A Pharmacist Guide to Probiotics

Probiotics have become increasingly popular with more and more patients seeking these out for various health concerns. Pharmacists, being the most accessible healthcare professional, are frequently asked about probiotic supplements. From understanding the different strains, the type of products, side effects and which conditions it can help, knowing the answers to these common probiotic questions might be an important factor for patients seeking to optimize their health. 

However, just like other supplements, it is also crucial to know who may benefit from these and who may not as they can pose significant health concerns for certain populations. This guide aims to equip you with the knowledge and tools to confidently navigate probiotic recommendations and effectively counsel patients on these supplements. 

What are probiotics? 

Probiotics are live bacteria and yeasts that work together (or synergistically) with your digestive system and organs associated with it. We usually think of bacteria and yeasts as germs that cause diseases. The human body is filled with trillions of microorganisms. Probiotics are often called “good” or “helpful” bacteria because they help keep your gut healthy.

These microscopic organisms live in your gut, also known as your gastrointestinal (GI) tract, and play an important role in digestion, nutrient absorption, and even immune function. A balanced gut microbiome, the community of microorganisms in your gut, is essential for overall health. Probiotics can help restore the balance of good and bad bacteria in your gut, which is often disrupted by illness, certain medications, and most importantly, the diet. 

How can you get probiotics? 

Probiotics can be obtained mainly in two major ways: either through certain foods or through supplements. 

Foods that contain probiotics: 

• Yogurt. Yogurt in general has many health benefits, but what makes them special is the fact that they contain live microorganisms that are good for the gut. And may be beneficial for those lactose intolerant since the bacteria can help break down the lactose. However, it is important to tell patients to read the food labels to ensure that there are live bacteria and to try to stay away from products with high sugar and fat content. Fat free Greek yogurt, with nut butter and fruit can help satisfy a sweet tooth.  
• Kefir. Kefir is a fermented probiotic milk drink that contains several major bacteria and yeast strains that are supportive to the gut and is actually a better source than yogurt. 
• Sauerkraut. Sauerkraut are finely shredded cabbage that has been fermented by lactic acid or bacteria. It has a salty, sour taste but it does contain fiber along with the vitamins C and K, as well as other important vitamins and minerals. Best way to eat sauerkraut is to top it with sausages, like a hotdog, or eat it as a side dish. 
• Temph. Tempeh is a fermented soybean product that forms a firm patty. It also contains a numerous amount of protein which can be used as a meat substitute for those that are vegetarian or vegan. 
• Kimchi. Kimchi is a fermented dish originating from Korea. It is mostly made from cabbage but it can be made from other vegetables as well. It is then flavored with red chili flakes, garlic, ginger, scallion and salt. 
• Miso. Miso is a Japanese seasoning which is made from fermented soybeans with salt and fungus (or koji). It is also a good source of protein and fiber. Add miso in water with seaweed and tofu for a nutritious and delicious soup. 
• Kombucha. Kombucha is a fermented black or green tea that contains a good amount of bacteria and yeast. 
• Pickles. Pickles are cucumbers that have been preserved in salt and water then are left to ferment. These are a great source of probiotics. It is important to note that the ones made with vinegar do not have live bacteria and therefore do not have probiotic effects. 
• Traditional buttermilk. Traditional buttermilk is leftover liquid from making butter and contains some probiotics. But before your patients rush to the grocery store to buy the buttermilk used to cook or fry their foods, they should know that cultured buttermilk, that is mainly used for this purpose, does not contain any probiotic effects. 
• Natto. Natto is a fermented soybean product similar to tempeh and miso which contains a bacterial strain. It is also rich in protein and Vitamin K2.

Supplements:

Probiotics are also available in supplement form as capsules, tablets, powders, and even chewable gummies. These supplements contain concentrated amounts of specific probiotic strains.

Probiotics and health conditions

Probiotics have been studied for a wide range of health conditions. While research is ongoing for some, there are others that have better evidence. 

• Atopic dermatitis and other skin conditions
• Antibiotic-associated diarrhea (including those caused by Clostridium difficile)
• Inflammatory bowel disease (IBS)
• Obesity 
• Mental Conditions 

Although probiotics may seem like a better treatment option than conventional medicine for certain conditions and diseases, there needs to be more conclusive results in order to fully support the idea as a mainstream treatment.  

Who should not use Probiotics?

While probiotics are typically safe for most people, there are certain circumstances where they might not be suitable for patients. 

• Individuals with compromised immune system:
  • People undergoing chemotherapy or radiation
  • People that have HIV/AIDS
  • Individuals with severe burns or other critical illnesses
• Infants with short bowel syndrome
• People with central venous catheters
• Premature infants 
• Pregnant and breastfeeding patients 
• Allergies 

What are the side effects of probiotics? 

Though probiotics are generally well-tolerated in most individuals, others might experience mild side effects, especially if they are just starting to take them regularly. Gas, bloating and abdominal discomfort are the common effects that may occur, but they will eventually go away after the first few days of use. 

It is important to note that if these effects are persistent or become severe, patients should be advised to stop taking them and consult with their doctor. 

What are the common probiotic strains? 

Probiotics can be complex, with numerous strains offering various benefits. There are a few strains that are commonly found in foods and supplements. 

Lactobacillus

• Lactobacillus acidophilus: Often found in yogurt, it supports digestive health.  
• Lactobacillus casei: Can help with digestive issues and immune function.  
• Lactobacillus rhamnosus: Known for its potential to support gut, immune function and vaginal health.  
• Lactobacillus plantarum: May help with digestive issues and skin health.  

Lactobacillus is the most commonly used strain and are often found in many supplements. 

Bifidobacterium

• Bifidobacterium animalis: Commonly found in dairy products, it supports digestive health.  
• Bifidobacterium longum: May help with digestive issues and immune function.  
• Bifidobacterium bifidum: Can contribute to gut health and immune support.  

Other Strains

• Saccharomyces boulardii: A type of yeast often used to treat diarrhea.  
• Bacillus subtilis: A spore-forming bacteria that can survive stomach acid.

Top 11 Tips to Give Patients

Overall, probiotics can be a great addition for patients wanting to be the healthiest version of themselves. It can be further useful when combined with a healthy diet, regular exercise and high quality sleep. Here are some tips to discuss with patients when helping them to find the right probiotics for their goals. 

1. Consult Your Healthcare Provider: Always discuss probiotic use with your doctor, especially if you have underlying health conditions or are taking medications.
2. Identify Your Goal: Determine what you hope to achieve with probiotics (e.g., digestive health, immune support, skin conditions).
3. Understand Probiotic Strains: Different strains have different benefits. Research specific strains linked to your desired outcome.
4. Look for Colony-Forming Units (CFUs): This indicates the number of live bacteria in the product. Higher CFUs generally mean more potency.
5. Prioritize Quality: Choose reputable brands that adhere to quality standards and testing. Here is a great source for finding quality supplements. 
6. Consider Storage: Many probiotics require refrigeration to maintain potency. Check the label for storage instructions.
7. Pay Attention to Expiration Dates: Ensure the product is fresh and effective.
8. Start Low, Go Slow: Begin with a lower dose and gradually increase if needed.
9. Be Patient: It may take several weeks to experience the full benefits of probiotics.
10. Diversify Your Gut Flora: Incorporate probiotic-rich foods like yogurt, kefir, and sauerkraut into your diet.
11. Don’t forget prebiotics: Prebiotics are the fuel needed for your bacteria to flourish. They are fibers that our bodies cannot digest. Common foods that contain prebiotics are whole grains, legumes, fruits (i.e. bananas, apples, berries), and vegetables.

In addition to discussing with patients about their probiotics, it is important to try to have a basic understanding of these supplements and how they can be used. To dive into a deeper knowledge, refer back to one of our past articles on choosing probiotic supplements and also consider utilizing this probiotic chart. Various resources can aid in helping your patients make the best decisions in their overall health. 

Resources: 

1. U.S. Department of Health and Human Services. (n.d.). Probiotics: What you need to know. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/probiotics-what-you-need-to-know  
2. Amara, A. A., & Shibl, A. (2015). Role of probiotics in health improvement, infection control and disease treatment and management. Saudi Pharmaceutical Journal, 23(2), 107–114. https://doi.org/10.1016/j.jsps.2013.07.001 
3. U.S. Department of Health and Human Services. (n.d.). Probiotics: What you need to know. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/probiotics-what-you-need-to-know  
4. Person. (2022, January 31). Do probiotics reduce the risk of Clostridioides difficile colitis?. AAFP. https://www.aafp.org/pubs/afp/afp-community-blog/entry/do-probiotics-reduce-the-risk-of-clostridioides-difficile-colitis.html 
5. Yang, Y., Olah, P., Radai, Z., Maia, G., Salava, A., Salo, V., Barker, J., Lauerma, A., Andersson, B., Homey, B., Fyhrquist, N., & Alenius, H. (2024). Exploratory multi-omics analysis reveals host-microbe interactions associated with disease severity in psoriatic skin. eBioMedicine, 105, 105222. https://doi.org/10.1016/j.ebiom.2024.105222  
6. Satish Kumar, L., Pugalenthi, L. S., Ahmad, M., Reddy, S., Barkhane, Z., & Elmadi, J. (2022). Probiotics in Irritable bowel syndrome: A review of their therapeutic role. Cureus. https://doi.org/10.7759/cureus.24240  
7. Wiciński, M., Gębalski, J., Gołębiewski, J., & Malinowski, B. (2020). Probiotics for the treatment of overweight and obesity in humans—a review of clinical trials. Microorganisms, 8(8), 1148. https://doi.org/10.3390/microorganisms8081148  
8. Madabushi, J. S., Khurana, P., Gupta, N., & Gupta, M. (2023). Gut biome and mental health: Do probiotics work? Cureus. https://doi.org/10.7759/cureus.40293  
9. Chatfield, S., & Chatfield, S. (2024, January 23). The 10 most common types of probiotics (and their benefits). Omni. https://omnibioticlife.com/blogs/blog/types-of-probiotics#:~:text=The%20most%20common%20types%20of,they%20act%20in%20the%20body. 
10.  Lactobacillus acidophilus. Mount Sinai Health System. (n.d.). https://www.mountsinai.org/health-library/supplement/lactobacillus-acidophilus#:~:text=The%20primary%20dietary%20sources%20of,cultures%2C%20miso%2C%20and%20tempeh.  
11. GoodRx. (n.d.). 8 tips for choosing safe & high-quality supplements. GoodRx. https://www.goodrx.com/well-being/supplements-herbs/how-to-know-if-youre-buying-a-good-supplement-brand  
12. Probiotic chart. (n.d.). https://usprobioticguide.com/?utm_source=intro_pg&utm_medium=civ&utm_campaign=USA_CHART