Updates to the Probiotics, Prebiotics WGO Guidelines
In this video, Francisco Guarner, MD, PhD, and Hania Szajewska, MD, PhD, discuss the latest updates to the Probiotics and Prebiotics Practice Guideline by the World Gastroenterology Organization (WGO), involving experts from the International Scientific Association for Probiotics and Prebiotics (ISAPP). They discuss common indications covered in the guideline, how uses for pediatric patients may differ from adult patients, and more.
Additional Resources:
- Guarner F, Sanders ME, Szajewska, et al. Probiotics and prebiotics. World Gastroenterology Organization. Published February 2023. Accessed September 13, 2023. https://www.worldgastroenterology.org/UserFiles/file/guidelines/probiotics-and-prebiotics-english-2023.pdf
Francisco Guarner, MD, PhD, is a consultant in gastroenterology at Teknon Medical Center in Barcelona, Spain and a past board member for ISAPP.
Hania Szajewska, MD, PhD, is a professor and chair of the Department of Pediatrics at the Medical University of Warsaw, in Warsaw, Poland and a member-at-large for ISAPP.
TRANSCRIPT:
Hania Szajewska: I'm Professor Szajewska in the Department of Pediatrics at the Medical University of Warsaw, Poland.
Francisco Guarner: My name is Francisco Guarner. I am currently a consultant in gastroenterology at the Teknon Medical Center, which is a hospital in Barcelona in Spain.
Consultant360: Could you discuss what prompted this update of the guideline? Why now?
FG: The World Gastroenterology Organization (WGO) is a federation of national associations of gastroenterologists. So in many countries physicians with a specialty in gastroenterology, they are members of a national association of gastro that usually organize meetings every year; many teaching activities. And then 100 of these associations are part of a federation which is called World Gastroenterology Organization. And then the WGO tries to organize programs that can be useful all over the world and one of the programs is the production of guidelines for diagnostics or for treatments in different gastroenterological diseases.
And when it refers to the probiotics and prebiotics guideline, what happens is that there are papers, there are clinical trials being done every year. So we have novelties of a new strain of probiotic or a new prebiotic that is useful to treat abdominal pain or whatever. And then what we do is every 4-5 years we review all the new papers and try to identify clinical trials that have a positive outcome in terms that they demonstrate that an intervention with a prebiotic or a probiotic is useful for a particular health outcome, usually in gastroenterology. We only cover gastroenterology and hepatology. And this is why we started in 2008 but maybe every 4 or 5 years we try to produce an update of the guideline.
HS: And if I can add something, I think it's important to stress that in many countries there are really many, many, many probiotic products. Like in my country, probably over 200. Some of them are well-studied or at least studied in one randomized controlled trial. The others are not. And it's really important for clinicians to have the knowledge which probiotics or prebiotics out of many which are available on the market can be used based on the evidence. So this is one additional reason to update.
FG: Very important point, yes.
C360: There were several gastrointestinal conditions that showed benefit from the use of probiotics or prebiotics that were highlighted in the guideline, such as inflammatory bowel disease and irritable bowel syndrome. Can you discuss the recommendations that may have the biggest impact on clinical practice or may be most surprising to some health care practitioners?
FG: Actually, in inflammatory bowel diseases the data are not very strong. So there are some data, some interesting studies. But it's important that patients need drugs. So the use of probiotics might help, but it's not the best area where probiotics are successful as a therapy for inflammatory bowel diseases.
In irritable bowel syndrome, it is different. In irritable bowel syndrome there are disorders, conditions where patients have symptoms without an organic alteration, without an ulcer; there is no objective organic alteration in their stomach or in their gut or the liver. And in this situation, yes, there are some probiotics, also a few prebiotics, that have been studied in controlled randomized trials. And if the data are positive that demonstrates a benefit from the use of this probiotic for the alleviation of the symptoms, then we include this data in the guideline.
Probably, I would say that in the guideline the most important topic is not IBS, irritable bowel syndrome, but probably the prevention of diarrhea associated with antibiotics. I think it’s the area where we have this; Well Hania, please.
HS: I think that especially in pediatric population, the most common indications for the use of probiotics is prevention of antibiotic-associated diarrhea so also like in adults. Because many antibiotics, not all of them but many of them, can cause antibiotic associated diarrhea more commonly than others because every single antibiotic can cause it. But more commonly than others. In pediatrics, I'm a pediatrician, so in pediatrics it's mainly amoxicillin and clavulanate which are very often used. And here one may consider the use of probiotics with proven efficacy. And in our guidelines we listed those probiotics with proven efficacy. So this is very much in line with recommendations for adults because also this is one of the common indications.
In pediatrics, there's also another indication which is treatment of acute infectious diarrhea. This is much more common in pediatric populations than in adults. Rehydration is key management. But the problem with oral rehydration solution, which are commonly used, is that they do not reduce the duration of diarrhea. So parents are asking for something that will shorten the duration of diarrhea. And some specific probiotics may reduce the duration of diarrhea by approximately 1 day. So again, in the guidelines we listed those probiotics which have proven efficacy. As I said earlier, it is important for clinicians to know which probiotics out of many which are available on the market can be used based on the evidence.
C360: How does the recommended use of probiotics and prebiotics in pediatric populations differ from adult populations?
HS: The rationale for creating recommendations is always exactly the same which means that we need evidence from randomized control trial, at least one randomized control trial. But the indications might be slightly different. For example, as I mentioned in pediatric population it's treatment of acute infectious diarrhea, prevention of antibiotic associated diarrhea, management or prevention of infantile colic. So these are the very common indications.
In adults, I mean, acute diarrhea is not such a big problem. There are other problems like prevention of antibiotic-associated diarrhea, Clostridioides difficile diarrhea, inflammatory bowel disease, but we already mentioned it, irritable bowel syndrome. There is a huge interest. Just in the diseases which occur in adult population and pediatric population, they slightly differ, but the approach to the guideline is exactly the same.
FG: Exactly. Yeah. Good. Yes. The fact is that sometimes the condition is not exactly the same because physiopathology might be different. And as well, the doses are not the same and the studies are not the same. So we always are based in randomized controlled trials. So we get the data from the population treated in that study. And usually, studies with children or within the infancy are different than studies done in adults.
HS: And we cannot extrapolate data from one population to another. We should really have data in the target population. So it's really important. And I think in pediatrics there's quite a lot of studies or people who try to study probiotic for the prevention of the diseases, not so much even for treatment, but for the prevention of the diseases.
C360: What knowledge gaps remain on the use of probiotics and prebiotics for gastrointestinal disorders?
HS: So I may start by saying what I said at the beginning. There are countries in which there are hundreds of different probiotic products, and we really need to have evidence in order to use them wisely because to use a probiotic, or prebiotic, or any biotic; if there is no evidence to support it, I will say if it's not even ethical to patients, to parents, because then you spend money on something that you don't know whether it works. Probably it works. I'm not saying it'll not work. It's likely that it works, but we need evidence. And for many biotics, probiotics, prebiotics, symbiotics, postbiotics, we really still need some evidence. And then Francisco, I think you agree with me, it's the same in pediatric populations and in adult populations.
FG: One point is that our philosophy, let's say, or criteria, are based in the criteria established by the FAO (Food and Agriculture Organization) and WHO in 2002 and 2003. So if you type in Google FAO probiotics, you will see a document that was prepared by experts. They established that to be characterized to be a probiotic, a particular stain has to be perfectly characterized at the level of strain. So the genus, the species, and the strain has to be deposited in international collection. So it has to be a very, very, very well-known strain and very well preferred and needs to be tested in this controlled trials where a number of people are receiving the treatment, other people are receiving placebo, and this is randomized. And then you can be sure that of the benefit related with the administration of such probiotic. So for us, these guidelines are the basis. And also ISAPP, which is the International Scientific Association for Probiotics and Prebiotics, in 2014 published another paper. It was in Nature Reviews in Gastroenterology and Hepatology, again confirming the importance of the indication need to be supported by serious studies.
C360: Is there anything else you would like to cover on the newly updated guideline?
HS: I think we did our best. Now I think it's on the part of the readers and if they found that something is needed, I think for the next update. Because guidelines usually have to be updated every, let's say 3, 5 years. So for the next update, probably we will need to include. But here, I think for this guidelines I hope that we included everything that we wanted.
FS: That’s right. One of the things, the number of strains now that are currently studied in clinical outcomes are strains that were related with food. So with the production of the dailies or so. And we only have a very few strains that are of human origin and maybe in the future we will have indigenous strains isolated from the human gut microbiota. And maybe we will include this in the future. Today we don't have enough evidence in gastroenterology for these novel probiotics but maybe in the future it will be something that we will improve.
HS: I will just add that the beauty of science is that it never solves all the problems without creating new ones. Makes it so fascinating because then you can really research again and again. It's a fascinating field on microbiota and all the ways of modifications, and probably in 10 years from now, the way we will modify microbiota, the gut microbiota, will be different compared to what we are doing at the moment. We will see. We will see.