REVIEW Ulcerative colitis and probiotics: An overview Irfan Ahmad Rather1, Rajib Majumder1, Fanar Hamad Alshammari1, Jae Gyu Park2 and Vivek Kumar Bajpai1* 1Department of Applied Microbiology and Biotechnology, School of Biotechnology, Yeungnam University, Gyeongsan, Gyeongbuk, Korea 2Pohang Technopark, Pohang Center for Evaluation of Biomaterials, Jigok-ro, Nam-gu, Pohang, Gyeongbuk, Korea Abstract: Ulcerative colitis is an inflammatory disease of the large intestine whose effects are bloody diarrhea, cramping and bloating. The disease is usually relapsing and remitting. However, the cause of ulcerative colitis is not yet known. Due to this reason, finding an effective treatment has been a great challenge. The suggested medical treatment is usually composed of two portions; keeping the flare up from happening and treating the flare up when it has happened. Active flare ups are treated with corticosteroids. There are several hypothesis which suggest that ulcerative colitis could be due to the micro flora present in gut. For this reason, several researchers tried to modify the gut microflora with probiotics. However, there is no probiotics found that can induce emission faster than the placebo. The ulcerative colitis patients taking probiotics showed fewer and less severe symptoms during the flare up. This means that even though the probiotics did not end up the flare up faster, it slowed up the severity of the symptoms of the patients. Keywords: Ulcerative colitis, inflammation, probiotics. INTRODUCTION important in digestion and also prevent other types of bacteria from occupying their spaces. This is the basic Ulcerative colitis (UC) is a chronic disease which is concept of the probiotics referred to as the good bacteria. characterized by diffuse inflammation of rectal and These probiotics work in different ways. First they act as colonic mucosa (Tannis 2008). The disease mainly affects barriers lining the intestinal tract where through the rectum, but extends to some parts of the large competition inhibition, they are able to prevent other intestines. The most conspicuous classical clinical sign of laminal bacteria from reaching the lamina propria and this disease is bloody diarrhea from the patients, and the stimulate mucosal immune system (Tannis 2008). The clinical course sign is a period of remission and second mechanism is by enhancing mucus production so exacerbation. The incidence of this disease has rapidly that patients have a thicker mucus layer which is increased in the developing nations (Tannis 2008). Many important in preventing invasion by bacteria. Probiotics reports confirm that there is an interaction between are responsible in altering the consistency of mucus hence genetic and environmental factors in the etiology of the changing the bacteria adherence pattern (Kabelitz 2005). disease (Potter 2004). In order to reduce mortality and The probiotics also aid in production of protective deaths, patients with this disease should be identified and immunoglobulins and protective defensins and treated early. (Potter 2004). There are many types of bacteriosins into the body lumen (Baumgart 2012). In medication available to treat mild to severe forms of UC. addition, probiotics help in altering the function of The goal of each medication is to maintain remission and mucosal immune system making it less inflammatory improve the quality of life. However, one of the serious (Lichtenstein 2014). However, it is still early to conclude concerns of all these medications is their adverse side if probiotics would be an alternative treatment for UC. effects. Therefore, finding new alternative treatments for UC have been always a new challenge. It believed that Epidemiology of ulcerative colitis UC could be due to complex interactions of gut Ulcerative colitis is the most common type of microbiome. Therefore, in past years many researchers try inflammatory disease of the bowel. In the United to modify the gut microflora with probiotics. The human Kingdom, its incidence is approximately 10 per 100,000 gastrointestinal tract is usually covered with bacteria. people per year (Wallace 2008), and prevalence is Most of the bacteria are harmless; however, some are approximated to be about 240 per 100,000 (Singleton harmful and causes infection that leads to persistent 2009). UC can develop to anybody at any age; but, its intestinal dysbiosis (Janeway et al., 2001; Parfenov and incidence peaks at the age of between 15 and 25 years, Ruchkina 2011). The bacteria in the intestines are and also between 55 and 65 years. The effects of UC are seen in both men and women equally (Wallace 2008). In *Corresponding author: e-mail: [email protected] the United State, more than 200 per every 100,000 people Pak. J. Pharm. Sci., Vol.29, No.5(Suppl), September 2016, pp.1877-1880 1877 Ulcerative colitis and probiotics: An overview are usually affected by this disease and is higher in whites Current treatment of ulcerative colitis and the Ashkenazi. Worldwide, this disease is mostly It has been seen that patients with mild to moderate distal concentrated in Europe, North America and Australia. The or left sided colitis, therapy includes oral or topical effects of this disease have increased in the developed mesalamine (5-ASA) agents or both (Baumgart 2012). countries (Singleton 2009). However, there is a difference The combination of two is more active than neither alone. in the incidence and prevalence of the disease in these This therapy maintains UC and remission and superior to regions. The incidence rate ranges from 0.5 to 31.5 per corticosteroids for distal disease. Steroid enemas are used 100, 000 people while the prevalence rate ranges from 5.3 for the active diseases; but, cannot be used in maintaining to 63.6 per 100,000 people annually (Lichtenstein 2014). remission (Kabelitz 2005). Some of the medications used This range is however higher in North America where it for these kind of patients are; sulfasalazine, olsalazine, ranges from 37.5 to 238 per 100, 00 people (Singleton balsalazide, mesalamine (pentasa, asacol, asacol HD, 2009); however, in South America the prevalence is less. liada, apriso) mesalamine suppository and mesalamine A study conducted in Puerto Rico show that the rectal suspension (Potter 2004). In addition, there are prevalence of the UC is 12.3per 100, 000 people while it number of new drugs of UC in pipeline (Table 1) and is 14.81 per 100,000 people in Brazil (Wallace 2008). many drugs have been stopped after clinical trials due to poor results. Mortality rate of people with UC was high in the first half of the twentieth century; but, currently it has greatly Probiotics for ulcerative colitis reduced due to the usage of corticosteroids and It is still assumed that UC is caused by integrative factors, sulfasalazine (Sutherland et al., 2014). Surgical such as genetic susceptibility which is an imbalance techniques have also been of great help in reducing between gastrointestinal probiotics and pathogens, an mortality rate. However, mortality rate due to UC is impairment of intestinal epithelial cells and host immune higher than the rate in the general population (Sutherland dysfunctions (Rutgeerts 1999). The human intestinal tract et al., 2014). plays host to approximately 100 trillion microorganisms, with at least 15,000-36,000 bacterial species. The The disease is more common in smokers than the intestinal microbiota is now considered to be a functional nonsmokers. It mostly affects people in the urban areas organ associated with normal physiological processes, compared to those in rural regions. This means that such as metabolism, immunological response and urbanization is a contributing factor to this infection intestinal epithelium morphogenesis. Thus, there are (Potter 2004). This is as a result of westernization of many areas of host health that can be compromised when lifestyle like change of diet, smoking, industrial the microbiota is drastically altered. Many probiotics are chemicals, pollution and difference in exposure to effective as traditional ulcerative medications like the sunlight (Martin et al., 2014). UC is more prevalent to gold-standard treatment mesalamine and have been people with white collar jobs (Wallace 2008). Many reported both had the same effects on the patients (Jewell reports showed that the use of oral contraceptives, et al., 2006). Recently, it was reported that probiotics perinatal and child infections, a typical mycobacteria suppress colitis-associated carcinogenesis (Do et al, infections among others were the other factors that 2015). However, these probiotics can influence the affected the rate of spread of the UC (Martin et al., 2014). activity of the immune cells and the cells that lines the intestines. The intestinal flora dysbacteriosis contributes Risk factors of ulcerative colitis to the pathogenesis of UC. Probiotics are nonpathogenic Genetic factors: Ulcerative disease can be hereditary. beneficial flora, which have important effects on Therefore, patient’s family or relatives could be at a maintaining the balance of intestinal flora (Onderdonk high risk of being infected. 2000). Probiotics can adjust the metabolic activity of the Environmental factors: Environmental changes such as intestinal flora and their components by preventing exposure of body with pollen, bacteria and chemicals bacterial overgrowth and by maintaining the integrity of could result in uncontrolled inflammation of the intestinal mucosal barrier, thereby adjusting and gastrointestinal tract.