Recently, I was asked to prepare a blogpost for pharmacists. What an amazing opportunity! However, I must warn you: I like to talk. A lot.
Many years ago, I was tasked to prepare a series of CCCEP-approved lectures for pharmacists and present them across Canada. I was traveling from Vancouver to Calgary to Toronto to Halifax, educating about the use of probiotics. At that time, in 2008, probiotics were still very much a mystery for us pharmacists. Research into probiotics was just starting to take off.
The medical community was slowly starting to understand that good bugs in our guts will determine our overall health. They'll make us feel good or feel bad. They'll make us urgently look for all available washrooms wherever we go, or allow us to enjoy life. They might change how we absorb certain foods, nutrients, and vitamins; they might also affect how some medications will work, and much more.
Before 2008 I was, as a ‘well-educated pharmacist’, telling my patients, “When you take antibiotics, why don't you take some yogurt!” What did I know? We never got any training on probiotics. We never even talked much about good bugs in our gut, we even used to call it ‘flora’ or ‘gut flora’ - like flowers! This is very wrong and now obsolete terminology.
Following the series of lectures in 2008, a common theme emerged: everyone was excited yet still very confused. Feedback from all sessions was excellent and overwhelmingly positive, but even so, pharmacists needed help on how to translate this newly-found, amazing, exciting knowledge into practical advice for their patients. “How would I communicate to patients that these bugs are good, but they have to be specific when selecting them?” As a result of that feedback, I was asked to prepare a handout. We, pharmacists, love handouts. We love tabulated references, we are always looking for a guide or reference. We like to have lots of details in it, but we also like to have it presented in a practical way.
What happened next? I prepared a one-page handout with two small tables comprising nine products available commercially, with all references actually fitting on one page.
This was the very first Probiotic Chart, a guide we named the ‘Clinical Guide to Probiotic Products Available in Canada’. Such a very serious name for such a small table. This guide was sent out to pharmacists as a follow-up to the cross-Canada lectures. I thought to myself: This is it, people will learn from it, and then they'll continue looking for more information as it becomes available or published. I am done. How very wrong I was….
Working on this probiotic project in 2008, I had very limited objectives: to look at what is the evidence for probiotics in patients with irritable bowel syndrome, and if probiotics can help babies with colic. Not really life-threatening, yet dramatically life-altering conditions. At that time there wasn't much research available, and we did not have many products available on our pharmacy shelves from which to choose.
Following the publication of this initial Guide in 2008, I was overwhelmed with the feedback coming from not only pharmacists, but nurses, dietitians, physicians, and other HCPs. My fellow pharmacists shared this tool with other healthcare providers and now people were sending comments, asking for updates. They were asking about specific products they had seen on the shelf or heard about. They were asking me to expand some of the indications, others were challenging why I assigned such and such indication to a specific product when it doesn't say that on the label. It became apparent that there were still lots of learning gaps and a huge need to have a clinically applicable, practical tool in the hands of healthcare providers to assist patients in navigating this confusing field.
In the years following the initial publication, I teamed up with a group of amazing colleagues (knowledge leaders and specialists in this field) and together we started an initiative of annual updates to this clinical tool. We still call it Clinical Guide to Probiotic Products. However, we continued to look very seriously into the specificity of the strain (or combination of stains) present in each product, then found what specific clinical studies this product/strain was used in, and reviewed the outcome of the study. Clinically relevant outcomes of a study would help us determine the expected benefit for patients. Finally, we would match the indication and recommendation to a commercially available product (listing a brand name) available on the market at that time. All of this data was fully referenced, though not all the studies we reviewed would be listed; only studies that are favourable, supporting the listed indication, were included as references in the guide.
The project we started in 2008 has been expanding over the course of more than a decade.Every year we get more data to review, some years we need to have numerous meetings with our reviewers, many discussions, and occasional disagreements until we reach consensus and agree on the changes to be implemented in the next edition of the Guide. We have become very proud of our efforts, and we also became aware of how much it actually helps healthcare providers in assisting their patients.
In 2015 the Guide expanded beyond Canadian borders. We started preparing and annually updating the US version of the guide, and interest in this clinical guide has been spreading like wildfire. At the same time, we got lots of feedback from healthcare professionals who are using it. The feedback is mostly positive, but we also get challenged; we receive suggestions and we learn from them. This is also why this project has been changing and expanding year after year, to add different kinds of indications.
In the past decade, things have been shifting worldwide: the research looking into the potential benefits of good bacteria in our guts and beyond the gut, has been exploding, with the number of published studies growing exponentially year after year. At the same time, interest in purchasing and using probiotics to improve health outcomes is also on the rise. Market offerings are numerous and products are popping up everywhere. Everybody is making a probiotic product, everyone wants to get on the bandwagon, everyone wants to get in on the profit when it comes to probiotic market. This can lead to irresponsible marketing promises, shiny labels that do not contain any live bacteria. That is why only probiotic products with scientific, peer-reviewed evidence are even considered for the Guide.
There is also a personal component to my commitment to the Guide. One of the things I do as a clinical pharmacist is to make an impact in a patient’s life, whether it is to help my patients lower their blood pressure or to improve their glucose control. Those patients may be grateful, but they never tell me that. No one ever told me, “Hey, I just wanted to thank you for helping me lower my A1c!” On the other hand, I have had numerous patients send me thank you cards, give me hugs, tell me, “Thank you for saving my life,” and those are patients that have suffered symptoms of IBS for years and have tried absolutely everything. They have had little or no benefit from most interventions until they tried a specific and evidence-based probiotic for their symptoms. Another example is when you hear from those young parents. After many sleepless nights with a colicky baby, they might stop by and say, “Thank you for recommending that probiotic for colic. Baby is so much calmer now, we’re all finally getting some much-needed rest.”
Probiotics are not a magic bullet. They might not be appropriate for all patients. They are not the solution for every single problem that ails our patients, but some of the most significant and most impactful solutions can be easily obtained by using a specific probiotic under specific conditions. This is why I do hope my fellow pharmacists will think about probiotics as the first-line approach for many issues that our patients are facing. As I like to say (to whoever wants to listen), “You need to use the right probiotic, for the right person, for the right reason.”
Dragana Skokovic-Sunjic is a clinical pharmacist with Hamilton Family Health Team and a NAMS Certified Menopause Practitioner. She is also a leader in knowledge mobilization for probiotics in Canada and the United States