Fermented milk containing Lactobacillus paracasei and Glycyrrhiza glabra has a beneficial effect in patients with Helicobacter pylori infection: A randomized, double-blind, placebo-controlled study

Abstract

Background:
Lactobacillus paracasei and Glycyrrhiza glabra have been reported as having beneficial effects on Helicobacter pylori infection. We aimed to assess the efficacy and safety of fermented milk containing L paracasei HP7 and G glabra in patients with H pylori infection.

Methods:
This multicenter, prospective, randomized, double-blind, placebo-controlled clinical trial was conducted in 2 hospitals from April to December 2017. Patients with H pylori infection were randomized into either the treatment group (fermented milk with L paracasei HP7 and G glabra) or placebo group (fermented milk only) once daily for 8 weeks. The primary endpoint was the gastric load of H pylori measured by C-urea breath test (UBT). Secondary endpoints were histologic and clinical improvement.

Results:
A total of 142 patients were randomly allocated to the treatment (n = 71) or placebo groups (n = 71). Compared to baseline data, the quantitative value of C-UBT at 8 weeks was significantly reduced in the treatment group (from 20.8 ± 13.2% to 16.9 ± 10.8%, P = .035), but not in the placebo group (P = .130). Chronic inflammation improved significantly only in the treatment group (P = .013), whereas the neutrophil activity deteriorated significantly only in the placebo group (P = .003). Moreover, the treatment group had significant improvement in gastrointestinal symptoms (P = .049) and quality of life (P = .029). No serious adverse events were observed.

Conclusion:
The combination of fermented milk containing L paracasei and G glabra reduced H pylori density and improved histologic inflammation. However, their mechanisms of action should be elucidated in further studies.

Full text

Fermented milk containing Lactobacillus
paracasei and Glycyrrhiza glabra has a beneficial
effect in patients with Helicobacter pylori
infection
A randomized, double-blind, placebo-controlled study
Jin Young Yoon, MD, PhD
a
, Jae Myung Cha, MD, PhD
a,∗
, Seong Soo Hong, MD, PhD
b,∗
,
Hyung Kyung Kim, MD, PhD
c
, Min Seob Kwak, MD, PhD
a
, Jung Won Jeon, MD, PhD
a
,
Hyun Phil Shin, MD, PhD
a
Abstract
Background: Lactobacillus paracasei and Glycyrrhiza glabra have been reported as having beneficial effects on Helicobacter
pylori infection. We aimed to assess the efficacy and safety of fermented milk containing L paracasei HP7 and G glabra in patients
with H pylori infection.
Methods: This multicenter, prospective, randomized, double-blind, placebo-controlled clinical trial was conducted in 2 hospitals
from April to December 2017. Patients with H pylori infection were randomized into either the treatment group (fermented milk with L
paracasei HP7 and G glabra) or placebo group (fermented milk only) once daily for 8 weeks. The primary endpoint was the gastric
load of H pylori measured by
13
C-urea breath test (UBT). Secondary endpoints were histologic and clinical improvement.
Results: A total of 142 patients were randomly allocated to the treatment (n =71) or placebo groups (n =71). Compared to baseline
data, the quantitative value of
13
C-UBT at 8 weeks was significantly reduced in the treatment group (from 20.8 ±13.2% to 16.9 ±
10.8%, P=.035), but not in the placebo group (P=.130). Chronic inflammation improved significantly only in the treatment group
(P=.013), whereas the neutrophil activity deteriorated significantly only in the placebo group (P=.003). Moreover, the treatment
group had significant improvement in gastrointestinal symptoms (P=.049) and quality of life (P=.029). No serious adverse events
were observed.
Conclusion: The combination of fermented milk containing L paracasei and G glabra reduced H pylori density and improved
histologic inflammation. However, their mechanisms of action should be elucidated in further studies.
Abbreviations: CLO =Campylobacter-like organism, EPS =extracellular polysaccharide, GC =greater curvature, GSRS =
gastrointestinal symptom rating scale, ITT =intention to treat, LC =lesser curvature, PPI =proton pump inhibitor, QOL =quality of
life, UBT =urea breath test, WHOQOL =World Health Organization Quality of Life.
Keywords: fermented milk, Glycyrrhiza glabra,Helicobacter pylori,Lactobacillus paracasei, probiotics
1. Introduction
Helicobacter pylori is a gram-negative spiral-shaped microaer-
ophilic bacteria colonizing the human gastric epithelial cell with
more than 50% prevalence and is associated with gastric
malignancy as well as chronic atrophic gastritis and peptic
ulcer.
[1–3]
The 1st-line standard regimen used for the eradication of
H pylori infection iscomposed of 2 antibiotics and 1 proton-pump
inhibitor (PPI).
[4]
Unfortunately, this triple therapy has limited
efficacy because of antibiotic resistance of the pathogen and poor
compliance dueto adverse effects.
[5]
A large number of studies have
been conducted to identify the optimal regimen for H pylori
eradication; however, its success rate still remains challenging.
Even though several studies have evaluated the effects of
supplementation with probiotics or alternatives along with
standard triple regimen in Hpylorieradication,
[6,7]
no studies
showed a beneficial effect in patients with Hpyloriinfection.
Gut microflora may be involved in the pathophysiology of
various diseases through immunoregulatory function.
[8,9]
Dys-
biosis, that is, imbalance between the protective and harmful gut
Editor: Amin Talebi Bazmin Abadi.
JMC and SSH contributed equally to this work as corresponding authors.
The authors have no funding and conflicts of interest to disclose.
a
Department of Internal Medicine, Division of Gastroenterology, Kyung Hee
University Hospital at Gang Dong, Kyung Hee University School of Medicine,
b
Division of Gastroenterology, Vievis Namuh Hospital,
c
Department of Medicine,
Graduate School, Kyung Hee University, Seoul, Korea.
∗
Correspondence: Jae Myung Cha, Department of Internal Medicine, Kyung Hee
University Hospital at Gangdong, Kyung Hee University School of Medicine, 892
Dongnam-ro, Gangdong-gu, Seoul 05278, Korea (e-mail: drcha@khu.ac.kr);
Seong Soo Hong, Vievis Namuh hospital, 627, Nonhyeon-ro, Gangnam-gu,
Seoul 06117, Korea (e-mail: sshong@vievisnamuh.com).
Copyright ©2019 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Medicine (2019) 98:35(e16601)
Received: 6 February 2019 / Received in final form: 1 July 2019 / Accepted: 3
July 2019
http://dx.doi.org/10.1097/MD.0000000000016601
Clinical Trial/Experimental Study Medicine®
OPEN
1

microbiome, could lead to stimulation of inflammatory response,
dysfunction of the intestinal epithelium, and increased perme-
ability of the mucosa. Therefore, probiotic supplementation
might be useful for the management of inflammatory conditions.
Recently, probiotics have been added in the treatment of H pylori
infection, as it might reduce the adverse effects of antibiotics and
improve the success rate of H pylori eradication.
[8,10,11]
Of these
probiotic strains, the genera Lactobacillus has been the most
frequently investigated for the anti-H pylori activity in animal
studies.
[12,13]
The genus Lactobacillus can produce extracellular
polysaccharides (EPSs),
[14]
which modulate the host’s immune
response by either stimulating or suppressing the response in
inflammatory disorders.
[15]
Lactobacillus paracasei, which is one
of the representative Lactobacillus strains producing large
amounts of EPS,
[16]
has demonstrated positive effects on health
and disease in many clinical trials,
[17–26]
such as improvement of
symptoms in gastroenteritis,
[18–20]
colonic diverticulitis,
[21,22]
or
irritable bowel syndrome
[23]
and lowering of serum triacylgly-
cerol level.
[24,25]
Currently, L paracasei has been widely used as a
single probiotic or in combination with other prebiotics.
[26]
Glycyrrhiza glabra (licorice) has been traditionally used as a
herbal medicine in various countries for many years.
[27,28]
G
glabra has been reported for various clinical effects, such as
antiinflammatory, antimicrobial, antiviral, antiprotozoal, anti-
oxidative, hepatoprotective, anxiolytic, and even antitumor.
[29]
Furthermore, a root extract of G glabra is also reported to have
favorable gastrointestinal effects, such as antiulcer activity,
gastric epithelial cell protection, and gastrointestinal motility
regulation.
[30–32]
In vitro, aqueous extract of G glabra suppressed
H pylori activity through inhibiting the adhesion of H pylori to
the gastric cells.
[33,34]
In this study, we aimed to assess the efficacy and safety of
fermented milk containing L paracasei HP7 and G glabra in
patients with H pylori infection with a randomized, double-blind,
placebo-controlled trial.
2. Materials and methods
2.1. Study population
Patients between the ages of 19 and 70 years were eligible, if they
were confirmed with H pylori infection by
13
C-urea breath test
(UBT), Campylobacter-like organism (CLO) test, or histologic
examination (Giemsa or hematoxylin and eosin stain) within 1
year. Patients were excluded if they had used nonsteroidal
antiinflammatory drugs, corticosteroids, antimicrobials, acid-
suppressing medications (such as PPIs and H2-blocker), bismuth
compounds, or probiotics <2 weeks before the screening visit;
had current active gastric or duodenal ulcer; had previous gastric
malignancy; had alarm signs (e.g., abnormal weight loss,
hematochezia, anemia, or significant bowel habit changes);
had lactose intolerance; had uncontrolled comorbidity; were
pregnant or breastfeeding; or were drug users or alcoholics. All
enrolled patients received comprehensive information about this
study, and informed consent was obtained before any study-
related processes began. The study protocol was reviewed and
approved by the institutional review board of our hospital
(KHNMC IRB 2017-02-003).
2.2. Study design
This multicenter, prospective, randomized, double-blind, place-
bo-controlled clinical trial was conducted at Kyung Hee
University Hospital and Vievis Namuh Hospital from April to
December 2017. After screening of the inclusion and exclusion
criteria, enrolled patients were assigned with consecutive
allocation numbers, which were matched at a 1:1 ratio to a
randomization code through a table of random numbers.
Subjects were randomized into either the treatment group
(fermented milk with L paracasei HP7 and G glabra) or placebo
group (fermented milk only) once daily for 8 weeks. The status of
H pylori infection was determined by
13
C-UBT, CLO test, and
histopathologic examination by gastric biopsy just before intake
of study products and at 8 weeks after completion of
administration. The participants, nurses, and researchers in-
volved in this study were blinded to the interventions until the
final database lock.
2.3. Study products and compliance
The study product was 1 bottle (150 mL) of fermented milk with
or without probiotics and licorice extract. The study product
contained 1.0 10
6
CFU/mL L paracasei HP7 KCTC 13143BP
as probiotics and 100 mg licorice extracted from deglycyrrhizi-
nated roots and rhizomes of G glabra developed by Korea Yakult
Co, Ltd (Seoul, South Korea). The placebo was prepared using
the same ingredients, but without the L paracasei HP7 KCTC
13143BP and G glabra, and had identical packaging to that of the
study product in the treatment group. One bottle (150mL) of the
study product was taken once daily at the same time every
morning. During the study period, patients recorded the time of
study product intake and adverse events in daily diaries. All
unused products had to be returned to the study site, and
compliance was calculated at 4- and 8-week follow-up visits.
Poor compliance was defined as taking an average of <75% of
bottles.
2.4. Assessments and study endpoints
The primary endpoint was the gastric load of H pylori assessed on
the 8th week. Gastric load of H pylori was quantified using
13
C-
UBT.
13
C-UBT was performed after 4 hours of fasting using the
UBT kit (Crystal Life Science, Bundang, South Korea). The 50-mg
13
C-urea was dissolved in water and then administered orally.
Baseline and 30-minutes breath samples were assayed with an
infrared spectrometer that produced computer-generated results.
Positive results were defined as a computer-generated d
13
CO
2
value ≥2%, and negative results as <2%.
[35]
The secondary
endpoints were histopathologic improvement assessed by the
Sydney grading system, negative conversion of H pylori by the
CLO test, and clinical improvement by 2 self-administered
questionnaires.
[36–38]
This Sydney grading system categorized
gastritis according to intensity of neutrophil activity, chronic
inflammation by mononuclear inflammatory cellular infiltrates,
mucosal atrophy, intestinal metaplasia, and H pylori density
(no=0, mild =1, moderate =2, severe =3).
[36,39]
Four biopsy
specimens were taken from both the lesser curvature (LC) and
greater curvature (GC) sites of the antrum and corpus for
histopathologic examination.
[40]
Four scores at each site were
summed up and ranged from 0 to 12 points. To assess clinical
improvement, gastrointestinal symptom rating scale (GSRS) and
World Health Organization Quality of Life Assessment Instru-
ment (WHOQOL)-BREF questionnaires were used.
[37,38,41]
The
GSRS questionnaire includes 15 questions, which assess severity
of gastrointestinal symptoms using a 4-point Likert scale, from 0
Yoon et al. Medicine (2019) 98:35 Medicine
2

to 3, in 5 domains: indigestion, diarrhea, constipation, abdomi-
nal pain, and reflux.
[37]
The symptom severity reported in the
GSRS increases with increasing score. The WHOQOL-BREF has
26 items divided into 4 factor structures that include physical
health, psychologic, social relationship, and environmental
domains to measure a person’s quality of life (QOL).
[38,41]
2.5. Statistical analysis
The sample size was calculated assuming 2.91% quantitative
change of
13
C-UBT as the primary endpoint in the treatment
group and 0.78% in the placebo group based on a previous
study conducted under a similar setting.
[42]
We estimated that a
sample size of 56 subjects per group would have a statistical
power of 80% and a 2-sided a-risk of 0.05. We planned to enroll
70 subjects in each group, assuming a 20% dropout rate. Efficacy
was assessed by per protocol analysis and safety by intention-to-
treat (ITT) analysis. The ITT analysis included all participants
who had taken at least 1 dose of study drugs.
In comparing the demographic factors between the 2 groups,
continuous variables were analyzed using Student t-tests and
categorical variables using Chi-squared or Fisher exact tests. To
assess the quantitative changes of primary and secondary
endpoints before and after the study period in both groups,
paired t-tests were performed. To evaluate values between the 2
groups at each time point, Student t-tests were used. All statistical
tests were 2 sided, and a P-value <.05 was considered statistically
significant. All statistical analyses were performed using the SAS/
STAT software (SAS 9.4; SAS Institute, Cary, NC).
3. Results
3.1. Baseline characteristics
A total of 253 subjects were invited to participate in the study,
and 111 subjects were ineligible as they did not meet the inclusion
criteria. A total of 142 subjects consented and were enrolled in the
study and then randomly allocated to the treatment group (n =
71) or placebo group (n =71). After allocation, eight subjects in
the treatment group were excluded because of prohibited
medication use (n =2), consent withdrawal (n =2), newly
confirmed pregnancy (n =1), adverse event (n=1), and poor
compliance (n =2). Six subjects in the placebo group were also
excluded because of prohibited medication use (n =3), newly
detected gastric ulcer on gastroscopy (n =2), and poor compli-
ance (n =1). Finally, 128 subjects (treatment group, n =63;
placebo group, n =65) were analyzed (Fig. 1). For the baseline
characteristics of the participants, age, sex, smoking, alcohol,
occupation, and comorbidity were not different between the 2
groups (Table 1).
Figure 1. Patient flow diagram.
Yoon et al. Medicine (2019) 98:35 www.md-journal.com
3

3.2. Histologic efficacy analysis
Compared to baseline data, the quantitative value of
13
C-UBT at
8 weeks was significantly reduced in the treatment group (from
20.8 ±13.2% to 16.9 ±10.8%, P=.035), but not in the placebo
group (from 19.1±12.7% to 16.9 ±11.8%, P=.130) (Table 2).
However, no significant difference was observed between the 2
groups at baseline and 8 weeks. Two patients in the treatment
group and 1 in the placebo group converted to negative status of
H pylori infection measured by
13
C-UBT after 8 weeks of
administration, which was not significant (P=.616).
After 8 weeks of intervention, H pylori density on histologic
examination showed no significant difference within and between
groups in the total score of the Sydney classification (Table 2). In
the subgroup analysis, severe inflammation (grade 3) decreased in
the treatment group at the antrum/GC, antrum/LC, and body/GC
(Fig. 2). However, severe inflammation (grade 3) rather increased
in the placebo group at the antrum/GC, antrum/LC, body/GC,
and body/LC (Fig. 2). In chronic inflammation judged from
infiltration of inflammatory cell, the degree of inflammation
improved significantly in the treatment group (P=.013), but not
in the placebo group. The neutrophil activity deteriorated
significantly in the placebo group (P=.003), but not in the
treatment group. There was no significant alteration in mucosal
atrophy and intestinal metaplasia in both groups (Table 3).
3.3. Clinical efficacy analysis
Overall gastrointestinal symptoms measured by GSRS improved
significantly in the treatment group (from 2.6 ±3.9 to 1.9 ±2.6,
P=.049), but not in the placebo group (from 3.2 ±3.4 to 2.4 ±
2.8, P=.106) (Table 4). In the WHOQOL-BREF, the QOL score
was significantly better in the physical health domain of the
treatment group (P=.029); however, the QOL scores were not
significantly improved in the psychologic, social relationship, and
environmental domains. There was no significant improvement
in all four domains of the placebo group. However, between the
treatment and placebo groups over the study period, no
significant differences were found for clinical symptoms
measured by the GSRS and WHOQOL-BREF.
3.4. Safety and tolerability
Adverse events developed in five patients (7.0%) in the treatment
group (n =71) and in 6 (8.5%) in the placebo group (n =71)
without significant difference (P=.771) (Table 5). Common
adverse events were minor infection/inflammation (5.6%),
gastrointestinal disorders (4.2%), dermatologic disorders
(2.8%), and others (2.8%), without significant difference
between the 2 groups. All adverse events were mild in intensity
without serious events, but one patient in the treatment group
abandoned this trial because of allergic contact dermatitis, which
has no direct association with this trial. The mean compliance
rate was 98.2 ±3.2% in the treatment group and 97.8 ±4.5% in
the placebo group (P=.509). Two patients in the treatment group
and 1 patient in the placebo group showed poor compliance,
defined as <75% intake rate (P=.509).
4. Discussions
The effects of probiotic supplementation along with the standard
triple regimen have been evaluated in the management of H
pylori.
[43]
Although several studies have reported the anti-H
pylori activity of Lactobacillus alone in vitro or in experimental
models, few human studies have evaluated their effects.
[44–47]
In
the present study, the beneficial effect of fermented milk
containing L paracasei HP7 and herbal extract (G glabra) for
8 weeks was evaluated as single agent in patients with H pylori
infection. We showed reduction in H pylori urease activity and
gastric inflammation only in the treatment group. In our study,
severe inflammation significantly decreased and the degree of
chronic inflammation significantly ameliorated only in the
treatment group. Higher density of H pylori in the gastric
mucosa is related to more severe gastritis and increased incidence
of peptic ulcers; therefore, reduction of the density may suppress
the development of pathologic conditions in the gastric
mucosa.
[48]
Furthermore, our combination regimen also led to
clinical improvement in gastrointestinal symptoms and QOL.
Table 1
Baseline characteristics of the study subjects in the treatment and
placebo groups.
Treatment group (n =63) Placebo group (n =65) P-value
Age 45.5 ±10.5 47.8 ±11.8 .264
Sex, n (%)
Male 14 (22.2) 13 (20.0) .758
Female 49 (77.8) 52 (80.0)
Marriage, n (%)
Yes 57 (90.5) 59 (90.8) .955
No 6 (9.5)) 6 (9.2)
Smoking, n (%)
No 58 (92.1) 63 (96.9) .227
Yes 5 (7.9) 2 (3.1)
Alcohol, n (%)
No 43 (68.3) 46 (70.8) .874
Social 17 (27.0) 17 (26.2)
Heavy 3 (4.8) 2 (3.1)
Occupation, n (%)
Yes 35 (55.6) 36 (55.4) .984
No 28 (44.4) 29 (44.6)
Comorbidity, n (%)
No 52 (82.5) 47 (72.3) .167
Yes 11 (17.5) 18 (27.7)
Table 2
Efficacy analysis for viral load of the Helicobacter pylori infection
before (0 week) and after (8 weeks) the treatment.
Treatment group
(n =63)
Placebo group
(n =65) P-value
∗
13
C-UBT
0 wk 20.80±13.20 19.06 ±12.65 .447
8 wks 16.98 ±10.76 16.94±11.80 .985
P-value
†
.035 .130
Density of H. pylori on
histologic examination
0 wk 10.46±1.77 9.75 ±2.49 .066
8 wks 10.06 ±2.21 10.14 ±2.28 .851
P-value
†
0.206 .182
UBT =urea breath test.
∗
Independent t-test.
†
Paired t-test.
Yoon et al. Medicine (2019) 98:35 Medicine
4

Therefore, our study product may have a beneficial effect in
patients with H pylori infection, as it reduced H pylori density
detected by the quantitative assessment and improved histologic
inflammation, even though it failed to eradicate H pylori.
The main pathogenesis of inflammation induced by H pylori is
characterized by neutrophil infiltration into the epithelial cell
layer.
[49]
Interleukin (IL)-8 is known as a key modulator, which
initially leads to the migration and activation of neutrophils in H
pylori-infected gastric epithelium.
[50]
After IL-8 expression, local
release of proinflammatory cytokines and chemokines also
induced recruitment of monocytes and lymphocytes and
increased H pylori attachment to the surface of the gastric
epithelium.
[50,51]
Persistent inflammatory process caused by
chronic H pylori infection might bring about mucosal damage,
such as atrophic change, intestinal metaplasia, ulcer, and even
cancer.
There is no golden standard in measuring H pylori load;
however,
13
C-UBT has been used as a quantitative assessment of
H pylori density. In previous studies, H pylori load was measured
indirectly by the UBT, because the bacterial urease activity is
correlated with values of UBT.
[52,53]
Therefore, in our study, a
Table 3
Histopathologic analysis of Helicobacter pylori infection before (0
week) and after (8 weeks) the treatment.
Treatment group
(n =63)
Placebo group
(n =65) P-value
∗
Neutrophil activity
0 wk 3.41 ±2.38 2.72 ±2.23 .093
8 wks 3.41 ±2.24 3.77 ±1.85 .328
P-value
†
1.000 .003
Infiltration of inflammatory cell
0 wk 10.37±1.46 10.14 ±1.53 .393
8 wks 9.81 ±1.50 9.95 ±1.72 .614
P-value
†
.013 .361
Mucosal atrophy
0 wk 1.08 ±1.64 1.05 ±1.64 .909
8 wks 0.97 ±1.49 0.94 ±1.35 .906
P-value
†
.663 .649
Intestinal metaplasia
0 wk 1.02 ±1.86 1.12 ±2.38 .778
8 wks 1.10 ±1.79 0.91 ±1.77 .552
P-value
†
.604 .256
∗
Independent t-test.
†
Paired t-test.
Figure 2. The proportion (%) of Helicobacter pylori density divided by the Sydney classification on histopathologic examination at the (A) antrum/greater curvature
(GC), (B) antrum/lesser curvature (LC), (C) body/greater curvature, and (D) body/lesser curvature before (0 week) and after (8 weeks) the treatment.
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5

decrease in UBT values in the treatment group could reflect a
decrease in the H pylori bacterial load. H pylori load may be
clinically important, as Tokunaga et al reported that the higher
the increase in H pylori density, the greater the risk of H pylori-
associated disease.
[54]
In contrast, we failed to show significant
change in H pylori load measured by histopathologic examina-
tion. However, unequal distribution of H pylori in the gastric
mucosa might make histopathologic examination less reliable
than UBT in the measurement of H pylori density.
[55]
The role of probiotics in the treatment of H pylori infection has
been more widely known as a supplement to standard regimens
than as a main therapy.
[10,11,56,57]
Currently, there are several
clinical trials on probiotics alone to identify their anti-H pylori
effect, as it may have beneficial effects on gastric H pylori through
several possible mechanisms.
[10,11]
Probiotics may prevent
colonization of H pylori by competing with H pylori for
adhesion to the epithelium, strengthen gastric mucosal barrier by
synthesizing antimicrobial compound, and stimulate mucin
production.
[58–60]
Probiotics also reduce gastric activity and
regulate the balance between proinflammatory and antiinflam-
matory cytokines.
[13,61]
Most effective strain of probiotics has
not been determined yet for the management of H pylori
infection, but Lactobacillus species showed proven efficacy
because they are resistant to acidic environment, pancreatic
enzyme, and bile salts and release lactic acid inhibiting the
adhesion of H pylori to the cells.
[43,62–64]
In our study, L
paracasei was used because it can produce a remarkable amount
of lactic acid, which is regarded as the origin of anti-H pylori
activity,
[65]
and has better immunomodulatory function in
preventing intestinal inflammation than L plantarum or L
rhamnosus.
[16,66]
Furthermore, L paracasei inhibited the eleva-
tion of IL-8 and regulated upon activation, normal T-cell
expressed and presumably secreted (RANTES) released from the
H pylori-infected gastric epithelium.
[62,67]
In our study, severe inflammation (grade 3) improved
dominantly in the antrum than in the corpus of the stomach
after the 8-week treatment, which was consistent with previous
findings where probiotics improved H pylori-induced histopath-
ologic features predominantly in the antrum.
[68]
The gastric
antrum is a major colonization site of H pylori as there are few
acid-secretory parietal cells
[48]
; therefore, probiotics may have
more beneficial effects in H pylori infection in the antrum than the
body. The gut microbiome may be altered by a standard regimen
for H pylori eradication including high-dose PPI and 2
antibiotics.
[10]
Previous meta-analysis about the role of probiotics
in the H pylori eradication demonstrated that overall adverse
effect rates significantly decreased with probiotics combination
by stabilizing or restoring gut microflora.
[6]
In our study, general
gastrointestinal symptoms measured by GSRS and QOL
measured by WHOQOL-BREF improved significantly in the
treatment group compared with those in the placebo group,
which may be explained by the beneficial effect of probiotics on
gut microbiota.
Glycyrrhiza glabra, commonly known as licorice, has been
traditionally used to treat patients with peptic ulcers in Oriental
medicine
[27]
and showed anti-H pylori and antiulcer activities in
in vitro studies.
[30,33,34,69]
Aqueous extract from the roots of this
plant was also reported to suppress H pylori activity through
antiadhesion effects of H pylori to the gastric epithelium and
antioxidative effects against gastric mucosal injury.
[31,33,69]
These results recently led to produce a commercial compound,
namely GutGard, a flavonoid-rich root extract of G gla-
bra.
[42,69,70]
Puram et al reported a 48% (24/50 subjects) H
pylori eradication rate in patients taking 150 mg GutGard alone
for 60 days compared with only 2% (1/50 subjects) H pylori
eradication rate in the placebo group measured by
13
C-UBT.
[42]
In our study, no eradication occurred in both treatment and
placebo groups; however, H pylori bacterial load was decreased
in the treatment group only. Further study is necessary to validate
our findings as we used less dose of G glabra than that in the
GutGard study.
[42]
There were several limitations in this study. First, we could not
evaluate the individual effect of probiotics or licorice because we
Table 4
Clinical efficacy analysis before (0 week) and after (8 weeks) the treatment.
WHOQOL-BREF score
Group GSRS score Physical health domain Psychologic domain Social relationship domain Environmental domain
Treatment (n =63)
0 wk 2.57 ±3.92 25.92 ±3.77 21.00 ±3.78 10.76 ±1.92 28.13 ±5.24
8 wks 1.87±2.56 26.70 ±4.25 21.13 ±4.16 10.62±1.86 28.60 ±5.06
P-value .049 .029 .684 .443 .253
Placebo (n =65)
0 wk 3.20 ±3.41 25.45 ±4.30 20.42 ±3.52 10.25 ±1.71 26.74 ±4.56
8 wks 2.43±2.79 25.72 ±3.79 20.62 ±3.34 10.35±1.58 26.88 ±4.34
P-value .106 .347 .481 .447 .697
GSRS =gastrointestinal symptom rating score, WHOQOL-BREF=World Health Organization Quality of Life Assessment Instrument-BREF.
Table 5
Adverse events reported over the entire treatment period through
intention-to-treat analysis.
Treatment group
(n =71)
Placebo group
(n =71) P-value
Infection/inflammation, n (%) 2 (2.8) 2 (2.8) 1.000
Gingivitis 1 (1.4) 0 (0.0)
Myalgia 1 (1.4) 0 (0.0)
Common colds 0 (0.0) 2 (2.8)
Gastrointestinal disorder, n (%) 0 (0.0) 3 (4.2) .245
Gastric ulcer 0 (0.0) 1 (1.4)
Nonulcer dyspepsia 0 (0.0) 1 (1.4)
Acute gastroenteritis 0 (0.0) 1 (1.4)
Dermatologic disorder, n (%) 2 (2.8) 0 (0.0) .496
Contact dermatitis 1 (1.4) 0 (0.0)
Nail dystrophy 1 (1.4) 0 (0.0)
Others, n (%) 1 (1.4) 1 (1.4) 1.000
Foot fracture 0 (0.0) 1 (1.4)
Mild thrombocytopenia 1 (1.4) 0 (0.0)
Yoon et al. Medicine (2019) 98:35 Medicine
6

did not perform a clinical trial to evaluate each of its efficacy.
Second, we found only significant interval change in the
intragroup analysis, but not in the intergroup analysis. This
discrepancy may be explained by insufficient duration of therapy
or the relatively small dosage. Previous studies reported that
efficacy of probiotics could vary according to the duration of
therapy; however, the optimal duration of therapy is still
uncertain.
[71,72]
Third, we did not assess intestinal microbiome
analysis results after administration of the study product. If fecal
microbiome analysis is conducted, more information on altered
composition by supplying L paracasei and G glabra can be
gained. Lastly, we did not evaluate the effect of this combination
as an adjunctive agent on improving H pylori eradication rates
and ameliorating adverse events associated with the standard
regimen. Furthermore, the role of this mixture in the prevention
of clinical consequences related to H pylori infection requires
further evaluation.
In conclusion, the combination of fermented milk containing L
paracasei and G glabra reduced H pylori density and improved
histologic inflammation. However, their mechanisms of action
should be elucidated, and their role in the prevention of clinical
consequences related to H pylori infection requires further
evaluation.
Author contributions
Conceptualization: Jae Myung Cha.
Data curation: Jin Young Yoon, Hyung Kyung Kim.
Formal analysis: Jin Young Yoon.
Investigation: Hyung Kyung Kim, Min Seob Kwak.
Methodology: Jung Won Jeon.
Resources: Min Seob Kwak, Jung Won Jeon, Hyun Phil Shin.
Supervision: Jae Myung Cha, Seong Soo Hong.
Writing –original draft: Jin Young Yoon.
Writing –review & editing: Jae Myung Cha.
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