Probiotics have gained tremendous currency in the popular literature as a potential treatment for a wide variety of illnesses. The concept is enormously attractive to patients and to the scientific community, because if probiotics work, they’re likely to be safer than most allopathic treatments, since they are naturally-occurring nonpathogenic bacteria used to replace or supplement a dysfunctional microbiome. Based on the number of presentations at Digestive Disease Week 2014 that mentioned or focused on probiotics, I’d suggest that the gastrointestinal specialty community is taking this very, very seriously.
In particular, two European studies looked at the efficacy of probiotic preparations as adjuvant for standard triple therapy for Helicobacter pylori. Does the addition of probiotic bacterial strains increase the eradication rate? Interestingly, the European Helicobacter Study Group already considers probiotics as an effective adjuvant, but only for reducing side effects during the standard H pylori eradication therapy—not for eradication.
The first study1 was a prospective, randomized, placebo controlled, double-blind multicenter trial of 804 subjects with documented initial infection with H pylori. Subjects were randomized to standard triple therapy (a proton pump inhibitor, amoxicillin, and clarithromycin) or triple therapy plus a probiotic preparation containing Lactobacillus rhamnosus GG and the Bifidobacterium strain, sold commercially as BB-12.® The primary end point of the trial was the proportion of subjects who were H pylori-negative at 6 weeks. Secondary end points were intensity of symptoms such as epigastric pain, bloating, flatulence, taste disturbance, loss of appetite, nausea, vomiting, heartburn, rash, and diarrhea. Cure rates were 88% in the probiotic arm versus 73% in the placebo arm. Overall, 21% more subjects experienced H pylori eradication when probiotics were used, and symptom intensity was lower in the probiotic group. Both effects were statistically significant.
So adding probiotics to standard triple therapy significantly contributed to treatment efficacy and decreased adverse effects of therapy and the symptoms of the underlying disease.
The second study2 was performed in a part of Turkey where cure rates with standard antibiotic regimens (plus proton pump inhibitor) are no higher than 45% to 50%; bismuth subcitrate is often added in modified therapy to boost cure rates. The Turkish investigators started with this regimen and added several probiotic strains—different from those used in the first study. In an open-label observational clinical study, the researchers compared patients who received modified triple therapy and bismuth subcitrate (Group 1, n=100) with patients who took a regimen that consisted of modified triple therapy and bismuth subcitrate plus concomitant NBL probiotic (Lactobacillus acidophilus, Enterococcus faecium, Lactobacillus plantarum, Bifidobacterium lactis, Streptococus thermophilus, Bifidobacterium longum) (Group 2, n=150). Eradication rates were 78% in the probiotic group, and 69% in modified standard therapy (P < .05). That’s a 13% boost in eradication rates, although the study shows that highly compliant subjects enrolled in a study do better than the population at large (69% eradication versus 45% to 50%).
In these two studies using different probiotic preparations, the addition of live bacteria modestly but importantly boosted cure rates for H pylori infection, when compared with standard or modified standard therapy. The use of these preparations will likely become more common in the United States.
1. Hauser G, Salkic NN, Vukelic K, Kuzmic V, Stimac D. The efficacy of probiotics as adjuvant treatment in eradicating H. pylori by standard triple therapy: a prospective, double blind and placebo-controlled trial. Paper presented at: Digestive Disease Week 2014; May 3-6, 2014; Chicago, IL.
2. Hakan Demirci H, Uygun A, Ozel AM, et al. Do probiotics improve eradication response rate of modified first-line treatment for Helicobacter pylori? Paper presented at: Digestive Disease Week 2014; May 3-6, 2014; Chicago, IL