Probiotic Treatment in Primary Sclerosing Cholangitis (PSC)
Probiotic treatment is not recommended for the management of Primary Sclerosing Cholangitis (PSC) based on current evidence. 1
Current Evidence on Probiotics in PSC
The European Association for the Study of the Liver (EASL) clinical practice guidelines on sclerosing cholangitis (2022) evaluated the evidence for microbiome-based interventions in PSC and found insufficient support for probiotic use. A small study (n=14) with probiotics containing Bifidobacterium and Lactobacillus showed no beneficial effects on liver biochemistries, including serum alkaline phosphatase (ALP), compared to placebo after 3 months of treatment 1.
Microbiome Manipulation in PSC Management
While dysregulation of the gut microbiome (dysbiosis) may be a critical factor in the development and progression of PSC, current evidence does not support routine use of probiotics:
Antibiotics: Some antibiotics have shown promising results in small studies, particularly vancomycin, which demonstrated reduction in serum ALP and Mayo PSC risk score in limited trials 1. However, long-term antibiotic use is not recommended for PSC treatment in the absence of recurrent bacterial cholangitis 1.
Fecal Microbiota Transplantation (FMT): A pilot study of FMT in 10 people with PSC showed preliminary efficacy signals with improved bacterial diversity and ALP in a subset of patients, but this remains experimental 1.
Current Management Recommendations for PSC
The British Society of Gastroenterology guidelines (2019) and AASLD guidelines (2010) do not recommend probiotics for PSC management 1. Current established recommendations include:
Against routine use of UDCA: Both guidelines strongly recommend against ursodeoxycholic acid (UDCA) for routine treatment of PSC 1.
Against immunosuppressants: Corticosteroids and immunosuppressants are not indicated for classic PSC treatment 1.
Management of complications: Focus on managing complications such as dominant strictures, cholangitis, and portal hypertension according to established guidelines 1.
Pitfalls and Caveats
Despite theoretical benefits of targeting the gut-liver axis in PSC, evidence for probiotics remains limited and insufficient to support clinical use.
Case reports of successful treatment with probiotics 2 should be interpreted with caution as they do not provide sufficient evidence for general recommendations.
The relationship between gut microbiota and PSC is an active area of research 3, 4, 5, but currently lacks translation into validated therapeutic approaches.
Patients may seek alternative therapies like probiotics due to limited conventional treatment options for PSC, but clinicians should counsel patients about the lack of supporting evidence.
In conclusion, while the gut microbiome appears to play a role in PSC pathogenesis, current evidence does not support the use of probiotics as an effective treatment for PSC. Management should focus on established approaches to complications and monitoring for disease progression.