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Probiotics for Inflammatory Bowel Disease (IBD)
Crohns and Ulcerative Colitis -
News from Digestive Disease Week 2002

Each year, more than 15,000 gastroenterologists gather at Digestive Disease Week where leading researchers and clinicians share the latest innovations with their colleagues.

Probiotics and IBD

At a symposium lead by Drs. Richard Fedorak, Balfour Sartor, and Fergus Shanahan, the use of probiotics in Inflammatory Bowel Disease was hotly debated. Dr. Fedorak explained how IBD develops, and how probiotics can play a role in this process. Inflammatory Bowel Disease - ie Crohns disease and Ulcerative Colitis - results from an antigen passing through the epithelium (due to defects in permeability, possibly a result of genetic susceptibility) where it then causes a abnormal immune response (also genetically controlled). "Bacteria adhere to the lining of the colon like icing on a cake," says Dr. Fedorak. "Probiotics are able to negotiate through this layer of bacteria and layer themselves against the epithelial surface."

Probiotics can therefore be beneficial in preventing bad germs from adherence to or crossing of the epithelium. Probiotics can therefore be used in a preventative way or also as a supplement to other therapies. He talked about the fact that studies are needed to test probiotic therapy against tried and tested traditional treatments and that standards are needed to regulate proper dosing and administration of probiotic therapy.

Currently probiotics or good bacteria are classified as a food supplement, so the FDA does not regulate them. Some feel that the FDA should play a role in helping to regulate dose and forumlation. Whether the FDA becomes involved or not, more clinical trials are needed to develop a standardization of how many organisms to give, what organisms to give, and how they're formulated.

Dr. Sartor called for a careful set of studies to understand what probiotics can and cannot do, and emphasized the fact that not all bacterial products are the same. There is therefore a need to identify specific probiotic species because certain strains may prove helpful in certain diseases such as Crohn's disease and yet may not be as effective in others like ulcerative colitis. A different strain may be more beneficial in treating Ulcerative Colitis. For example, a strain of E. coli has been shown to have the effectiveness of low dose masalamine in maintaining remission in UC.

Several trials have been conducted regarding probiotics. The most notable of these was a trial for VSL#3 probiotics, a combination of eight different lactic acid bacteria. A once daily dose was found effective in maintaining remission in patients with recurrent, chronic pouchitis that had been healed by antibiotics. "Pouchitis" is inflammation that occurs in people who have had a certain type of ostomy surgery. Some people who have had their colon removed may have the end of the small intestine fashioned into a pouch so that normal bathroom habits can be maintained. However, sometimes the pouch can become infected and inflamed. Doctors are not sure if "pouchitis" is a recurrence of IBD in the pouch of a different type of post-surgical infection.

The success of the VSL#3 trial indicated the need for further investigation of other probiotics. In the placebo treated group patients started having relapses after a month, and then all 20 patients eventually relapsed over the next three months. In the VSL#3 arm of the study 3 of the 40 patients had relapse over 9 months. The probiotics used in this trial were shown to provide protection from relapse in the subgroup of patients with pouchitis in the setting of ileoanal anastamosis with chronic pouchitis who had been well controlled on drugs. 85% of patients had a prolonged benefit, compared to 0% on placebo. The study is randomized and controlled, the patient groups are well described, and sufficient detail is provided to understand the expected benefits of the treatment.

Stem Cell Transplants

Physicians at Northwestern Memorial have led the way in researching the use of stem cell transplants for the treatment of autoimmune diseases, including lupus, rheumatoid arthritis, Crohn's disease and multiple sclerosis (MS). Stem cell transplants are considered highly experimental therapy for Crohn's Disease and are extremely rare; only five people in the world have received stem cell transplants for Crohn's disease. This option is only available for the most severe, life-threatening cases - those patients who are the most ill and who have not responded to any current medical intervention.

Richard Burt, MD, (Professor of Medicine and Chief, Division of Immunotherapy for Autoimmune Diseases at Northwestern University) explains that "the idea is to harvest some of the patients' own stem cells from their blood, then deliberately destroy the immune system with chemotherapy and then re-implant the stem cells and hope they will multiply into a healthy immune system". It is hoped that this healthy immune system will then prevent further intestinal inflammation resulting from an exaggerated immune response.

Dr. Burt performed the world's first adult stem cell transplant to treat Crohns disease, a disease in which white blood cells attack the immune system. Dr. Burt and his third patient to have a transplant for Crohns disease, Kathy Duffey, were recently featured on Chicago's WGN-TV News. Kathy is one of an estimated 1 million Americans with Inflammatory Bowel Disease (Crohn's disease and ulcerative colitis). Kathy, a nurse, now 38 years old, was diagnosed her freshman year in college. While Crohn's disease afflicts people of all ages, it is considered to be a disease primarily afflicting the young.

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