of Americans are familiar with the use of probiotics to improve digestive health and about 43% consume some form of probiotics, spending $1.2 billion annually on probiotic foods and dietary supplements.

But different strains of even the same species can be dissimilar and may not necessarily provide the same health benefits, Sandal cautioned.

Existing research is limited by small study sample sizes and the wide variety of probiotic strains, but studies indicate that specific strains may be effective in treating and preventing certain diseases and may stimulate immune function.

Level A evidence suggests that patients with infectious diarrhea who take probiotics are sick for shorter periods of time, and that strains such as Saccharomyces boulardii and the Lactobacillus species may be effective in preventing antibiotic-associated diarrhea and treating Clostridium difficile infections.

Advise patients to take antibiotics and probiotics at least two hours apart, so the antibiotic does not kill the probiotic, and for a week after the antibiotic, Sandal recommended.

Data from meta-analyses suggest that Lactobacillus reuteri administered early in life may reduce atopic sensitization and prevent colic in newborns.

Although the evidence base is not as strong, some evidence exists that suggests probiotics may also be effective for irritable bowel syndrome, traveler's diarrhea (Culturelle, two capsules daily, two to three days before travel and during trip; Florastor, one to two capsules, five days before travel and for trip duration), and constipation (Yakult or Activa, one to two servings daily for at least two weeks).

Sandal offered several tips to help clinicians evaluate the growing number of probiotic dietary supplements:

Know the genus, species and strain of a particular product. Become familiar with research and studies that demonstrate health benefits associated with specific organisms.

Know the dose. Adequate numbers of viable organisms are necessary to achieve benefit. Colonies forming units, or CFUs, represent the measure of viable microorganisms in a probiotic. The level of CFUs necessary to yield benefit differs by probiotic, ranging from 50 million to more than 100 million CFUs per day. Suggested serving sizes can be used to inform patients of how much to consume and when.

Beware of expiration dates. Probiotics contain live microorganisms and may lose their effectiveness after a certain date. Some probiotics require refrigeration to preserve the active ingredients. Dairy products, specifically, tend to have a short shelf life. Advise patients to follow handling and storage instructions on the package.

Make sure it's from a trusted source. Advise patients to check the product website to determine if the manufacturer is reputable and review the evidence base for a given product.

Clinicians should keep in mind that continued administration is necessary for probiotics to be beneficial in the gastrointestinal tract. Encourage patients to look for labels that say “live active cultures,” as many prepackaged and processed foods contain little to no active ingredients, Sandal said.

Several sources of accurate information on probiotics are the American Gastroenterological Association, the International Scientific Association for Probiotics and Prebiotics and the FDA's website on dietary supplements, according to Sandal.

Overall, adverse events from probiotics are rare and generally mild and gastrointestinal in nature.

Reference

  1. Sandal C et al. #14.2.101. “Probiotics: What the Nurse Practitioner Needs to Know.” Presented at: AANP 2014. June 17-22, 2014; Nashville, Tenn.
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