Written by Student, Katherine Rivera Narvaez, PharmD Candidate Mercer University College of Pharmacy

In the United States, the American College of Gastroenterology estimates that 10-15 percent of the adult population suffers from IBS symptoms, yet only 5 to 7 percent of adults have been diagnosed with the disease. IBS is the most common disease diagnosed by gastroenterologists and one of the most common disorders seen by primary care physicians.

Many people suffer from Irritable Bowel Syndrome and Ulcerative Colitis. These two conditions can cause a lot of pain, discomfort, and embarrassment for those who have to deal with them on a day-to-day basis.

What is Irritable Bowel Syndrome? 

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder that affects the large intestine. It causes abdominal pain, bloating, and changes in bowel habits. IBS can be caused by food sensitivities or allergies, bacterial infections, stress, lack of exercise, hormonal fluctuations, and other factors affecting intestinal function.

IBS can come in many forms sub-classified by their predominant bowel movement abnormality as: 

• IBS-C (with constipation) 
• IBS-D (with diarrhea) 
• IBS-mixed (both diarrhea and constipation) 

Common symptoms of IBS include abdominal pain, bloating, and changes in bowel habits. People with this condition often have difficulty managing their bowel movements because they may experience constipation or diarrhea at different times during the day. Some may also suffer from a low-grade fever or experience significant weight loss, which can be caused by decreased appetite due to gastrointestinal distress.

What is Ulcerative Colitis?

Ulcerative colitis (UC) is a chronic inflammatory disease of the colon characterized by periods of remission or relapses. People typically experience with bloody diarrhea, increased urgency, abdominal cramps, frequency of bowel movements, anemia and weight loss. ^1

What is the difference between UC and IBS? 

Although both diseases present with similar gastrointestinal symptoms, two key factors differentiate UC from IBS: the presence of inflammation and rectal bleeding. In UC, inflammation occurs beginning in the rectum but can extend further into the colon. Diagnosis typically requires an endoscopy or colonoscopy to confirm the presence of inflammatory processes such as lesions or sores in the intestinal walls. In contrast, IBS occurs in the absence of inflammation and has no clear identifiable cause. ^2,3

The Role of Gastrointestinal Microflora

In a healthy individual, the microflora (various microorganisms) of the gastrointestinal (GI) tract interacts with the host’s cells in a mutualistic relationship where the host provides an environment for their growth while the colonizing bacteria aid in several functions including immune responses, nutrient processing and digestion, and resistance to pathogens. The microflora is also capable of communicating with various cells of the body to modulate the normal perception of visceral pain, inflammation, and immunity.

It is the balance of these bacterial colonies that make up what we know as a healthy GI tract and to maintain this delicate balance, several factors must be considered including genetics, diet (e.g., high intake of processed foods), lifestyle choices such as antibiotic use or lack thereof and stress levels among others.

In humans, there isn’t just one single type of microflora present in their GI tracts but rather an enormous diversity which allows it to take on many different functions and purposes according to its environment within the intestine.

Studies have found that those with IBS and UC have a different species of bacteria in their gut than healthy individuals. In chronic gut disorders like IBS and UC, some studies suggest an increase in pathogenic or harmful bacteria, such as SIBO (Small Intestinal Bacterial Overgrowth). ^4

Probiotics and Prebiotics:

Probiotics

A probiotic is defined by the World Health Organization as a “live organism that, when ingested in adequate amounts, confers a benefit to one’s health”. Probiotics work by competing for nutrients with the pathogenic bacteria; producing substances to prevent their growth; and reducing their ability to adhere to intestinal walls.

Probiotic strains are identified by their genus, species, subspecies and alpha numeric designation. Some strains have unique properties that influence certain immunological, neurological and antimicrobial activities. For example, lactobacillus plantarum is a microorganism that is thought to be better at adapting when things are stressful and doing well. For this reason, the American Gastroenterology Association (AGA) recommends using more than one type of microorganism over single-strain products. Some studies have shown that people do better when they use a mixture rather than just one product. Recommendations should also be tied to specific strains and at the same dosage that has evidence from human clinical studies.

Shop icHealth.store for probiotic supplements.

We encourage you to talk with your healthcare providers (doctor, registered dietitian, pharmacist-etc.) about your interest in or use of probiotic supplements and what may be best for your overall health.

Table 1: Commonly studied probiotic strains in IBS and UC

Prebiotics

A prebiotic is “a selectively fermented ingredient that results in changes in the composition and/or activity of the gastrointestinal microflora, thus conferring benefits upon host health.” They are not digestible by the host and positively influence the beneficial microflora by increasing their numbers while decreasing the population of pathogenic microorganisms. In addition to microflora benefits, prebiotics possess additional properties that may aid in increased calcium absorption, shortening of GI transit time, and production of short-chain fatty acids (SCFA), which are thought to play a role in regulating leukocyte production of cytokines and eicosanoids. Examples of prebiotics include oligofructose, inulin, galactooligosaccharides, and lactulose. ^8

The AGA published “AGA Technical Review on the Role of Probiotics in the Management of Gastrointestinal Disorders,” where they concluded that there is not enough data to recommend for their use in UC and IBS. Various studies have explored their use in IBS and UC, with some data suggesting an improvement to symptoms such as abdominal discomfort/pain, bloating, and bowel movements, and prolongation of periods of remission in UC. Various combinations of probiotics strains have been studied, making it difficult to provide a specific product formulation that would be efficacious. Thus, the selection and dosage of probiotics for particular disease states should be based on published research literature providing evidence of efficacy.

The following are examples of published clinical research on probiotics and their efficacy in IBS and UC:

A systemic review published in 2020 concluded that “low-certainty evidence suggests probiotics may induce clinical remission in active ulcerative colitis compared to placebo.”^9

A randomized controlled trial compared the use of mesalamine to mesalamine with a probiotic in patients with UC. During the 24 months of study, patients using the addition of probiotics showed better results to their Modified Mayo Disease Activity Index and “shortened significantly the time of recovery”. ^7

“Probiotics reduce pain and symptom severity scores. The results demonstrate the beneficial effects of probiotics in IBS patients in comparison with placebo”. ^10

“When comparing the results from studies administering a multi-strain versus a mono-strain probiotic supplement, the overall tendency is that a supplement with multi-strain probiotic has the potential to improve IBS symptoms. Some studies found a general improvement in specific IBS symptoms, whereas others reported improvements in specific symptoms like abdominal pain and bloating”. ^11

At this time, data is conflicting and provides limited evidence to provide a strong recommendation for their use. Moreover, because these diseases are multifactorial in nature, treatment should be individualized to each patient and require various strategies that may include probiotics. ^4,6,7,8

Compounding Medications for IBS Conditions

Many people with Irritable Bowel Syndrome and Ulcerative Colitis are not aware of the potential benefits that compounded medications and probiotics can have in managing their conditions.

A compounded medication is a custom-made drug, which means that it has been created specifically for your needs by a pharmacist. The compounding pharmacist may use different ingredients to make sure they work well with other medicines you take and even change the shape, taste, or color of the pill, so it’s more enjoyable to take.

What are the benefits of pharmaceutical compounding? 

To exert their benefits to the gut microflora, probiotics must be able to survive their transit through the gastrointestinal tract. Various factors can reduce the survival of probiotics being administered, including acidity of the stomach, bile, and pancreatic juices. Pharmaceutical compounding allows for the development of formulations that improve the beneficial bacteria’s survival when ingesting probiotics. 

Pharmaceutical compounding also allows for the formulation of medications not available commercially that may provide more targeted therapy or doses that may otherwise be difficult to achieve with commercially available products. Active pharmaceutical ingredients used in gastroenterology compounded medications that have been used in the treatment of UC and IBS include low dose naltrexone (LDN), low dose amitriptyline, sodium butyrate, nifedipine, diltiazem, SCFA, erythromycin, and tacrolimus.

Our Pharmacists Recommend

At Innovation Compounding Pharmacy, we have developed a probiotic supplement specially formulated to ensure the survivability of the beneficial bacteria in low pH (acidic) environments. Our product, Probiotics Daily Support, contains over 5 billion beneficial organisms mixed in a base of prebiotics. The various probiotic strains contained are manufactured using a patented poly matrix preservation system to preserve and ensure stability without refrigeration. Meanwhile, the prebiotic blend help supports the growth of probiotics to optimize their benefits.