Disclaimer added after article publication: Check with a healthcare professional before deciding if a probiotic may be appropriate for you. A recent, updated guidance made by the American Gastroenterological Association (AGA) recommends against the use of probiotics for most digestive conditions.
To potentially select a probiotic supplement, it is useful to first know the semantics differentiating probiotics, prebiotics, and synbiotics.
Probiotics are living microorganisms that provide the intestines with bacteria that help an individual gain a positive health benefit. In order to function optimally, a person’s intestines need certain naturally-occurring bacteria to be present to aid functions like digestion, gut motility, chemical regulation, immune system function, drug metabolism, acid-base regulation, protective effects from certain harmful substances, etc. Probiotic foods, drinks, and supplements can help to provide these important bacteria if they are absent or deficient in a person.
In contrast, a prebiotic is a dietary substance that alters the composition or activity of the bacteria in the gut. However, prebiotics are not microorganisms themselves. Utilizing an analogy to gardening, prebiotics can be thought of as a soil fertilizer whereas probiotics can be thought of as seeds.
A synbiotic is simply a combination product of a probiotic and prebiotic. It is acceptable to combine taking probiotics and prebiotics, but it is not typically necessary to take multiple probiotic supplements or prebiotics unless recommended by a pharmacist or physician.
This article focuses on probiotics specifically. Details about prebiotics and synbiotics will be discussed in future Pharmacist Consult articles. Described below are five thoughts to think through prior to potentially purchasing a probiotic supplement online or at a pharmacy.
1. Consider Your Options
Probiotics are contained within a variety of everyday foods, drinks, and medicinal supplements. Typically, for more minor needs, individuals can supplement their gut bacteria by consuming foods or drinks that have a high probiotic content. For individuals who may require even more probiotic supplementation, it may be warranted to obtain a designated probiotic supplement.
Individuals that need probiotic supplements typically have needs that extend beyond the scope of supplementation from foods or drinks alone. To determine if someone may be a candidate for a probiotic supplement itself (versus consuming certain foods or drinks), it is best to discuss with a local pharmacist or physician. A pharmacist or physician can help to determine what an individual’s specific needs are from a probiotic source.
For example, individuals that have diarrhea, ongoing antibiotic usage, inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), or are at high risk of hepatic encephalopathy commonly may be given a recommendation to take a probiotic supplement. Of note, probiotic supplements are not considered to be effective for acute pancreatitis or Crohn’s disease.
NOTE: For a thorough chart of different gastrointestinal conditions that may benefit from probiotic use, reference this chart provided by the American Academy of Family Physicians (AAFP).
2. Look Beyond the Brand Name
Similarly to how someone’s pain might respond better to Tylenol (acetaminophen) than Advil (ibuprofen), depending on the reason for a person taking a probiotic, one probiotic strain may be more appropriate than another strain.
In order to choose the most appropriate probiotic for an individual, it is important to look at the back of a supplement’s packaging to see what probiotic strain specifically is contained inside of the product. The brand name of a probiotic does not usually indicate what strain of probiotic is contained inside of the product unless it is specifically known by the consumer.
Probiotic strain names consist of two to three words – genus, species, and sometimes a subspecies. For example, consider the name Bifidobacterium longum infantis. For this probiotic, the genus is Bifidobacterium, the species is longum, and the subspecies is infantis. All three of these words together describe the strain of probiotic. This is the strain inside of Align® probiotic capsules.
Table 1. Common Probiotic Examples
| Foods and Drinks | Probiotic Strain (Brand Name) |
| Buttermilk Kefir Kimchi Kombucha Miso Pickles Sauerkraut Tempeh Yogurt | Bifidobacterium longum infantis 35624 (Align) Lactobacillus rhamnosus GG (Culturelle) Saccharomyces boulardii CNCM I-745 (Florastor) |
See Table 2 (below) for a more detailed breakdown of probiotic names and usages.
3. Considering a Probiotic Supplement – Know the ‘Why’
Probiotics contain different strains of bacteria, and different medical studies have linked varying strains to different purposes. So, depending on a person’s specific need for a probiotic, it is important to choose a probiotic strain that corresponds with the medical need for supplementation.
For example, if an individual is at risk of developing antibiotic-associated diarrhea after taking a certain antibiotic for a prolonged period of time, they may opt to take Bio-K, Culturelle, or Florastor (see Table 2). These three probiotics have evidence that display effectiveness for this condition.
Table 2. Probiotic Bacteria with High Evidence for Use (Not An All Inclusive List)
| Indication | Probiotic Bacteria Strain | Brand Name | Recommended Dose (CFUs) |
| Functional constipation | Lactobacillus reuteri DSM 17939 | BioGaia | 100 million CFUs twice daily |
| IBD (maintenance of ulcerative colitis remission) | Escherichia coli Nissle 1917 | EcN | 50 billion CFUs daily |
| IBS (may help relieve overall symptom burden) | 1. Bifidobacterium bifidum MIMBb75 2. Bifidobacterium longum infantis 35624 3. Escherichia coli DSM17252 | 1. N/A 2. Align 3. Symbioflor-2 | 1. 1 billion CFUs daily 2. 1 billion CFUs daily 3. 10 million CFUs three times daily |
| IBS (potential reduction in abdominal pain) | 1. Bacillus coagulans GBI-30 2. Bifidobacterium animalis lactis DN-173 010 3. Escherichia coli DSM17252 4. Lactobacillus plantarum 299v (DSM 9843) | 1. Digestive Advantage Gas Defense Formula 2. Actavia 3. Symbioflor-2 4. Jarrow Formulas Ideal Bowel Support | 1. 2 billion CFUs daily 2. 10 billion CFUs twice daily 3. 10 million CFUs three times daily 4. 10 billion CFUs daily |
| Prevention of antibiotic-associated diarrhea | 1. Lactobacillus acidophilus CL1285 + Lactobacillus casei 2. Lactobacillus rhamnosus GG 3. Saccharomyces boulardii CNCM I-745 | 1. Bio-K 2. Culturelle 3. Florastor | 1. 10 billion CFUs daily (minimum) 2. 10 billion CFUs twice daily 3. 5 billion CFUs twice daily |
| Prevention of hepatic encephalopathy | 1. Lactulose 2. Mixture of strains of Lactobacillus plantarum, Lactobacillus casei, Lactobacillus acidophilus, Lactobacillus delbrueckii bulgaricus, Bifidobacterium infantis, Bifidobacterium longum, Bifidobacterium breve, Streptococcus salivarius thermophilus. | 1. Enulose 2. Various | 1. 45-90 grams per day 2. 100 million CFUs three times daily |
| Supplemental treatment for individuals undergoing Helicobacter pylori treatment | 1. Lactobacillus rhamnosus GG 2. Saccharomyces boulardii CNCM I-745 3. Lactobacillus reuteri DSM 17938 | 1. Culturelle 2. Codex / Reflor 3. BioGaia | 1. 6 billion CFUs twice daily 2. 5 billion CFUs twice daily 3. 100 million CFUs three times daily |
Note: For a more thorough chart of different probiotic strains that may be effective, reference this chart provided by the American Academy of Family Physicians (AAFP).
4. Helping To Optimize Your Dose
Dosing units for probiotics are different from most other medicines. Many medicines quantify their strengths in terms of grams (g) or milligrams (mg). However, probiotic doses are represented in terms of colony-forming units (CFUs). For example, one probiotic supplement capsule may represent 5 billion CFUs per capsule.
A probiotic’s dose effectiveness hinders upon the specific probiotic strain in combination with a person’s condition they are taking the probiotic for.
Note: for a specific list of recommended doses, please reference the fourth column of Table 2 above. Especially as the above table is not all inclusive, always confirm with a local pharmacist or physician that a dose of a probiotic is appropriate.
The dose of a probiotic supplement is typically described on the “Supplement Facts” section on the back of a product’s packaging. It is recommended to always follow the described dose and directions for use as listed on every product’s specific packing.
5. Check In Consistently With a Pharmacist or Physician Throughout Probiotic Treatment
Simply put, digestive health needs change over time and they require ongoing maintenance and observation. At a minimum, checking in with a pharmacist or physician at least every 3 months is important to ensure that a probiotic supplement is still effective.
Similarly, pharmacists and physicians can also help to determine if a probiotic supplement may still be necessary to take if it is thought that an individual’s digestive health no longer requires the use of a probiotic supplement.
Pharmacists are known as the most accessible healthcare provider. A quick, free phone call to a pharmacist is an easy yet important step to ensure that health outcomes are maximized over time.
References:
- Guarner F, Sanders ME, Eliakim R, et al. World Gastroenterology Organisation Global Guidelines. Prebiotics and Probiotics – 2017. WGO Global Guideline.
- Hungin AP, Mulligan C, Pot B, et al. The European Society for Primary Care Gastroenterology (ESPCG). Systematic review: probiotics in the management of lower gastrointestinal symptoms in clinical practice – an evidence-based international guide. Aliment Pharmacol Ther 2013; 38(8):864–86
- Wilkins T, Sequoia J, Dorn WJB. Probiotics for Gastrointestinal Conditions: A Summary of the Evidence. Am Fam Physician. 2017 Aug 1;96(3): 170-178.
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