‘Be clear-eyed’ when discussing expectations of probiotics with GI patients
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The lead article on the use of probiotics in gastroenterology highlights a conundrum that we have all been dealing with in the trenches for at least decade.
The concept behind altering the microbiome of the gut to treat various diseases is simple and seductive. It seems so easy on paper, “Grow the good bacteria, crowd out the bad bacteria, and all will be well is appealing to patients, physicians and providers. This concept could treat so many diseases, both gastrointestinal and non-GI. Unfortunately, for many reasons, it’s not so simple. The science of the intestinal microbiome is still in its infancy — we can’t even culture half of the microbes in the gut via conventional microbiological means.
Categorizing the microbiome through DNA fingerprinting in its entirety is time- and resource-intensive. For complex diseases such as Crohn’s and ulcerative colitis, it stands to reason that there are literally scores (if not hundreds) of ways to get to the final common pathway of an inflamed gut. Therefore, there is not going to be a one-size-fits-all solution to inflammatory bowel disease, let alone other GI conditions such as irritable bowel syndrome. On the one hand, in most cases, there isn’t going to be much downside to administering a probiotic or prebiotic (with the possible exception of a severely immunocompromised patient with a defective intestinal barrier). However, on the other hand, it’s not clear that the upside is going to be large.
We are doing our patients a service in being even-handed and evidence-based when we discuss the utility of probiotics with them for various GI conditions. We should absolutely continue to study the efficacy and safety of these agents in the various diseases of our specialty — but we should be clear-eyed when setting expectations with our patients.
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