Do patients with celiac disease need probiotics?

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One of the most common questions that I receive from patients diagnosed with celiac disease is if they should take a probiotic. The only available treatment for celiac disease, an autoimmune disease characterized by destruction of the absorptive surface of the small intestine which develops in genetically compatible individuals, is a gluten free diet. However, patients and providers often question whether supplementation with probiotics may hasten the healing process.

Probiotics are live microbes that, when administered, are thought to benefit our overall health by directly influencing our intestinal microbiome (the community of trillions of microbes that reside in our gastrointestinal tract). Laboratory studies suggest that probiotics may contribute to gastrointestinal health specifically in patients with celiac disease by fortifying the protective mucus layer that lines the gastrointestinal tract, dampening the inflammatory response caused by gluten ingestion, decreasing intestinal permeability (the leakiness of the intestinal surface) in response to gluten, and possibly by aiding in gluten digestion. Despite these promising results, these findings do not seem to be upheld once outside of the controlled environment of the laboratory.

To date, no study aimed to clinically evaluate the use of probiotics in patients with celiac disease has met its primary outcome. Patients with untreated celiac disease administered Bifidobacterium infantis did not have an improvement in intestinal permeability compared to patients with untreated celiac disease who received placebo.  Patients with celiac disease with  persistent symptoms despite a gluten-free diet treated with VSL #3 were found to have a fecal microbiota (distribution of microbes in the stool, which is thought to be fairly representative of that of the intestine) that was not significantly different than patients treated with placebo. Finally, the possibility of probiotics aiding in gluten digestion seems slim given the recent failure of a mixture of two gluten-targeting enzymes to significantly alter the intestinal healing process in patients with celiac disease in a phase 3 study.

Given the paucity of data, currently, there are more questions than answers. Which probiotic or mix of probiotics is most beneficial? How often and at what dose should they be administered? Should probiotics be given in early childhood? Should they be administered before or after the onset of the disease and for how long should they be given? Should we focus on prebiotics (foods that feed the good bacteria)? Additionally, for patients with celiac disease, probiotics may come with risks. In the United States, the live microbes are not monitored by the Food and Drug Administration (FDA) which means that they may not be indeed “live.” It is also possible that the supplements may contain unidentified ingredients, such as traces of gluten, as research from the Celiac Disease Center at Columbia University found in 2015.

So how can patients with celiac disease and individuals without an autoimmune disease increase the diversity of their intestinal microbiome and safely improve their overall gut health? It is unlikely that a single probiotic or mix of probiotics currently on the market and taken transiently will work for the population at large. Until personalized pre or probiotics with a known mechanism of action are available, patients should focus on increasing their exposure to good microbes through diet. In order to do this, individuals should start with a well-balanced, high-fiber, plant-based diet and focus on including prebiotics such as whole grains, legumes, garlic, and chicory root. The diet should also include foods with a natural source of probiotics such as yogurt, kefir, sauerkraut, and Kombucha. Choosing a diet rich in pre and probiotics will naturally provide a healthy mix of microbes that will not only feed the good bacteria, but also provide more of them which will help to support a diverse microbiome. In this way, individuals can nourish their body and their intestinal microbiome without overwhelming it with one or more unsubstantiated supplements. For patients with celiac disease who are already adjusting to a new gluten-free diet, learning to include these foods in the long-term will provide long-standing health benefits.

Maureen Leonard is clinical director, Center for Celiac Research and Treatment, MassGeneral Hospital for Children, Boston, MA. She can be reached on Twitter @celiacdoc.

Image credit: Shutterstock.com

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