Updated September 2020
Probiotics can be a useful and effective treatment option for people with diagnosed IBS or functional gastrointestinal symptoms. It can however be a bit confusing knowing which probiotics have any research evidence behind them at which ones are just good marketing! Thankfully there are some very good websites, mainly designed for health professionals, which provide links to the researched probiotcs.
Starting with the Probiotic Database by Optibac; you can search the evidence for the specific probiotic strain you are interested in and find out what medical conditions it has been researched in. Annoyingly however the articles do not link to the specific brand of probiotcs unlike the other two resources below.
The Clinical Guide to Probiotic Products websites provide a brilliant resources for health professional and consumers on evidenced based probiotcs available in USA. The same Clinical Guide to Probiotic Products website is repeated but for products available in Canada. The resources links the researched probiotic strain and the product it is found in. I recommend this website to anyone searching for a probiotic to suit their gastro condition who wishes to try the available probiotics on the market. Big thanks to Prof Whelan who first mentioned these very useful resources.
If you are interested in reading research papers the two most practical reviews on probiotics and their use in gastrointestinal symptoms are as follows: 1. The rather lengthy titled British Dietetic Association systematic review of systematic reviews and evidence‐based practice guidelines for the use of probiotics in the management of irritable bowel syndrome in adults (2016 update) which unfortunately is not open access. 2. The slightly older Systematic review: probiotics in the management of lower gastrointestinal symptoms in clinical practice – an evidence-based international guide (2013) which is open access.
Suitable probiotics for the low FODMAP diet
If the restriction phase of the low FODMAP diet has not improved your symptoms then probiotics could be worth a trial. However as yet there is no evidence that probiotcs will improve symptoms in those who do not respond to a low FODMAP diet (watch this space however as our research group have investigated this!). It is perhaps a better option to try probiotics before you even attempt a low FODMAP diet. Otherwise it is best to wait until the end of the low FODMAP restriction diet to try a probiotic so you are not implementing two interventions (treatments) at once.
You can also trial a probiotic after you have reintroduced FODMAPs back into your diet after completing the reintroduction phase. There is a theory that probiotics may help improve tolerance levels to high FODMAP foods but this has not been evaluated or proven.
There are thousands of probiotics available but only a very small minority have been shown to improve functional gastrointestinal symptoms and IBS. The probiotics with the best evidence for their effectiveness in bowel disorders, such as IBS, and available in the UK are as follows.
There is a nice link to the research papers and a summary of this research found on the Alflorex website: https://www.precisionbiotics.science/35624-clinical-evidence Here the two main IBS research studies using Alflorex are detailed.
Although the mechanism of how the probiotic Alflorex can improve symptoms of IBS is not truly known there is a good explanation of the theory and related scientific research available here: https://www.precisionbiotics.science/35624/mechanisms
In clinical practice I find Alflorex is more effective in patients with IBS-D or loose stools than those with constipation.
Vivomixx (formerly VSL#3)
Vivomixx (formerly VSL#3) VSL#3 is the first probiotic most health care professionals had heard of for treating IBS and is probably still the one most recommended (although Alflorex prehaps has the stronger research evidence). Confusingly its branding has changed in different countries and in Europe VSL#3 is known as Vivomixx while in the United States its trademark is Visbiome. Therefore make sure you buy these brands and not the old brand of VSL#3. VSL#3 / Vivomixx has been used in several IBS studies and in other medical conditions and if you are interested follow the link here for a list of the research articles. In regards to IBS & FODMAPs the best quality and most important research study using VSL#3 / Vivomixx (in my opinion) was published in 2017: A Diet Low in FODMAPs Reduces Symptoms in Patients With Irritable Bowel Syndrome and A Probiotic Restores Bifidobacterium Species: A Randomized Controlled Trial. This article is open access. In the study VSL#3 was found to be just as effective as the low FODMAP diet at reducing IBS symptoms over 4 weeks. The 4 weeks low FODMAP diet reduced levels of bifidobacteria. Interestingly however patients taking VSL#3 with the low FODMAP diet did not see a reduction in their bifidobacteria. There was no additional benefit of taking VSL#3 with a low FODMAP diet in terms of reducing symptoms but it does seem these two interventions can be used together without any detrimental effects. Indeed the use of Vivomixx with a low FODMAP diet may prevent the reduction in bifidobacteria as this study showed. If you would like a really good summary of this research study then read this AGA Journals blog post: Can a Diet Low in FODMAPs Reduce IBS Symptoms in the Real World?
Very recently the use of VSL#3 in all randomised controlled trials in IBS have been put under review: Systematic review and meta-analysis: Efficacy of patented probiotic, VSL#3, in irritable bowel syndrome This review highlights that the pooled data from RCT’s using VSL#3 show it is no more effective than a placebo although there is a trend towards overall symptom improvement and VSL#3 seems well tolerated in IBS. Additionally the mechanism by which VSL#3 may help improve symptoms in IBS it is still not known…..
Symprove has only been studies in one Randomised clinical trial: a liquid multi‐strain probiotic (Symprove) vs. placebo in the irritable bowel syndrome – a 12 week double‐blind study (open access)
Those who were on a current a low FODMAP diet were excluded while those on wheat and dairy exclusion diets were permitted if started more than 3 months previously and if the patient agreed to not change dosing regimens or diets during the study.
Patients were instructed to keep study medications refrigerated (between 2 °C and 7 °C) throughout the study and to self‐administer 1 mL/kg each morning on an empty stomach. Food and fluids were allowed 20 min later. Missed doses could be taken later in the day provided no food had been consumed during the preceding 2 h.
Other probiotic options…..
Dicoflor 60 (L. rhamnosus GG)
This product can also be used with the low FODMAP diet. It had similar efficacy as a low FODMAP diet for overall symptoms in IBS, IBS-D and IBS-M but not IBS-C over 6 weeks (see article linked here: Pedersen et al 2014 Ehealth: Low FODMAP diet vs Lactobacillus rhamnosus GG in irritable bowel syndrome). The actual product can be found here for example: https://www.agpharma.eu/en/product/dicoflor-60/
When taking these probiotics follow the manufactures guidelines. For general guidelines on taking probiotics see this useful fact sheet (pdf) created by the British Dietetic Association: BDA Probiotic Fact Sheet and also this blog post by Monash Probiotics for IBS.
Patients feedback from using these probiotics is mixed. Some find they help improve symptoms while others find no benefit at all. A small minority find the probiotics make their symptoms worse.
Activia Yoghurts (Bifidobacterium animalis DN‐173 010)
Effect of a fermented milk containing Bifidobacterium animalis DN‐173 010 on the health‐related quality of life and symptoms in irritable bowel syndrome in adults in primary care: a multicentre, randomized, double‐blind, controlled trial
The test product was a fermented milk (yoghurt) (Activia, Danone), containing Bifidobacterium animalis DN‐173 010 and 274 primary care adults with constipation‐predominant IBS (Rome II) were randomised to consume, daily for 6 weeks, 2 yoghurt pots (one at breakfast, one at dinner).
In those subjects with less than 3 stools/week, stool frequency increased (P <0.001) over 6 weeks in the Activia vs. control group and therefore may be beneficial for those with constipation / IBS-C. After 3 weeks bloating and discomfort were reduced but this was not replicated at 6 weeks when compared to the controls.
In this double-blind trial 400 adult patients with moderate-to-severe symptomatic diarrhea-predominant IBS (IBS-D) were randomized to treatment with the multi-strain probiotic Bio-Kult® (14 different bacterial strains) or placebo for 16 weeks.
Probiotic treatment significantly improved the severity of abdominal pain in patients with IBS-D. (69% reduction for probiotic versus 47% for placebo). The proportion of patients who rated their symptoms as moderate-to-severe was reduced from 100% at baseline to 14% for the multi-strain probiotic at follow-up (month 5) versus 48% for placebo. The number of bowel motions per day from month 2 onwards was significantly reduced in the probiotic group compared with the placebo group.
This is an excellent study and one of the largest of its kind for probiotics and IBS. It is based on a cohort of patients from Bangladesh and it is unknown if the positive effects from the study would be replicated in Western populations. I do now however suggest Bio-Kult as first line choice for patients with IBS-D and an India heritage.
There is a fantastic critical appraisal of this study found here and well worth a read: Probiotics for Treating Irritable Bowel Syndrome: Are Bugs the Best Drugs?