What probiotics are recommended for a patient with Primary Sclerosing Cholangitis (PSC) and Ulcerative Colitis (UC)?

Probiotics for Primary Sclerosing Cholangitis (PSC)

Current evidence does not support the use of probiotics for treating PSC itself, as a randomized controlled trial showed no beneficial effects on liver biochemistry, symptoms, or liver function in PSC patients. 1

Evidence for PSC-Specific Treatment

The only randomized placebo-controlled crossover trial specifically evaluating probiotics in PSC (using a multistrain formulation containing four Lactobacillus and two Bifidobacillus strains) demonstrated:

• No significant changes in alkaline phosphatase, bilirubin, gamma glutamyl transpeptidase, or other liver enzymes 1
• No improvement in pruritus or fatigue 1
• No changes in liver function parameters (albumin, prothrombin) 1

The 2022 EASL guidelines on sclerosing cholangitis similarly found that a small study with Bifidobacterium and Lactobacillus showed no beneficial effects on liver biochemistries, including serum alkaline phosphatase, compared to placebo. 2

Management of Concurrent Ulcerative Colitis

Since approximately 90% of PSC patients have concurrent inflammatory bowel disease (particularly UC), probiotics may have a role in managing the UC component, though not the PSC itself. 1

For Active UC (Mild to Moderate Disease):

Selected probiotics can be used as an alternative to 5-ASA if 5-ASA is not tolerated:

• E. coli Nissle 1917 has been shown non-inferior to 5-ASA for maintaining remission 2
• Multistrain probiotics (particularly those containing bifidobacteria and multiple strains) demonstrated superiority to placebo in several studies 2
• VSL#3 and E. coli Nissle 1917 have the strongest evidence base supported by meta-analysis 2, 3

For UC in Remission:

• E. coli Nissle 1917 was found non-inferior to 5-ASA for maintenance of remission in one large study 2
• However, six studies found no effect of adding probiotics compared to placebo for maintaining remission 2

For Pouchitis Prevention (if applicable):

Multistrain probiotics can be considered to prevent pouchitis in UC patients who have undergone colectomy with ileal pouch-anal anastomosis. 2

• VSL#3 specifically has Grade B recommendation for primary and secondary prevention of pouchitis 2
• The 2024 AGA guidelines note that patients with PSC are at high risk for pouchitis and may consider probiotics for primary prevention, though this has not been specifically studied in PSC populations 2

Critical Caveats

Avoid Lactobacillus rhamnosus GG in acute severe colitis due to case reports of bacteremia with the administered probiotic in both children and adults. 2

Clinical Algorithm

1. For PSC liver disease itself: Do not use probiotics—no evidence of benefit 1, 2

2. For concurrent mild-moderate active UC:

   • First-line: 5-ASA therapy
   • If 5-ASA not tolerated: Consider E. coli Nissle 1917 or multistrain probiotics 2

3. For UC in remission:

   • E. coli Nissle 1917 may be considered as alternative to 5-ASA 2
   • Evidence is mixed; six studies showed no benefit 2

4. For post-colectomy with pouch:

   • Consider VSL#3 for pouchitis prevention, especially given PSC as high-risk factor 2

The bottom line: While one case report suggested benefit from combined steroid, salazosulfapyridine, and probiotic therapy 4, the only controlled trial showed no benefit for PSC itself 1. Probiotics should only be considered for managing the UC component, not for treating the PSC liver disease.