Pro Biotics Im Sig
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Transcript of Pro Biotics Im Sig
7/31/2019 Pro Biotics Im Sig
http://slidepdf.com/reader/full/pro-biotics-im-sig 1/22
Probiotics
Integrative Medicine SIG
APA Meetings
May 1, 2006
David K. Becker, MD, MPHUCSF Department of Pediatrics
“You’ve been fooling around with alternative medicine, haven’t you?”
7/31/2019 Pro Biotics Im Sig
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Outline
What are probiotics and how do they work
Current proposed uses and a look at some of the evidence
Issues in prescribing their use
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Probiotics: definitions
World Health Organization:
“live microorganisms which when administered in adequateamounts confer a health benefit on the host”
A bacterial strain that:
Survives the stomach acid and bile
Adheres to intestinal lining
Grows and establishes temporary residence in the
intestines Imparts health benefits
R Fuller. Probiotics: The Scientific Basis. London: Chapman and Halls. 1992
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Probiotics
Lactobacillus sp.
reuteri
casei
ramnosus
acidophilus
Streptococcus sp. Bifidobacterium sp.
infantis
lactis
longum
breve bifidum
Sacharomyces boulardii (non-human)
VSL no.3
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Probiotics
Colonization at birth
Similar to maternal species
Specific organisms vary by
age in first year Become established by 1
year
In children and adults, “Successful” treatment with
probiotics leads to temporarycolonization only
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Probiotics: Proposed uses
Infectious diarrhea
Antibiotic-associated diarrhea
IBD, IBS, and pouchitis
Necrotizing Enterocolitis
Bacterial vaginosis Recurrent UTI’s
Atopic diseases
Immune system enhancement
H pylori infections
Dental caries
Radiation induced diarrhea
Cardiovascular risk reduction
Constipation
Rheumatoid arthritis
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Probiotics: Proposed uses
Rating the Evidence Floch et al (2006) Natural Standard (2006)
Infectious diarrhea A B
Antibiotic-associateddiarrhea
A C
Diarrhea prevention B B
IBS C B Atopicdermatitis/Allergy
B? B/C
Ratings: A: strong B: good C: fair
Floch, et al. Recommendations for Probiotic Use. J Clin Gastro. 40(3). 2006www.naturalstandard.com
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Probiotics: Proposed uses
Rating the Evidence Floch et al (2006) Natural Standard (2006)
Ulcerative colitis C B
Crohn’s disease C
H pylori infection C A
NEC C
Bacterial vaginosis C CUTI’s C
Ratings: A: strong B: good C: fair
Floch, et al. Recommendations for Probiotic Use. J Clin Gastro. 40(3). 2006
www.naturalstandard.com
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Probiotics: the evidence
Antibiotic-associated diarrhea:
D’Souza et al (BMJ 2002)
Systematic review of 9 placebo-controlled studies (2 in children)
Various probiotics (4 uses S Bouladarii )
60% reduction in antibiotic associated diarrhea compared withplacebo (OR 0.37, 95% CI 0.26-0.53)
Vanderhoof et al (J Pediatr 1999)
202 children, 6 mo - 10 yr, otitis/pharyngitis, amox/amox-clav
Oral antibiotics in an outpatient setting for 10 days
Lactobacillus GG , 10 (<12kg) or 20 (>12kg) billion cfu’s for 10 d Rated stool consistency and frequency
26% of controls and 8% of L GG had diarrhea
Of those with diarrhea, 5.9 days in placebo, 4.7 days in L GG
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Probiotics: the evidence
Infectious diarrhea:
Van Niel et al (Peds 2002)
Systematic review of 9 studies (all outside US, 1-36 months)
Various probiotics (4 used L GG )
Mean reduction in diarrhea of 0.7 days (95% CI: 0.3-1.2) 1.6 fewer stools in L GG groups (95% CI: 0.7-2.6)
Dose response curve with higher L GG dose
Two other meta-analyses also showed benefits, particularly with LGG
Allen et al. Cochrane Database Syst Rev , 2004 Szajewska et al. J Pediatr Gastroenterol Nutr , 2001
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Probiotics: the evidence
Prevention of infections in day care:
Weizman et al (Peds 2005)
Double-blind, placebo-controlled RCT
14 day care centers in Israel, 4-10 months of age
Formula with B lactis , L reuteri , or no probiotics (no breastfeeding) Mean intake: 1 billion orgs
Intervention and follow-up totaled 12 weeks
Both probiotic groups had: Fewer febrile episodes
Fewer diarrhea episodes
Shorter diarrhea episodes
No difference in rate or duration of respirator illnesses
L reuteri group did significantly better than B lactis group
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Probiotics: prescribing
Which organism to use?
Which product?
For what conditions?
What dose?
For How long?
Any side effects to be aware of?
How much does it cost?
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Probiotics: prescribing
Lactobacillus GG best studied to date
Combination products not well studied, but
may work as well 10 billion organisms/d
Keep in fridge
Give in cool food/drink
2% risk bloating/gas
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Probiotics: prescribing
ConsumerLab.com tested 25 probiotic products
19 for general population, 3 for children, 3 yogurts
8 claimed a specific number of organisms per serving
13 claimed only a number of organisms at time of manufacture
8/25 contained less than 1 percent of the claimednumber of live bacteria or of the expected minimum of 1 billion.
7 of the 8 that gave expected numbers per serving metthose counts
None contaminated with bacteria, mold, or fungus
All enteric-coated capsules passed testing
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Probiotics: prescribing
ABC Dophilus Jarro-DophilusEPS
Baby’s Jarro-Dophilus
Culturelle
Organisms B bifidum
S thermophilus
B infantis
L rhamnosus
L casei
L plantarum
L acidophilus
B longum
B breve
P adidilactici
L diacetylactis
B breve
B lactis
Blongum
B bifidum
L casei
L rhamnosus
Lactobacillus GG
Quantity per “dose” 1 bill total orgs 4.4 bill total orgs 3 bill total orgs 10 billion orgs
(Consumer Labs)
Cost per dose for 9-10 billorgs/dose
$4.00 $0.57 $0.69 $0.67
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Probiotics: prescribing
Nature’s Way
PrimidophilusNature’s Way
Primidophilusfor children
Nature’s Way
Primidophilusfor kids -chewable
Nature’s Way
Primidophilusjunior
Organisms L acidophilus
L rhamnosus
B longum
B infantis L acidophilus
L rhamnosus
B longum
L acidophilus L rhamnosus
B breve
B longum B infantis
L acidophilus
L rhamnosus
Quantity per “dose”
2.9 bill total orgs 1.5 bill orgs
(Consumer Labs)
1 bill total orgs 1 bill total orgs
Cost per dose for 9-10 billorgs/dose
$0.50
(30-60doses/cont)
$1.88
(8 doses/cont)
$1.33
(3 doses/cont)
$1.50
(9 doses/cont)
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Probiotics: prescribing
Nature Madeacidophilus
Breyers 99% FatFree Fruit on theBottom…
Stonyfield FarmFrench VanillaNonfat Yogurt
UAS Labs DDSJunior
Organisms L acidophilus L acidophilus
? others
Bifidus ?
L acidophilus L casei
L bulgaricus
L reuteri
B infantis
L acidophilus FOS
Quantity per “dose”
500 million
(Consumer Labs)
1 billion org ??
(8 oz cont.)
(Consumer Labs)
1 bill total orgs ??
(8 oz cont.)
(Consumer Labs)
2 (?5) bill totalorgs
(Consumer Labs)
Cost per dose for 9-10 billorgs/dose
$5.00
(2 doses/cont.)
? $$$ ? $$$ $1.00
(14 doses/cont)
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Take home points…
Good evidence for:
Infectious diarrhea
Antibx-assoc diarrhea
Promising evidence for:
Prevention of infectiousdiarrhea
Prevention of atopicconditions
other uses?
In the future we may be usingprobiotics as we use antibioticstoday: with specific strains usedfor certain clinical situationsguided by controlled studies
Prescribing
Lactobacillus GG beststudied to date
Combination productsnot well studied, but may
work as well 10 billion organisms/d
Keep in fridge
Give in cool food/drink
2% risk bloating/gas
7/31/2019 Pro Biotics Im Sig
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Studies at UCSF
Probiotics to prevent antibiotic-associateddiarrhea in hospitalized children (Andi Shane,
MD) 2mo - 12 yrs
L GG, 10 billion cfu’s, given throughout
antibiotic course
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Studies at UCSF
Trial of Infant Probiotic Supplementation toPrevent Asthma (TIPS) (Michael Cabana,
MD) L GG , 10 billion cfu’s, given within 2 weeks for
6 months
Follow development of asthma over 3 years
Beginning recruitment