Can probiotics (Probiotic Supplements) decrease Primary Sclerosing Cholangitis (PSC) progression?

Probiotics Are Not Recommended for Decreasing PSC Progression

Based on current clinical guidelines, probiotics are not recommended for decreasing Primary Sclerosing Cholangitis (PSC) progression as there is insufficient evidence supporting their efficacy in altering disease outcomes.

Current Evidence on Probiotics in PSC

The European Association for the Study of the Liver (EASL) 2022 clinical practice guidelines strongly recommend against the long-term use of antibiotics for PSC treatment in the absence of recurrent bacterial cholangitis 1. While this recommendation doesn't directly address probiotics, it reflects the overall cautious approach to microbiome manipulation in PSC management.

A small randomized placebo-controlled crossover pilot study specifically examining probiotics in PSC patients found:

• No beneficial effects on symptoms
• No improvements in liver biochemistry or liver function
• No changes in pruritus, fatigue, or stool frequency 2

Microbiome and PSC: Theoretical Connection

The gut-liver axis has been implicated in PSC pathogenesis:

• 70-80% of PSC patients have concurrent inflammatory bowel disease (IBD), suggesting a potential gut-liver connection 3
• Dysbiosis (imbalance in gut microbiota) has been observed in PSC patients 4
• Intestinal flora diversity is reduced in PSC patients with increased abundance of potentially pathogenic bacteria 4

Despite this theoretical connection, clinical evidence for microbiome-targeted therapies remains limited.

Current Treatment Recommendations for PSC

The British Society of Gastroenterology and UK-PSC guidelines (2019) do not mention probiotics as a treatment option 1. Similarly, the American Association for the Study of Liver Diseases (AASLD) guidelines do not include probiotics in their recommendations 1.

Current management focuses on:

1. Addressing dominant strictures when present through endoscopic intervention 1
2. Managing complications such as bacterial cholangitis with appropriate antibiotics 1
3. Liver transplantation for end-stage disease, as it remains the only definitive treatment 5

Potential Future Directions

While current evidence doesn't support probiotic use, research into microbiome manipulation continues:

• Fecal microbiota transplantation is being investigated as a potential therapeutic strategy 6
• Antibiotics have shown some biochemical improvements in small studies, particularly vancomycin, though long-term benefits remain unproven 1

Important Considerations and Pitfalls

• Avoid delaying standard care: Focusing on unproven therapies like probiotics may delay appropriate management of dominant strictures or disease complications
• Monitor disease progression: Regular follow-up with liver biochemistry and imaging is essential regardless of supplementary treatments
• Consider clinical trials: Patients interested in microbiome-based therapies should be encouraged to participate in clinical trials rather than self-administering unproven treatments
• Address concurrent IBD: In patients with both PSC and IBD, optimal management of the intestinal inflammation remains important

Conclusion

While the gut microbiome likely plays a role in PSC pathogenesis, current evidence does not support the use of probiotics to decrease PSC progression. Management should focus on evidence-based approaches including monitoring for dominant strictures, managing complications, and timely referral for liver transplantation when appropriate.