Exploring resources to inform probiotic recommendations: New UK Probiotic Guide Released
Well-informed healthcare professionals know the importance of recommending evidence-based probiotic products to their patients to achieve specific health benefits. But finding the available evidence and matching it with specific products available on the market can be challenging. Moreover, not all of the studies on probiotic products are high-quality, making the evidence difficult to assess.
Clinical guidelines are often the first source of reliable information for clinicians looking for guidance in practice. Typically, probiotic guidelines released by relevant clinical associations are the result of a rigorous evaluation of the evidence and are one of the most valuable sources of information for clinicians. Such guidelines are usually developed through transparent criteria on the levels of evidence supporting each probiotic strain or formulation.
While guidelines by clinical associations typically provide recommendations for scientifically supported strains or formulations, product names are not provided. Clinicians who wish to recommend products by name need to further match the strain recommendations to finished products in market. Sometimes relevant commercial products are not available in their country.
Linking evidence to specific products is the focus of an organization called AEProbio (Alliance for Education on Probiotics). Last month AEProbio launched a new Guide to Probiotic Products Available in the United Kingdom, following their popular versions for Canada (introduced in 2008) and the United States (2014). The authors of the UK guide were dietitian Sarah Danaher and pharmacist Dragana Skokovic-Sunjic, and the new guide was funded by the University of Reading’s academic-industry partnership called INFORM Hub. The content and recommendations of the guide were reviewed and approved by the 11 independent academic experts on the UK Expert Review Board (listed at the end of this article) before publishing.
Sarah Danaher emphasized the new resource was motivated by the need of clinicians to understand the evidence around specific probiotic products. She says, “While healthcare professionals generally have a positive attitude towards probiotics, many do not routinely recommend them to patients and are hesitant to do so (Fei et al. 2023).”
Danaher says, “Several key barriers contribute to this reluctance including lack of probiotic knowledge, uncertainty about the strength of clinical evidence, insufficient training in probiotics during professional education, and lack of product regulation. Pharmacists were found to be the most knowledgeable about probiotics. Among doctors, probiotic recommendations were more common among gastroenterologists than GPs, reflecting a greater awareness of the gut-related clinical applications of probiotics. Despite positive attitudes, few HCPs consistently advise on probiotics for patients as there is such uncertainty about which products to recommend or when it is appropriate to do so (Fei et al. 2023).”
AEProbio produced the guides to support the selection of probiotic products for both healthcare professionals and consumers, including the names of relevant products in market. In each country, the authors of the guide aim to include as many products as possible that have probiotic strains (or strain combinations) supported by evidence.
To be included in the latest UK guide, products had to meet minimum criteria for adequate information on the label, as well as recognition of strain safety. Danaher says, “Many products fail to disclose essential information, such as the specific probiotic strain(s) used (just stating the genus and species) or the colony-forming units (CFUs) at the end of shelf life.” For more information on what clinicians should look for on a product label, see ISAPP recommendations here (European version, US version).
Dragana Skokovic-Sunjic authored the initial version of the Clinical Guide to Probiotic Products Available in Canada as a supplement to a series of live continuing medical education modules. What was originally meant to be a one-time resource, however, soon became an ongoing project. She says, “The fast-changing market and growing research over the following few months highlighted the need for regular updates. The initial team of Expert Reviewers was then formed, comprising gastroenterologists, epidemiologists, and pharmacists. Ever since that initial publication, the content of the Guide has been updated annually. All changes are reviewed and approved by the Expert Review Board.”
Skokovic-Sunjic notes, “Evidence is reviewed for the guide if it is from human populations, published in peer-reviewed journals, and addresses clinically relevant outcomes: that is, reducing symptoms, resolving a condition, or enhancing prevention.”
In the guides, different types of evidence are classified into Levels of Recommendation (see here). In brief, Level 1 recommendations are based on RCT evidence regarded as suitable quality by the expert review panel, Level 2 is based on lower quality RCT evidence and other intervention studies, and Level 3 includes professional opinions and reports. It is important to highlight that the committee does not use a recognized recommendation protocol but comes to an agreement based on the panel’s evaluation.
“In categorizing evidence, the Expert Review Board uses its discretion to assign different Levels based on a variety of reasons, such as the small number of study subjects, the impact of the proposed indication, the vulnerability of the intended population (e.g. pediatrics, chronic diseases)”, explains Skokovic-Sunjic. “In case we can’t all agree on higher level of recommendation, then the lower level is assigned until additional studies are completed.”
ISAPP recommends clinicians using the guides focus only on products with Level 1 recommendation. Level 2 and 3 recommendations alone, while of interest, are generally not considered sufficient to guide practice. Since clearly defined criteria (beyond expert panel agreement) are not applied for classifying Level 1 recommendations in the guide, combining use of the guide with recommendations from clinical societies (see resources below) may provide a stronger rationale for clinicians to guide their practice.
Whenever scientific evidence is applied to practice, clinicians are encouraged to review supporting evidence for products and indications of interest to ensure study design, population and clinical effects observed are relevant to their own clinical practice and patients.
With the constant emergence of new evidence on probiotic safety and efficacy as well as the dynamic selection of probiotic brands and products on the market in each country, the task of recommending appropriate probiotics is often a challenge for clinicians. But with knowledge of the strengths and limitations of various resources and an understanding of how they may be used, clinicians can gain more confidence in their recommendations and ensure better patient outcomes overall.
UK Probiotic Guide Authors
Sarah Danaher RD, Dragana Skokovic-Sunjic RPh MSCP
UK Probiotic Guide Expert Review Board
Dr. Gemma Walton PhD
Prof. Glenn Gibson PhD
Prof. Kieran Tuohy PhD UNIMRI
Dr. Anthony Buckley PhD
Lorraine Bailey RD
Fiona Lee HNC
Prof. Kevin Whelan PhD RD
Dr. Eirini Dimidi PhD RD
Prof. Janet Cade PhD RNutr FafN
Dr. James Kennedy BMBCh MRCP(UK) DTM&H
Dr. Andrea Monteagudo-Mera PhD
Additional resources for clinicians
- Guarner, F. et al. World Gastroenterology Organisation Global Guidelines. Probiotics and prebiotics, February 2023. Access online at https://www.worldgastroenterology.org/guidelines/probiotics-and-prebiotics/probiotics-and-prebiotics-english
- Szajewska H, et al. Probiotics for the Management of Pediatric Gastrointestinal Disorders: Position Paper of the ESPGHAN Special Interest Group on Gut Microbiota and Modifications. J Pediatr Gastroenterol Nutr. 2023 Feb 1;76(2):232-247.
- Merenstein DJ, Sanders ME, Tancredi DJ. Probiotics as a Tx resource in primary care. J Fam Pract. 2020 Apr;69(3):E1-E10.
