Probiotics and Prebiotics Probiotics are live bacteria and yeasts that are good for your health, often colloquially referred to as “friendly bacteria”. Our bodies are full of bacteria, and our digestive system alone is home to more than 400 different bacterial and yeast species. This microbiome helps to maintain the lining of the gut and assists in digestion and absorption of food. Imbalances in the microbiome, caused by external factors such as diet, antibiotic use or infection, can result in symptoms such as bloating, constipation, diarrhoea or pain. Imbalances have also been linked to more generalised disorders such as eczema, heart disease, obesity, and several autoimmune conditions. Epidemiologists have noted a higher prevalence of such conditions in societies with very good hygiene, possibly because our immune systems are not being properly challenged by pathogenic organisms. Probiotics may help with many of the ailments listed above; however, research is still very limited and most evidence supports the role of probiotics in boosting the immune system. Common probiotics Research into the effects and benefits of probiotics is ongoing. It is important to realise that not all probiotics have the same effect so it is important to make sure the specific strain you recommend is one appropriate for your customer’s needs or ask the customer exactly which specific strain they are wanting. Combinations of different strains or species may work better for certain conditions such as ulcerative colitis or pouchitis. Most probiotics need to be taken regularly for full effect. Lactobacillus species The lactobacillus species of bacteria is the largest and most well-known group of probiotic bacteria that inhabit the intestine. Over 18 different strains exist and all are gram-positive rods that produce lactic acid. They tend to be well tolerated although mild flatulence that subsides with therapy is a common side effect. The following conditions are just some examples of where evidence of an effect has been documented: • antibiotic-associated diarrhoea: L. rhamnosus GG • atopic eczema: L. rhamnosus GG, L. sakei, L. reuteri • bacterial vaginosis: L. acidophilus • chemotherapy-induced diarrhoea: L. rhamnosus GG • hay fever: L. paracasei • high cholesterol: L. reuteri NCIMB 30242, L. plantarum • infantile colic: L. reuteri • irritable bowel syndrome (IBS): L. acidophilus • mouth sores from chemotherapy: L. brevis • respiratory tract infections: L. acidophilus, L. rhamnosus GG • rheumatoid arthritis: L casei • rotaviral diarrhoea: L. casei, L. reuteri, L. rhamnosus GG. Bifidobacteria There are at least seven different strains of bifidobacteria and their main function is to provide a microbial barrier to infection. They mainly colonise the human colon and are the predominant intestinal flora of breastfed infants (especially B. bifidum). Different bifidobacteria strains differ in their effectiveness due to differences in their ability to adhere to epithelial cells. B. longum is particularly resistant to gastric acid. Bloating and flatulence may occur initally but this tends to subside with continued use and they may cause diarrhoea in children. Evidence of an effect has been documented for (not all inclusive): • constipation: B. longum BB536 + milk/yoghurt • irritable bowel syndrome: B. infantis • respiratory tract infections: B. animalis • rotaviral diarrhoea: B. bifidum • ulcerative colitis: B. bifidum, B. breve. Saccharomyces boulardii S. boulardii is a yeast that enhances the protective effects of the normal, healthy, human gut flora. It has a wide range of effects including inhibiting the growth of bacteria and parasites, neutralising viruses, preventing bacterial adherence, stimulating antibody production and acting as an immune stimulant. Research has found it to be beneficial in the prevention and treatment of diarrhoea, PROBIOTIC AND PREBIOTICS Category Examples Comments Digestive health eg, L. acidophilus and/or B. lactis (eg, Bioglan Restore, Clinicians, Go Healthy, Inner Health Plus, Lifestream Bowel, Nutralife) eg, L. reuteri (Blackmores Digestive Bio Balance) eg, kiwifruit extract (Phloe Capsules/Chewable Tablets) Oral health eg, S. salivarius K12 (eg, BLISS K12 range), S. salivarius M18 (BLIS M18 Probiotic for Teeth and Gums) Contain probiotic bacteria to aid digestive health and other conditions resulting from an imbalance of bacteria within the gut. Helps restore the balance between beneficial and harmful bacteria. Kiwfruit extract contains a combination or prebiotics, enzymes and fibre to aid good digestive health and help relieve constipation. Use in conjunction with regular oral hygiene to establish a healthy balance of bacteria in the mouth. Page 126 HEALTHCARE HANDBOOK 2017-2018 Common Disorders
CONTINUING OTC EDUCATION decrease the appearance of acne, and help symptoms of Crohn’s disease or ulcerative colitis. Flatulence may be an issue and it may not be suitable for people with a yeast allergy or those who are immunocompromised. S. cerevisiae is another probiotic yeast with strong antioxidant activity that may help reduce pain associated with IBS. Streptococcus salivarius S. salivarius K12 and M18 are oral cavity probiotics which are have activity against bacteria implicated in bad breath, gingivitis (see Oral Health), and tooth decay. K12 also helps stimulate antiviral immune defenses and reduce episodes of otitis media. S. thermophiles has been widely used in the dairy industry in the production of milk, cheese and yoghurt since the 1900s. Live cultures of S. thermophiles can help people who are lactose-intolerant digest dairy products. Safety of probiotics Although probiotics are generally considered safe and cause few side effects, assessments are ongoing into the safety and toxicity of these substances. Reassuringly, yoghurt, cheeses, and many other foods that contain live cultures (probiotics) have been eaten for centuries with few reported ill effects. However, people with a weakened immune system or a serious illness have a reduced ability to fight infection and may be vulnerable to infection from probiotics, and should avoid them. Probiotics: foods versus supplements? The form of the probiotic (ie, as a powder, tablet, capsule, or food) generally does not matter as long as it contains at least 7–9 billion colony forming units (CFU) per dose, although recommended dosage for different strains varies. As a general rule, most foods do not contain enough organisms or the content varies widely from batch to batch as a result of the manufacturing process or storage. Choose commercially prepared probiotic products from a reputable company that guarantees a specific number of organisms at the time of purchase, and ensure storage requirements are adhered to. Products stored for long periods of time or improperly stored may contain few live and active organisms to start with. Prebiotics Prebiotics are non-digestable food ingredients. They are mostly obtained from carbohydrate fibres called oligosaccharides. Sources of prebiotics include whole grains, bananas, onions, garlic, honey and artichokes. Prebiotics can increase the number of beneficial bacteria in the intestine by stimulating their growth. A prebiotic combined with a probiotic is called a symbiotic – a substance that contains both live bacteria and the fuel it needs to survive. Prebiotics available in New Zealand mostly contain inulin or oligofructose. Both are effective for the treatment of constipation. Inulin can also lower Refer to PHARMACIST The following questions aim to identify customers who would benefit from further input from a pharmacist. Your initial assessment may have already provided some answers. Decide if any further questions still need to be asked and refer any “yes” answers to a pharmacist. • Does the person have any other health conditions (eg, immunosuppression, cancer, is pregnant or breastfeeding)? • Does the person take any regular medicine that has been prescribed by a doctor? • Is the person wanting a probiotic for a very young child or an elderly person? • Does the person have any symptoms of concern (eg, blood in the faeces, unexplained weight loss, inconsistent bowel movements)? • Has the person recently travelled to a developing country? • Have probiotics been tried before without success? • Does the person have any allergies to milk or lactose? triglycerides and is included in several meal replacement formulae or weight loss products as it suppresses hunger by making people feel full. A kiwifruit extract is also available that contains prebiotics, dietary fibre to bulk up and improve the water-retaining properties of the faecal mass, and enzymes. The main side effect of prebiotics is bloating and flatulence. Initial assessment Ask questions to ensure you select the correct species and strain of probiotic for your customer's condition. Refer any "yes" answers from the Refer to Pharmacist questions to a pharmacist. Advise customers to take probiotics with food to take advantage of the increased alkalinity of the stomach (and therefore ensure better survival of the probiotic) and to separate the administration of probiotics and antibiotics by at least two hours. Discard all products once they are past their expiry date. • Store probiotics strictly according to the storage requirements on the label. Now you can complete your ENHANCE modules on your phone or tablet www.pharmacytoday.co.nz Page 127
According to Stéphane Rossini, incoming Chairman of the Agency Council, the culture of collaboration will remain a factor in ensuring that Switzerland is successful in retaining a high-quality medicines control system: “A globalised economy and the international consumption of therapeutic products entail synergies and collaboration.”
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