New AGA guideline finds that evidence to support use of probiotics to treat digestive diseases is greatly lacking, identifying only three clinical scenarios where probiotics may benefit patients

AMERICAN GASTROENTEROLOGICAL ASSOCIATION

Bethesda, MD (June 9, 2020) — It is estimated that more than 3.9 million American adults have taken some form of probiotics, with many patients looking to probiotics to improve their gastrointestinal health. However, after a detailed review of available literature, the American Gastroenterological Association (AGA) has released new clinical guidelines finding that for most digestive conditions there is not enough evidence to support the use of probiotics. This is the first clinical guideline to focus on probiotics across multiple GI diseases while also considering the effect of each single-strain or multi-strain formulation of probiotics independently instead of grouping them all under the single umbrella of “probiotics.” These guidelines are published in Gastroenterology, AGA’s official journal.

The guideline supports use of certain probiotic formulations in three settings: for the prevention of Clostridioides difficile (C. difficile) infection in adults and children taking antibiotics, for the prevention of necrotizing enterocolitis in preterm, low birthweight infants, and for the management of pouchitis, a complication of inflammatory bowel disease. There was insufficient evidence to recommend probiotics for treatment of Crohn’s disease, ulcerative colitis, irritable bowel syndrome (IBS) and C. difficile infection. For acute infectious gastroenteritis in children, AGA recommends against the use of probiotics.

“Patients taking probiotics for Crohn’s, ulcerative colitis or IBS should consider stopping,” says 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. Talk with your doctor.”

Given widespread use and often biased sources of information, it is essential that the public have objective guidance about the appropriate use of and indications for probiotics. AGA employed the gold-standard for guideline development, GRADE methodology, to evaluate the available evidence on clinical efficacy of probiotics.

“While our guideline does highlight a few use cases for probiotics, it more importantly underscores that the public’s assumptions about the benefits of probiotics are not well-founded, and that there is also a major variation in results based on the formulation of the probiotic product,” says Dr. Su.

Key guideline recommendations:

• For preterm (born before 37 weeks), low birthweight (< 2500 g) infants, specific probiotics can prevent mortality and necrotizing enterocolitis, reduce the number of days required to reach full feeds, and decrease the duration of hospitalization.
• Certain probiotics should be considered for the prevention of C. difficile infection in adults and children who take antibiotics and for the management of pouchitis, a complication of ulcerative colitis that has been treated surgically.
• Probiotics do not appear to be beneficial for children in North America who have acute gastroenteritis – they should not be given routinely to children who present to the emergency room due to diarrhea.
• There was insufficient evidence for AGA to make recommendations regarding the use of probiotics to treat C. difficile infection, Crohn’s disease, ulcerative colitis or IBS. For these conditions, AGA suggests that patients consider stopping probiotics, as there are associated costs and not enough evidence to suggest lack of harm.
• Well-designed clinical trials will be needed to refine these AGA recommendations on probiotics and to investigate other clinical conditions relevant to gastroenterology.?
• Gastroenterologists should suggest the use of probiotics to their patients only if there is clear benefit and should recognize that the effects of probiotics are not species-specific, but strain- and combination-specific.?

Read the AGA Institute guidelines and technical review on the role of probiotics in the management of gastrointestinal diseases to review the complete recommendations.

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WHAT ARE PROBIOTICS?

Probiotics have been around for many years but have lately become more popular. Probiotics are living, microscopic (very small) organisms, including certain bacteria and yeasts, that are usually found in foods or dietary supplements. Some experts believe that probiotics may supplement treatments, but do not often replace them. Since there are many kinds of probiotics with different strains and combinations, it’s important for patients to talk to their doctor before starting a probiotic. Learn more about probiotics in the AGA GI Patient Centerhttps://gastro.org/practice-guidance/gi-patient-center/topic/probiotics/.

GUT MICROBIOME EXPERTS

AGA has recruited leading experts in the gut microbiome and digestive health to serve as the scientific advisory board for the AGA Center for Gut Microbiome Research & Educationhttps://gastro.org/aga-leadership/centers/aga-center-for-gut-microbiome-research-and-education.

Email [email protected] to speak with our experts about probiotics or other microbiome topics.

Resources

Reporter cheat sheet on probiotics https://aga-cms-assets.s3.amazonaws.com/202052916035—Probiotics%20Guideline_Media%20Brief_Final.pdf

Patient information on probiotics https://www.gastro.org/practice-guidance/gi-patient-center/topic/probiotics

Guidelines https://www.gastrojournal.org/article/S0016-5085(20)34729-6/fulltext

Technical review https://www.gastrojournal.org/article/S0016-5085(20)34732-6/fulltext