Yvette C. Terrie, BSPharm, RPh

Pharmacy shelves are lined with a plethora of probiotic supplements, and the selection may be overwhelming for some consumers.

In the past decade, there have been countless inquiries from consumers about the potential health benefits associated with the use of probiotic supplements, also sometimes referred to as “super” microbes.

Probiotics are “live microorganisms (eg, bacteria) that are either the same as or analogous to microorganisms found naturally in the human body and when administered in sufficient amounts may be beneficial to health,” according to the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine and the World Health Organization.

Classification of probiotics is based on the genus, species, and strain, and an array of studies have explored various strains of probiotics to ascertain potential health benefits associated with their use.

Although probiotics have documented health benefits outside the gastrointestinal (GI) tract, digestive health remains the key benefit. Examples of potential protective effects associated with probiotics include alteration of epithelial cell cytokine production, enhancement of antiviral activity, GI barrier function, inhibition of the growth of potential pathogens, and regulation of T-cell induction.

Meta-analyses have indicated several ways that probiotics can exert health benefits, such as the treatment of certain types of constipation, diarrhea, and inflammatory diseases of the intestine. Continuing research has also provided compelling evidence regarding the role of probiotics in decreasing the incidence of some diarrheal illnesses, allowing those with lactose intolerance to better digest the sugar and lactose, and enhancing immune function.

Results from a study published in May 2013 showed that there was a moderate amount of evidence to conclude that probiotics are both effective and safe for preventing diarrhea associated with

Increased awareness of the importance of the microbes that live in the human gut has sparked a great deal of research on the microbiome and fueled a booming probiotics industry. Pharmacists can provide patients with pertinent information to make informed decisions about probiotic supplements.

showed that a daily capsule of a cocktail of probiotics may reduce both the severity and symptoms of moderate atopic dermatitis and the need for topical corticosteroids to treat symptom flare-ups in pediatric patients.

Results of another 2018 study suggest that probiotics can improve not only gut health but hepatic health as well.

Furthermore, treating patients who received antibiotics with multistrain probiotics decreases the incidence of

infections in hospital settings over time, according to the results of 2 studies published in

The results of another study showed that twice the number of adults with irritable bowel syndrome (IBS) reported improvements from coexisting depression when they took a specific probiotic compared with adults with IBS who took a placebo.

Infection Control & Hospital Epidemiology

Probiotics are often present in fermented products such as dairy products (eg, buttermilk, yogurt, and yogurt drinks), some juices, and soy beverages and plants (miso and sauerkraut), as well as in dietary supplements, which are available in a variety of forms, including capsules, powders, and tablets. In both dietary supplements and probiotic foods, the bacteria may be already present or added during food preparation.

Probiotic supplements may contain 1 or more of the species of

is the most prevalent in the human body. However, supplements on the market may contain

products are recommended for antibiotic-associated diarrhea, and

Prior to recommending the use of any probiotic supplement, pharmacists should advise patients, especially those with medical conditions, to seek advice from their primary health care provider to ascertain appropriateness. Women who are breast-feeding or pregnant should always consult their doctors before using supplements. It is important to note that though there is limited data, there are no reports of harmful effects associated with the use of probiotics in women who are breast-feeding or in late-term pregnancies.

Patients should be reminded to use products from reputable companies only and to adhere to the manufacturer’s guidelines for use and dose. Concurrent administration of probiotic supplements and any antibiotics or antifungal agents is typically not recommended, and dosing intervals of these agents should be spaced at least 2 hours apart.

Although generally well tolerated, probiotics may cause mild episodes of bloating and flatulence, which tend to decrease over time.

Adverse effects can be minimized if dosing is titrated slowly in small increments. Episodes of diarrhea have been reported within the pediatric population and should be monitored.

Patients with compromised immune systems should be advised not to use probiotics because of the potential of systemic infections, and those with serious medical conditions should be monitored closely for adverse effects while taking probiotics, according to the NIH.

Research exploring the possible benefits of probiotics is ongoing.

For more information on the clinical trials investigating the use of probiotics, visit the NIH’s clinical trials website at

clinicaltrials.gov/ct2/results?term=probiotics

Examples of probiotic supplements are shown in full article on

Probiotics: in depth. National Center for Complementary and Alternative Health website. nccam.nih.gov/health/probiotics/introduction.htm. Updated February 22, 2018. Accessed May 20, 2018.

Kale-Pradhan P, Wilhelm S. Prebiotics and probiotics. In: Krinsky D, Berardi R, Ferreri S, et al, eds.

19th ed. Washington, DC: American Pharmacists Association; 2018.

. 2010;67(6):449-458. doi: 10.2146/ajhp090168.

Probiotics. National Center for Complementary and Integrative Health website

nccam.nih.gov/health/probiotics. Updated September 24, 2017. Accessed May 20, 2018.

Najm W, Lie D. Dietary supplements commonly used for prevention. Prim Care. 2008;35(4):749-767. doi: 10.1016/j.pop.2008.07.010.

Probiotic basics. California Dairy Research Foundation website. cdrf.org/home/checkoff-investments/usprobiotics/probiotics-basics/

McQueen C. Nonbotanical natural medicines. In: Krinsky D, Berardi R, Ferreri S, et al, eds.

Washington, DC: American Pharmacists Association; 2012.

Goldenberg JZ, MA SS, Saxton JD, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children.

2013;(5):CD006095. doi: 10.1002/1465185CD006095.pub3.

Navarro-López V, Ramírez-Boscá A, Ramón-Vidal D, et al. Effect of oral administration of a mixture of probiotic strains on SCORAD Index and use of topical steroids in young patients with moderate atopic dermatitis: a randomized clinical trial.

2018;154(1):37-43. doi:10.1001/jamadermatol.2017.364.

Growing evidence that probiotics are good for your liver.

sciencedaily.com/releases/2018/04/180423085445.htm. Published April 23, 2018. Updated June 18, 2018.

Trick WE, Sokalski SJ, Johnson S, et al. Effectiveness of probiotic for primary prevention of Clostridium difficile infection: a single center before-and-after quality improvement intervention at a tertiary-care medical center [published online April 26, 2018].

Johnston BC, Lytvyn L, Lo CK, et al. Microbial preparations (probiotics) for the prevention of Clostridium difficile infection in adults and children: an individual patient data meta-analysis of 6851 participants [published online April 26, 2018].

Pinto-Sanchez MI, Hall GB, Ghajar K, et al. Probiotic Bifidobacterium longum NCC3001 reduces depression scores and alters brain activity: a pilot study in patients with irritable bowel syndrome.

. 2017;153(2):448-459.e8. doi: 10.1053/j.gastro.2017.05.003.

Articles

Probiotics: The Mighty Power of the Super Bugs in Digestive and Overall Health

Optimizing the Management and Treatment of Allergic Conjunctivitis

Senior Practice Manager with CVS Health/MinuteClinic

On completion of this activity, the participant will be able to:

Distinguish between different etiologies and differential diagnoses of allergic conjunctivitis

Differentiate between treatment options currently available for allergic conjunctivitis including mechanism of action, delivery methods, efficacy, and safety

Examine the roles of convenient health care professionals in proper patient education to improve clinical outcomes of patients diagnosed with allergic conjunctivitis

This activity is intended for advanced practice nurses, nurse practitioners, and physician assistants working in convenient care clinics.

This Continuing Education Activity is jointly provided by Dannemiller and Pharmacy Times Continuing Education.

Despite constant reminders, many individuals still underestimate the importance of taking care of their skin.

Many individuals attempt to be proactive about their overall health, but they often underestimate the importance of taking care of their skin—that is, until a dermatologic issue occurs. If you are like most people, you are always looking for better ways to take care of your skin and eyes and protect them from sun damage. Although sunburn is the most common dermatologic issue caused by excessive exposure to ultraviolet radiation (UVR), premature aging, cataracts, and wrinkles (also known as photoaging) can also result.

Moreover, studies dating back to the 1950s show a strong correlation between chronic, excessive, and unprotected sun exposure and carcinoma of the skin.

Due to the number of skin cancers diagnosed each year, it is important to understand the importance of daily sun protection and avoid excessive exposure to UVR to decrease the incidence of skin cancer, premature skin aging, and other long-term dermatologic issues.

According to the Skin Cancer Foundation, skin cancer is the most common form of cancer in the United States: more than 3.5 million cases are diagnosed every year and in 2012 alone, an estimated 76,250 individuals were diagnosed with malignant melanoma.

The foundation also reports that almost 90% of nonmelanoma skin cancers are associated with excessive exposure to UVR and up to 90% of the visible dermatologic changes commonly attributed to aging are caused by the sun.

Moreover, the foundation reports that 42% of the population gets an episode of sunburn at least once a year and that an individual’s risk of developing skin cancer may double if 5 or more episodes of sunburn are experienced at any age.

Having 1 or 2 cases of blistering sunburn during childhood may even double an individual’s chance of developing melanoma later in life.

The good news is that if detected early, melanoma can be treated and many cases of nonmelanoma skin cancers can be cured.

For additional information on the 2 types of UV rays, UVA and UVB, and how they can damage the skin, see

Although all types of skin complexions have the potential to burn or develop other UVR-induced issues due to excessive sun exposure, certain factors may increase your risk of developing dermatological issues due to sun damage. Examples include

â—— Previous skin growth caused by UVR exposure

â—— Individuals with a history of 1 or more serious or blistering sunburns

â—— Infants and children, since their skin is more sensitive than adult skin

â—— Individuals taking certain pharmacologic agents associated with photosensitivity reactions

â—— Individuals who use tanning beds or sun lamps

â—— Being exposed to the sun during peak hours (10 am to 4 pm) without using UV protection

One of your best defenses against sun damage is the routine use of topical sunscreens when outdoors. Sunscreens absorb or reflect UVA and UVB rays. Their routine use is crucial in protecting your skin from both the short- and long-term damaging effects of sun exposure, since they can decrease incidences of sunburn, premature skin aging, photodermatoses, and skin cancer.

Many studies have demonstrated that when applied correctly, sunscreen can block most of the sun’s harmful UVR and effectively protect your skin.

If you need assistance in selecting the best sunscreen product to suit your individual needs, you should always consult your health care professional. Sunscreen products are available in various forms (lotions, creams, and sprays) and sun protection factor (SPF) ranges, and can be water-resistant, as well. Many cosmetics, lip balms, and facial moisturizers also contain sunscreen. It is important to note that the higher the SPF, the more effective the product is at preventing sunburn; however, an SPF higher than 30 may not afford extra protection. Topical sunscreen products can be divided into 2 categories: chemical and physical. See

When selecting a sunscreen, you may consider several factors to find the product that best suits your needs, including cost, skin type and complexion, reasons for use, ease of use, formulation, SPF level, history of sunburn, and medication history (since some pharmacologic agents may be associated with photosensitivity reactions).

Many of these products— such as broad-spectrum sunscreens, lip balms, cosmetics, and moisturizers&mdash; contain a combination of ingredients. The Environmental Protection Agency recommends the use of a broadspectrum sunscreen with a minimum SPF of 30 even on cloudy days.

The use of sun protective clothing and sunglasses when possible is also recommended. Sunglasses should block 99% to 100% of both UVA and UVB rays and the frame should be large enough to shield your eyes, eyelids, and surrounding areas.

Sunscreens should be applied liberally to all exposed areas at least 15 to 30 minutes before sun exposure and as often as the product label recommends, or at least every 2 hours.

In general, an estimated one-half teaspoon should be applied thoroughly to each exposed area to obtain adequate coverage and protection, and sunscreen should be reapplied especially after swimming, towel drying, or excessive sweating.

If you work outdoors, it is recommended that sunscreen should be reapplied often throughout the day.

You should always use a sunscreen when outdoors, especially for extended periods of time. Despite constant reminders about avoiding overexposure to the sun, however, many individuals will still experience sunburn because they do not always use sunscreen when outdoors—especially during the summer&mdash;or they apply sunscreen incorrectly. It is important to remember that there are many ways to protect your skin against sun damage as well as to prevent and treat sunburn (Tables 3-5). You should remember that sun protection is equally important during the winter since snow reflects up to 80% of the sun’s rays, which can cause sunburn and damage to exposed skin. Because some medications such as tetracyclines, antidepressants, antihistamines, estrogens, sulfonamides, and nonsteroidal anti-inflammatory drugs can increase your risk of photosensitivity, it is important to always ask your health care professional if you are taking any medications that may cause photosensitivity.

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

1) Crosby K. Prevention of sun-induced skin disorders. In: Krinsky D, Ferreri S, et al, eds.

. 18th ed. Washington, DC: American Pharmacists Association; 2015.

2) Skin cancer facts. Skin Cancer Foundation website. www.skincancer.org/Skin-Cancer-Facts/. Updated February 9, 2015. Accessed February 20, 2015.

3) Facts about sunburn and skin cancer. Skin Cancer Foundation website. www.skincancer.org/prevention/sunburn/facts-about-sunburn-and-skin-cancer. Accessed February 20, 2015.

4) SunWise program summary. US Environmental Protection Agency website. www2.epa.gov/sunwise. Accessed February 20, 2015.

Yvette C. Terrie, BSPharm, RPh

Articles

Probiotics: The Mighty Power of the Super Bugs in Digestive and Overall Health

Optimizing the Management and Treatment of Allergic Conjunctivitis

Sun Damage: Protecting Your Skin and Eyes