As our understanding of the microbiome in patients with ulcerative colitis grows, so does the potential for more effective and personalized treatments to help improve disease control. Dr Sunanda V. Kane discusses the role of prebiotics, probiotics, synbiotics, and more in the management of the disease.

The microbiome can drive the immune system, both locally in the colon and systemically. Studies show that patients with ulcerative colitis have a microbiome with less diversity of anti-inflammatory bacterial species than patients who do not have ulcerative colitis. The question remains whether they have either an altered microbiome because they have ulcerative colitis or ulcerative colitis because they have an altered microbiome. The only way we will know the answer is through the findings of prospective studies.

We know that the microbiome is not static, changing based on disease activity, and that it can also be manipulated. When patients ask me if they should be on a probiotic, I tell them that they can probably change their microbiome if they were to take a probiotic consistently. I also encourage probiotics for patients who are having difficulty getting to full remission and for those with symptoms of gastrointestinal irritability, such as bloating or stools that might be more frequent or not quite solid. I find it hard to tell a patient with ulcerative colitis who is on therapy and has 1 formed stool per day, no bloating, and no complaints to take a probiotic because I do not know what the end goal is for that individual.

Now, determining which probiotic a patient takes should be individualized. I explain to my patients that probiotics are like perfume in that there are hundreds of options but not all of them are going to smell good on you. It is a similar idea with probiotics. There are hundreds of probiotic formulations, and certain combinations may not be tolerable for a particular patient and might cause diarrhea, bloating, or nausea, for example. If any of these happen after taking a probiotic, then you know that that is not the right one. Unfortunately, knowing what the right probiotic is takes a lot of trial and error. I give my patients a list of quality probiotics and recommend that they try each one for approximately 1 week.

People also ask me about incorporating prebiotics into their diets. A prebiotic is an entity that serves as a food source for bacteria, and fiber is a great prebiotic that can help keep the microbiome of your colon healthy. I think that the sweet spot is the combination of probiotics and prebiotics, which is called a “synbiotic.” The Mediterranean diet is, in and of itself, what I would consider a synbiotic if followed properly.

Additionally, some patients ask me about receiving a fecal microbiota transplant (FMT), but the data are all over the place. An individual’s success with an FMT might depend on the health of the donor stool. The US Food and Drug Administration (FDA) has not approved FMT for ulcerative colitis, and insurance does not cover the costs of FMT for the treatment of ulcerative colitis. There are ongoing studies, but, in clinical practice, we do not currently recommend FMT in patients with ulcerative colitis.