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This article is part of our special May 2020 issue. Download the full issue here.
Relation
Liang D, Longgui N, Guoqiang X. Efficacy of different probiotic protocols in irritable bowel syndrome: a network meta-analysis.Medicine (Baltimore). 2019;98(27):e16068.
Objective
A meta-analysis to evaluate the effectiveness of the different types of probiotic protocols for treating the symptoms of irritable bowel syndrome (IBS).
method
The authors searched various databases between January 2006 and April 2019, including PubMed, Medline, Embase, Web of Science and Cochrane Central Register of Controlled Trials. They analyzed a total of 14 placebo-controlled randomized trials with 1,695 patients. In this analysis, the 2 primary multistrain protocols presented in the studies that demonstrated effectiveness were:
DUO =Lactobacillus acidophilus, Lactobacillus plantarum, Lactobacillus rhamnosus, Bifidobacterium breve, Bifidobacterium lactis, Bifidobacterium longum,andStreptococcus thermophilus
Pro =Bifidobacterium lactis Bb12, Lactobacillus acidophilus La5, Lactobacillus delbruecki subsp bulgaricus LBY-27,andStreptococcus thermophilus STY-31
Key insights
The researchers found that protocols with a daily dose of 1010colony forming units (CFU) that were combinedLactobacilliandBifidobacteriumStrains were more effective than single strains or overdose protocols. The DUO protocol showed the greatest effectiveness in diarrheal-type irritable bowel syndrome, while Pro was more effective in undifferentiated-type irritable bowel syndrome.
Researchers also considered the probiotic protocols safe, with adverse events not statistically different from placebo.
Practice implications
Rome criteria are used to diagnose and classify functional gastrointestinal disorders such as IBS. Rome IV is the most recent version of these criteria and changed the term from functional gastrointestinal disorders to disorders of gut-brain interaction (DGBI); Of these, IBS is the most common worldwide.1Although IBS prevalence has increased significantly, it may be even more common than previously thought due to self-diagnosis and self-management. Interestingly, a 2019 online survey comparing Rome IV-based IBS with self-diagnosed IBS found that nearly 69% of respondents met Rome IV criteria, but only 21% of respondents sought medical attention for their symptoms.2
In this meta-analysis, doses of more than 1010CFU were not more effective in treating IBS symptoms. Some research suggests that high-dose probiotics may actually promote bacterial proliferation, which worsens GI symptoms.
Based on data from the International Classification of Diseases, Tenth Revision (ICD-10), IBS is classified as a functional disorder of the colon that causes abdominal pain, cramps, bloating, and changes in bowel habits that include diarrhea, constipation, or alternating diarrhea and constipation.3In addition, based on the Rome IV classification, IBS can have different bowel patterns:4
- Durchfall vorherrschend (IBS-D)
- Verstopfung vorherrschend (IBS-C)
- Gemischter Durchfall und Verstopfung (IBS-M)
- Nicht klassifiziert und passt in keinen der 3 Subtypen (IBS-U)
The fact that this meta-analysis identified which probiotic strain combinations were effective in relieving symptoms of the different IBS classifications is clinically helpful. This analysis also confirms that multi-strain probiotic formulations are more effective than a single strain, which many clinicians have seen in their practice.
The issue of high doses is also important and relates to the intended clinical use of the probiotic formulation. In this meta-analysis, doses of more than 1010CFU were not more effective in treating IBS symptoms. Some research suggests that high-dose probiotics may actually promote bacterial proliferation, which worsens GI symptoms. This was the case in a 2018 study of patients with small intestinal bacterial overgrowth (SIBO), who noted an increase in symptoms such as brain fog, bloating, and bloating.5
The results of this meta-analysis are consistent with another analysis conducted by Dale et al. Published in the magazine in 2019Nutrients.6This analysis evaluated 11 randomized placebo-controlled trials of probiotics, with 7 of the trials finding significant improvement in IBS symptoms. This analysis also showed that multi-strain supplements were more effective than single strains. All studies that showed a benefit from multistrain probiotics used 1 or bothLactobacillispp andBifidobacteriumspp. Dosage was not addressed in this meta-analysis.
In addition to the meta-analysis by Liang et al. discussed here. Other studies have found that multi-strain probiotics are safe, have no serious adverse events, and have only a limited number of mild to moderate side effects.7
Given that intestinal dysbiosis and intestinal permeability contribute to IBS symptoms,8It makes sense that probiotics are clinically effective for this common condition.9This latest meta-analysis sheds light on which strains might be effective for which subtype and at what dose. Additionally, this analysis and other studies illustrate the favorable safety profile of probiotic interventions for this condition.
There is a large inter-individual variation in response to different probiotic formulas. This may reflect the previous status of an individual's microbiome, nutritional factors that support or interfere with the therapeutic response to the administration of exogenous organisms, and concomitant use of medications that alter the intestinal flora, as well as unique genetic factors that may determine an individual's susceptibility to the introduction of new biota. When it comes to probiotics for IBS, it really can be “different strokes for different people.”
With this information, clinicians can confidently choose from the many multistrain probiotics available on the market for their patients struggling with IBS.