Probiotics should only be recommended for specific patient populations since there is not enough evidence to support their use in the majority of digestive conditions, according to new clinical guidelines released by the American Gastroenterological Association (AGA) and recently published in Gastroenterology.
Greater than 3.9 million Americans are estimated to have taken probiotics at one time or another to improve their gastrointestinal (GI) health. Since probiotics are not considered “drugs” in the United States, the industry remains unregulated and marketing is often aimed directly at consumers. Additionally, information disseminated to the public about probiotics is typically confusing and is often obtained from biased sources.
In developing the guidelines, the AGA followed the GRADE approach, the gold standard for guideline development, to assess available evidence on the clinical efficacy of probiotics. “We hope to provide clinicians with clear guidance regarding the appropriate use of specific probiotics in the context of specific gastrointestinal diseases,” the panel stated. When the information was available, the panel considered the effects of single-strain and multistrain formulations independently, rather than as a group, for specific GI diseases.
The guidelines recommend the use of probiotic strains or strain combinations in 3 settings: (1) to prevent Clostridioides difficile (C. difficile) infections in adult and pediatric patients taking antibiotics, (2) to prevent necrotizing enterocolitis in preterm, low birthweight infants, and (3) to manage pouchitis.
With regard to treatment of C. difficile infection, Crohn disease, ulcerative colitis, or irritable bowel syndrome (IBS), the panel recommended the use of probiotics only in the context of a clinical trial. “Patients taking probiotics for Crohn’s, ulcerative colitis or IBS should consider stopping,” said guideline panel chair Grace L. Su from University of Michigan, Ann Arbor. “The supplements can be costly and there isn’t enough evidence to prove a benefit or confirm lack of harm.”
Additionally, the experts recommend against the routine use of probiotics in children in North America who present to the emergency room with diarrhea since these agents do not appear to benefit children with acute infectious gastroenteritis.
“We identified that significant knowledge gaps exist in this very promising and important area of research due to the significant heterogeneity between studies and variability in the probiotic strains studied,” the panel concluded. They added that “future high-quality studies are urgently needed which address these pitfalls.”
Su GL, Ko CW, Bercik P, et al. AGA clinical practice guidelines on the role of probiotics in the management of gastrointestinal disorders [published online June 9, 2020]. Gastroenterology. doi: 10.1053/j.gastro.2020.05.059.