The problem with the probiotics or maybe the good point of probiotics is that, when you stop the probiotic, the risk comes back. All of these patients-within several weeks of stopping the probiotic-developed some signs and symptoms of pouchitis. Or I should say, a large majority of these patients did. And so the good part is that probiotics may help keep a person from redeveloping recurrent pouchitis, but the patient really needs to be taking the medication all the time. You're altering the population of bacteria in the pouch, and it's probably that bacteria-pouch interaction that's leading to the pouchitis. Once the probiotic is out of the pouch or out of the system, the normal bacteria repopulate the pouch and you're back to the same situation where you're driving a response, probably an immunologic response, to cause the pouchitis.

There are a couple of major issues with probiotics. One is that their manufacturing is variable. They don't fall under the same regulations as what we consider our drugs, our standard drugs. And so, one, you don't always know what you're getting when you buy a certain probiotic.

We don't have a lot of trial data. We have a lot of anecdotal experience. And as we know from clinical trials with drugs, is that we may see very, very good results in an uncontrolled fashion, you put it to the rigors of a clinical trial and you don't see that same benefit. So I think we're lacking in that area.

It's considered a food additive, many probiotics right now and so we don't know what else is in the probiotic. If you look at certain probiotic populations-products right now, there are some that actually are combined with lactose. And if we have a patient who's lactose-intolerant and they're taking a probiotic that has lactose in it, you may actually make the diarrhea worse.

So I think one needs to be very careful about the source of the probiotic. And as a practitioner, we should be looking for controlled trials. If we recommend these probiotics for the treatment of inflammatory bowel disease or pouchitis, we're subjecting the patients to a fairly large cost that's uncovered by their health insurance. So we need to be sure that our recommendations-this is something that is proven to be helpful as an adjunct to their therapy.