Making a Niche as Promising Health Supplements and Complementary Medicines

Abstract

Hippocrates once quoted, "Let food be thy medicine and medicine be thy food,‰ this ancient statement has certainly become a belief in todayÊs scenario. The live microbial food supplements, called as Probiotics (known to have beneficial effects on human health in various ways) are widely used now a days. Owing to their potential as alternative or complementary therapeutic agent in combating large number of pathological conditions and ability to enhance immune response, an overwhelming interest have developed for probiotics in medical field. Probiotics, being widely used around the globe by consumers and in clinical practice, a thorough understanding of the risks and benefits related to their use are of vital importance. This review addresses the concept of probiotics, historical development, their sources and probable mechanisms of action, clinical applications along with associated risks and contraindications related to the use of probiotics.

Full text

International Journal of Drug Delivery 6 (2014) 329-338
http://www.arjournals.org/index.php/ijdd/index
Review Article
Making a Niche as Promising Health Supplements and Complementary
Medicines
Charanjit Kaur1, Amit Sharma1, Ashish K Garg2, Junaid Niazi3, Rajesh Kumar*1
*Corresponding author:
Rajesh Kumar
1Rayat-Bahra Institute of Pharmacy,
Hoshiarpur, Punjab (India)
2Akal College of Pharmacy, Mastuana
Sahib, Sangrur, Punjab (India)
3Bahra Institute of Pharmacy, Patiala-
Sangrur Highway, Patiala, Punjab
(India)
Abstract
Hippocrates once quoted, „Let food be thy medicine and medicine be thy food,‰ this ancient
statement has certainly become a belief in todayÊs scenario. The live microbial food supplements,
called as Probiotics (known to have beneficial effects on human health in various ways) are widely
used now a days. Owing to their potential as alternative or complementary therapeutic agent in
combating large number of pathological conditions and ability to enhance immune response, an
overwhelming interest have developed for probiotics in medical field. Probiotics, being widely used
around the globe by consumers and in clinical practice, a thorough understanding of the risks and
benefits related to their use are of vital importance. This review addresses the concept of probiotics,
historical development, their sources and probable mechanisms of action, clinical applications along
with associated risks and contraindications related to the use of probiotics.
Keywords: Health, GIT, microflora, infants, immunity.
.
Introduction
The human gastrointestinal tract has long been considered for their
main functions of digestion and absorption of nutrients and
excretion of their waste products. However, GIT also fulfills many
other functions which are essential to our sound health. GI mucosa
poses a barrier, excluding and eliminating various antigens
entering the GIT from external environment. [1,2]
The human GIT has got a vast number of microbes and harbors,
many of which live in symbiotic relationship with host. This mutual
beneficial relationship is termed as host-microbes cross-talk. [3,4].
However few of these bacteria also contribute to the development
of various diseases by a variety of mechanisms [5,6]. Disturbance
in the existing balance between host and friendly microbes can
lead to various GI complications by stimulating the host immune
system. A few of methods by which intestinal microflora can be
altered are: administration of antibiotics, dietary supplements
which enhance physiological functions and thus growth of health
friendly bacteria (prebiotics, which act an alternative for probiotics
or their cofactors e.g. lactulose, galactooligosaccharides, inulin and
its hydrolysates etc.) and probiotics. [7]
History
Microbial cultures have been a niche in food and alcoholic
fermentations and for the past few decades have undergone great
scientific scrutiny for their ability to cure a variety of diseases. A
Nobel laureate Russian biologist, also known as father of modern
immunology, Dr. Ellie Metchnikoff in the year 1908 postulated the
prolongation of life with the consumption of large quantities of
cultured food especially yoghurt on the basis of growth of lactic
acid bacteria which could lead to displacement of the disease
causing microbes in the intestine [8]. In 1915, cultured food therapy
was also found to be beneficial in urogenital infections [9-11].
However, this therapy was ignored over 7-8 decades due to
growing interest in antibiotics. In 1965, Lilly and Stillwell coined the
term "probiotic" for the substances secreted by one organism
which stimulate the growth of another. The term probiotics was
derived from Greek word meaning "for life". Marteul
et al.
in 2002,
redefined them as "microbial preparations or components of
microbial cells that have a beneficial effect on health and well
being" [12-13]. WHO defines probiotics as "live microorganisms"
which when administered in adequate amounts confer a health
benefit on the host [14-15]. A breakthrough came in the field of
probiotics with the evolution of friendly bacteria such as
lactobacilli,
bifidobacteria
in various dosage forms like powders, tablets, liquid
suspensions and lyophilized powder filled capsules [16].
Source of Probiotics
Approximately 500 different microbial species have been reported
in the GIT amongst which 20 genera predominate, a few of which
are namely Bacteroides, Lactobacillus, Clostridium,
Fusobacterium, Bifidobacterium, Eubacterium, Peptococcus,
Peptostreptococcus, Escherichia, and Veillonella. Out of these,
bifidobacteria and lactobacilli were reported to have beneficial
properties [17-19]. In the neonates, the microbiota starts
developing immediately after the birth and is dependant mainly on
the maternal microbiota, mode of delivery, birth environment and
ISSN: 0975-0215
This work is licensed under a Creative Commons Attribution 3.0 License.

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sometimes on genetic factors [20-21]. The vaginal and intestinal
flora of mother constitutes the source of bacteria by colonizing the
intestine of newborn dominating strains being facultative
anaerobes such as enterobacteria, lactobacilli and coliforms. Once
the child starts taking stuff other than mother's milk, the
composition of intestinal microflora gradually start altering to
resemble to that of adult's microflora [1].
Criteria for being Probiotic
For an organism to be considered as probiotic, it should possess
the following properties:
It should be host friendly
It should not have pathogenic and toxic potential
It should be able to survive through the entire length of GIT
It must retain its viability for long periods during storage
The source species should be same as that of intended host
It must have capacity to influence local metabolic activity
It must be able to persist in the intestine even in the absence of gut
colonization by probiotic strain [1,3,13]
Table 1. List of Microorganisms used as probiotics [3,7,13]
Lactobacillus
species
Bifidobacterium
species
Streptococcus
species
Saccharomyces
species
Other
s
L.acidophilus,
L.plantarum,
L.casei
L.salivarius
L.brevis
L.fermentum
L.helveticum
L.delbruekii
L.bulgaricus
L.gasseri
L.Reuteri
L.rhamnosus
L. johnsonii
B.bifidum
B.longum
B.infantis
B.breve
B.lactis
B.adolescentis
S.thermophilu
s
S.salivarius
S.boulardi
i
Lactococcous lacti
s
Bacillus cereus
Clostridium butyricum
C. cremoris
Enterococcus faecium
Eschericia coli
Lactis pedicoccus
acidilactici,
Propionibacterium
freudenreichii.
Clinically beneficial effects of Probiotics

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Table 2. The clinically beneficial effects of probotics are listed below.
Intestinal effects
• Promotes recovery from diarrhea induced by rotavirus and antibiotics
• Produces lactase and thus alleviates symptoms of lactose intolerance and mal absorption
• Helps in relieving constipation
• Beneficial in the treatment of colitis
Immune system effects
• Probiotics enhance immune response (both specific and non-specific)
• They reduce the chances of infection from pathogenic microorganisms like Salmonella and Shigella
• They are helpful in inhibiting pathogenic growth and translocation
• Probiotics also stimulate gastrointestinal immunity
Other effects
• Detoxification of carcinogens and thus reduced risks of colon and bladder cancer
• Suppression of tumors
• Lowering of serum cholesterol level
• Treatment of food allergies
• Enhances nutrient bioavailability
• Improves urogenital health
• Reduces blood pressure
• Synthesis of nutrients like vitamin B2, B3, B6
,
B9 and B12
Mechanism of action
Probiotics act in several ways to protect the host organism.
Competitive inhibition:
Probiotics competitively inhibit the binding of pathogens to the
enteric epithelial surface8. A good example of this mechanism is
inhibition of adhesion and invasion of (enteroinvasion)
E.coli
by
streptococcus
thermophilus
and
lactobacillus acidophilus
in human
intestinal cell lines [23].
Competitive consumption of nutrients:
Probiotics prevents the growth of pathogens by competitively
consuming the nutrients and thus not allowing the pathogens to

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grow. Probiotics, by consuming the monosaccharides, prevent the
growth and development of
Clostridium difficile
[24].
Working through reduction of luminal pH
Several investigations have shown that probiotics like lactobacillus
exert antagonistic action against intestinal pathogens and related
organisms. Organic acid such as acetic acid and lactic acid are the
byproducts of bacterial metabolism. These acids inhibit the growth
of many pathogens including pathogenic gram negative types [25]
and lower pH value also potential the activity of these acids
because undissociated forms are more bacterial than the
dissociated ones [26].
Through stimulation of immune response to pathogens
Probiotics are shown to promote the endogenous host defense
mechanism which is characterized by stabilization of the gut
microflora [27].
a) Probiotic bacteria have been shown to enhance humoral
immune responses and thereby promote the intestineÊs
immunological barrier [28,29].
b) Probiotic bacteria have been shown to stimulate non-specific
host resistance (proinflammatory cytokines TNF and IL6) to
microbial pathogens and thereby facilitate the exclusion of
pathogens in the gut [30,31].
c) Probiotics modulate the hostÊs immune responses to potentially
harmful antigens with potential to down regulate hypersensitivity
reactions [32,33].
d) Probiotics exhibit protective mechanism by association with gut
intestinal colonization suppression of pathogens growth and/or
invasion
e) Probiotics enhance and modulate innate and adaptive immune
responses in the host.
f) Probiotics modulate the immune activity and epithelial function in
both large as well as small intestine [34].
g) Oral intake of probiotics such as
Lactobacillus casei
and
Lactobacillus bulgaricus
activate the production of macrophages
and administration of
L.casei
and
L. acidophilus
activates
phagocytosis [35].
h) Specific strains of probiotics such as
Bifidobacterium
and
Lactobacillus
give promising results in the treatment and/or
prevention of eczema in infants and children by alteration of
colonization [34].
Integrity of GI mucosa
Probiotics (
Streptococcus faecalis
and
Clostridium butyricum
), by
the synthesis of glutamine in presence of ammonia and glutamic
acid, maintain integrity of GI mucosa. Therefore, it is postulated
that the probiotics administered to humans can have positive effect
in cases such as diarrhea, constipation, colitis, and recolonization
by pathogens, immunostimulation [36].
By producing inhibitory substances
Probiotic bacteria produce a variety of inhibitory substances
include organic acids, hydrogen peroxide and bacteriocins which
are inhibitory to both gram positive and gram negative bacteria. It
may reduce not only the number of viable cells but may also affect
bacterial metabolism or toxin production [37].
Degradation of toxin receptor
By the degradation of the toxin receptor on the intestinal mucosa,
probiotics
(e.g. Saccharomyces boulardii)
protects the intestine
from disease causing microbes (e.g
C.difficile
) [25,38]
Clinical Applications
Role of probiotics on faecal water-induced DNA
damage in human colon adenocarcinoma cells
Probiotics may have protective effects against the early stages of
colon cancer, although there are many studies in laboratory
animals indicating that administration of probiotics and/or prebiotics
reduces the incidence of tumours and precancerous lesions in the
colon [39-44], but there was no evidence clinically. A recent study
on human volunteers has suggested that in comparison to
conventional yoghurt, the strains of
Lactobacillus
acidophilus
and
Bif. longum
has demonstrated a reduction in faecal water
genotoxicity [45]. Thus,
Lact. plantarum
and
Bif. Bb12
have
intrinsic antigenotoxic potential and probiotics certainly are worthy
of further evaluation in
in vivo
assays for anti carcinogenic effects.
Probiotics in infants
One of the fatal intestinal disorder; necrotizing enterocolitis, which
is known to occur in 10-25% of premature infants and very low birth
weight babies and has a high mortality of 20-30%1. Bacterial
colonization or intestinal infection aggravates the risks of
necrotizing enterocolitis. Modification of the intestinal flora by
increasing the predominance of specific nonpathogenic bacteria
would seem a reasonable means of attaining a prophylactic or
therapeutic effect against enteropathogens. A combination of
increased bifidobacterial counts and decreased concentrations of
other enterobacteria and luminal host factors may play a role in
protecting premature babies and newborns from enterocolitis.
Trials showing reduction of necrotizing enterocolitis in population of
premature newborns given supplements of Lactobacillus GG daily
compared with historical control subjects have been reported.
These findings suggested a correlation between the reduction of
lactobacilli and the increased risk of necrotizing enterocolitis
[46,47].
Wang Y
et al.
conducted a double blind randomized controlled trial
on 100 full term infants with critical illness according to scores of
neonatal acute physiology. Out of them, 50 infants received
Probiotics three times a day after birth for 8 days and remaining 50
were kept on placebo. The incidence of sepsis, multiple organ
dysfunction syndrome (MODS), nosocomial pneumonia and
necrotizing enterocolitis were recorded. Prognosis of probiotic
treatmenr was determined on the basis of rate of recovery and
hospitalization days. Serum IgA, IgG and IgM concentrations were
measured on days 4 and 8. Infants receiving Probiotics showed
significantly reduced rate of nosocomial pneumonia and MODS
(due to increase in the level of IgA) compared with the placebo
group of infants [48].

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Role of Probiotics on Cold and Influenza-Like
Symptoms, Incidence and Duration in Children
Daily dietary supplementation of probiotics during the winter
months was a safe effective way to reduce episodes of fever,
rhinorrhea, and cough, the cumulative duration of those symptoms,
the incidence of antibiotic prescriptions.
L acidophilus
alone was
effective. There was a broader protective effect with the
combination of
L acidophilus
and
B lactis
Bi-07 [15].
Probiotics in pregnancy
Probiotics have been shown to decrease the risks of bacterial
vaginosis (which has been suggested as a factor that increases the
risk of preterm labour and infant mortality) and maintain normal
lactobacilli vaginal flora [49,50]. These strains were found to be
safe in pregnant animal studies and improving the health of
mothers and newborns [51].
Prevention of allergic reactions by probiotics taken during
pregnancy is another area of interest. Ingestion of probiotics like L
rhamnosus GG and B lactis BB12 during pregnancy and in
newborns during first 6 months of birth was found to prevent atopic
dermatitis (a condition that causes severe skin rashes in up to 15%
of babies) in 50% cases [52].
Role of Probiotics in Lowering of serum cholesterol level
in hypercholesterolemia
Lactobacillus acidophilus,
is
the natural
inhabitant of intestine and
possesses bile-salt
hydrolase activity and possibly can be used for
the
manufacture of acidophilus milk and thus recommended as a
source for reducing cholesterol
level. Anderson and Gilliland
et al.
(1985) in their study reported that
Lactobacillus acidophilus
reduces the blood cholesterol by direct breakdown of cholesterol
and deconjugation of bile salt. In the year 1999, they also
examined effects of consumption of one daily serving of yogurt on
serum lipids in two controlled clinical studies and in those studies it
was concluded that regular intake of fermented milks containing an
appropriate strain of
L. acidophilus
has the potential of reducing
risk for coronary heart disease by 6 to 10%.
L.
acidophilus
showed
highest deconjugation ability and BSH activity towards bile
mixtures that resembled the human bile in a study done by Liong
and Shah in which they screened eleven strains of lactobacilli and
analyzed bile salt deconjugation ability, bile salt hydrolase activity
(BSH) and co-precipitation of cholesterol with deconjugated bile.
Lactobacillus acidophilus
strains had higher deconjugation ability
than
L. casei
strains. Cholesterol co-precipitation with
deconjugated bile increased with decreasing pH [53].
Lactobacillus bulgaricus
is an acid-producing bacterium and in
general, it occurs in dairy products and some plant products. A
study conducted on fifty four volunteers in a randomised cross over
trial; revealed reductions of between 5-10% in serum cholesterol
levels after several weeks of moderate consumption of yoghurt
fermented with
Lactobacillus bulgaricus
and
S.thermophilus
[54].
Use of
Bacillus coagulans
(Probiotics
)
as an attractive
alternative to drug therapy in case of
hypercholesterolemia
Bacillus coagulans,
formerly known as
Lactobacillus Sporogenes,
is a shelf stable, nonpathogenic Gram positive spore-forming
bacteria that produces L(+) lactic acid (dextrorotatory) in
homofermentation conditions. In particular,
B. coagulans
strains
were used to reduce serum cholesterol in certain formulations
(Mohan, 1990). Seok, (1987) concluded that
L.sporogenes
lowers
LDL cholesterol by eliminating it directly from inside the intestines
before it can be absorbed into the blood stream. In another clinical
study,
L. sporogenes
not only lowered total serum cholesterol and
LDL cholesterol in humans, it also improved the ratio of „good‰
HDL cholesterol to total cholesterol. US patent was given to a
therapeutic composition including
Bacillus coagulans
, in
combination with bifidogenic oligosaccharides or other cholesterol-
reducing agents for use in reducing LDL cholesterol and serum
triglycerides (US patent 7232571). This unique microorganism
proved effective in lowering cholesterol by 104 points in a three-
month study performed at the G.B. Pant hospital in New Delhi,
India. There was a highly significant reduction in the LDL
cholesterol levels, and a small but significant increase in HDL
cholesterol levels [55].
products without prescription. Lack of awareness about the risk
factors associated with probiotics needs regulation.
Generally probiotics are safe however some rarely observed side
effects associated with probiotics vary from strain to strain
individually such as bacteremia or sepsis from lactobacilli [28],
fungemia with saccharomyces in immune compromised patients or
ICU patients [60,61].
Some cases of liver abcess [62],
Lactobacillemia
[63,64] and
S.
boulardii
fungemia [65,66] have been reported in such patients. On
the other hand, S.boulardii has been used without complications to
treat chronic diarrhea in AIDS patients [67,68].
Another reason of concern is the risk of transfer of resistance via
probiotic agents as these agents have to be resistant to the
antibiotics because they are to be used alongside. In fact, a study
has demonstrated transfer of plasmid pAMb1, from
L. reutri
to
E.
faecium
and from
E. faecium
to
E. Faecalis
in mouse intestinal
tract [69].
In long term study, in children for 1 year, consumption of 106-109
CFU of Lactobacilli and Bifidobacteria daily did not only result in
any adverse effect but also showed that Probiotics taken over a
long time improve gastrointestinal function and reduce the
incidence of diaper rash [70].
Many lactobacillus strains are resistant to vancomycin naturally;
however, it has been revealed in conjugation studies that these
resistant genes are non-transferrrable [54]

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Table 2. Probiotics associated fungal sepsis cases in human beings
Note:
CVC- central venous catheter COPD- chronic obstructive pulmonary disease GI- gastrointestinal 250 mg S.boulardii= 5.425 X 1013 live cells

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Table 3. Probiotics associated risks and contraindications
Possible risk factors of Probiotic therapy
Sr. No. Major risk factors
1. Immune compromisation resulting in debilitated state or malignancy
2. Premature infants
Minor risk factors
1. Central venous catheter
2. Diarrhea and intestinal inflammation due to impairment of intestinal epithelial barrier
3. Administration of probiotics by jejunostomy
4. Co-administration of probiotic resistant antibiotics
5. Probiotics with known pathogenic potential
Problems associated with the use of Probiotics
Viability of Probiotics
The maintenance of viability associated with use of probiotics is a
major issue. The Probiotics need to survive in several
environments including processing treatments, storage conditions
and human body conditions especially gastric acidity and action of
bile salts. The ability to survive through stressful acidic conditions
and bile solutions in the body vary among the strains of probiotic
bacteria.
Only those Strains which tolerate these adverse conditions better,
should be preferred. The viability of Probiotics may also be
improved by using a medium, nutrient and temperature, which
supports their survival.
Viability of
Lactobacilli
has been enhanced by
Encapsulation in artificial sesame oil for storage and in simulated
high gastric or bile salt conditions as compared to free cells [71].
Storage at 4ĈC temperature is reported to be a most important
factor in keeping probiotic
Bifidobacterium
viable during 4 weeks
storage time [72].
The use of prebiotics like isomalto-oligosaccharides has been
found to be associated with higher levels of Probiotics like
Lactobaccilus
and
Bifidobacterium
after 1month storage [73].
The issue of viability of Probiotics from the stage of processing till it
is used by consumer to produce benefits still remains a fertile field
for more research [74].
Commercially available Probiotics (single and multiple
strains)
The optimal use of one or more strain cannot be precisely
determined. While it seems intuitive that a combination of strains
might be convenient to suite a range of indications and individual
variation, this is dependent on the optimal probiotic bacterial
numbers in different situations and assuming that the probiotic
constituent of any cocktail are not mutually antagonistic which
requires further study. Furthermore, the activities of individual
components require definitions and optimization before firm
recommendations can be made.
Single-strain-
Saccharomyces boulardi
(Laboratories Biocodex,
Montrouge, France) is commonly given in doses of 2 capsules
containing 250 mg morning and evening, equivalent to
approximately 10 billion live organisms/d. The nonpathogenic E coli
serotype O6:K5:H1 (Mutaflor;Ardeypharm GmbH, Herdecke,
Germany) is referred to as Nissle 1917 is commonly given in doses
of less than 10 billion LAB/d.
Lactobacillus
GG (LGG) (Valio,
Helsinki, Finland) commonly is given in doses of 1 to 5 billion
LAB/d.
L acidophilus
LA1 (LA1) (Nestle, Vevey, Switzerland) is
commonly given in doses of less than 5 billion LAB/d (sometimes
<1 billion LAB/d).
Multistrain- The probiotic cocktail VSL#3 (Sigma-Tau, Pomezia,
Italy, and VSL Pharmaceuticals, Fort Lauderdale, Florida) is the
only multistrain probiotic tried so far. It consists of four
Lactobacillus
strains (
L. acidophilus
,
L. casei
,
L. delbruecki
subsp
bulgaricus
, and
L. plantarum
), three
Bifidobacterium
strains (
B.
longum
,
B. infantis
,
B. breve
), and
S. salivarius
ssp
thermophilus
(5
1011 cells/g). It is commonly given in high doses,usually 1800
billion LAB and more recently up to 3600 billion LAB/d [1].
Conclusion
Probiotics are gaining popularity in consumers for their health
benefits and are recommended by many health care professionals
too. Prebiotic, probiotic and synbiotic treatment is still in its infancy
but is rapidly moving into the mainstream. Several probiotic
preparations seem to have promise in prevention or treatment of
various conditions. Normalization of the properties of unbalanced
indigenous microflora of the intestinal tract by ingestion of specific

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strains of the healthy microflora forms the rationale of probiotics
therapy. There exists quite a good number of evidences for the
therapeutic use of probiotics in infectious diarrhea in children,
recurrent Clostridium difficile induced infections and post-operative
pouchitis. Evidence is also emerging for the use of probiotics in
other gastrointestinal infections, irritable bowel syndrome and in
ulcerative colitis and CrohnÊs disease. However, most studies have
been in small number of patients and many have important
methodological limitations, making it difficult to make unequivocal
conclusions regarding efficacy, especially when compared with
proven therapies. Furthermore, considerable differences exist in
composition, doses and biologic activity between various
commercial preparations and one consistent feature is that not all
probiotic bacteria have similar therapeutic effects. The enthusiasm
for probiotics has perhaps outpaced scientific support for these
therapeutic approaches. They are generally regarded as safe, but
physicians should monitor their use in high-risk patients. However,
when used appropriately, probiotics represent a potentially
beneficial adjunct to other proven therapies and with more
controlled and larger studies clear data may emerge in the future.
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