American Journal of Gastroenterology
ISSN 0002-9270
doi: 10.1111/j.1572-0241.2005.41794.x
C 2005 by Am. Coll. of Gastroenterology
Published by Blackwell Publishing
VSL#3 Probiotic-Mixture Induces Remission in Patients
with Active Ulcerative Colitis
Q1
Rodrigo Bibiloni,1 Richard N. Fedorak,2 Gerald W. Tannock,1 Karen L. Madsen,2 Paolo Gionchetti,3
Massimo Campieri,3 Claudio De Simone,4 and R. Balfour Sartor5
1
Department of Agricultural, Food and Nutritional Science; and 2 Division of Gastroenterology, University of
Alberta, Edmonton, Alberta, Canada; 3 Division of Gastroenterology, University of Bologna, Bologna, Italy;
University of L’Aquila, L’Aquila, Italy; 4 and Division of Gastroenterology and 5 Division of Hepatology,
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
BACKGROUND
AND AIMS:
Intestinal bacteria have been implicated in the initiation and perpetuation of IBD; in
contrast, “probiotic bacteria” have properties possibly effective in treating and preventing relapse of
IBD. We evaluated, the safety and efficacy of VSL#3 and the components and the composition of the
biopsy-associated microbiota in patients with active mild to moderate ulcerative colitis (UC).
METHODS:
Thirty-four ambulatory patients with active UC received open label VSL#3, 36,000 billion bacteria
daily in two divided doses for 6 wk. The presence of biopsy-associated bacteria was detected using a
nucleic acid-based method and the presence of VSL#3 species confirmed by DNA sequencing of 16S
rRNA.
RESULTS:
Thirty-two patients completed 6 wk of VSL#3 treatment and 2 patients did not have the final
endoscopic assessment. Intent to treat analysis demonstrated remission (UCDAI ≤ 2) in 53%
(n = 18); response (decrease in UCDAI ≥ 3, but final score ≥3) in 24% (n = 8); no response in 9%
(n = 3); worsening in 9% (n = 3); and failure to complete the final sigmoidoscocpy assessment in 5%
(n = 2). There were no biochemical or clinical adverse events related to VSL#3. Two of the
components of VSL#3 were detected by PCR/DGGE in biopsies collected from 3 patients in
remission.
CONCLUSION:
Treatment of patients with mild to moderate UC, not responding to conventional therapy, with VSL#3
resulted in a combined induction of remission/response rate of 77% with no adverse events. At
least some of the bacterial species incorporated in the probiotic product reached the target site in
amounts that could be detected.
(Am J Gastroenterol 2005;100:1–8)
INTRODUCTION
the sites most frequently affected by ulcerative colitis (UC)
and Crohn’s disease (8). Furthermore, enteric bacteria and
their products have been detected in the affected mucosa of
inflammatory bowel disease patients and alterations in fecal
flora of inflammatory bowel disease patients have been noted
(9–12). Clinical interventions that target bacteria affect the
progress of the UC and Crohn’s disease in different ways,
nevertheless there are few controlled studies with these interventions and the majority remain anectodal. Antibiotics
tend to be most effective in Crohn’s colitis, ileocolitis, and
pouchitis, but are less effective in UC and isolated Crohn’s
ileitis (13–15). Another method that has been suggested to
alter the bacteriological milieu of the gut involves the use
of probiotics (16, 17). Probiotics are preparations of living
microbial cells that, when ingested, are believed to influence
the composition of the gut microbiota and consequently to
benefit the health of the consumer (18, 19). Probiotics have
been shown to reduce colitis in animal models (6, 20, 21)
The intestinal microbiota has been implicated in the pathogenesis of chronic intestinal inflammation by experimental
animal and human studies (1). Rodents with dysfunctional
immune systems, which serve as models of inflammatory
bowel diseases do not develop inflammation when kept under germ-free conditions. They develop colitis when associated with gut bacteria (2, 3). Such models have shown an
increased adherence or invasion of bacteria, which precedes
the development of inflammation (4), and exhibit antigenspecific CD4+ T lymphocyte responses directed at cecal bacteria (5). This implies that commensal enteric bacteria have
a primary role in the development of colitis (6). Moreover,
bacterial species have differential abilities to induce colitis
(4–7), demonstrating that not all gut bacteria are equal in
their abilities to induce disease. In humans, it is known that
the anatomical sites of highest bacterial concentration are
1
2
Bibiloni et al.
and to help to treat acute, and maintain remission of, UC in
humans (22–28). A probiotic preparation consisting of a mixture of eight lactic acid bacterial species (VSL#3) has been
reported to be effective in preventing flare-ups of refractory
pouchitis (29, 30), as a prophylactic agent to prevent the development of pouchitis after ileo-anal pouch formation (31)
and in maintenance of remission of UC (26). In contrast to the
convincing controlled evidence for VSL#3 in prevention and
maintenance of remission the role of VSL#3 in acute active
disease remains to be determined. VSL#3 is a unique probiotic mixture that appears to have antiinflammatory activities
both with the live organism (26, 29–32) as well as thorough
its DNA (33).
The primary objective of this study was to study the proportion of patients achieving an improvement in UC activity
from baseline following 6 wk of VSL#3 therapy as measured
by the Ulcerative Colitis Disease Activity Index (UCDAI).
Additional analyses were conducted to monitor the safety of
VLS#3. Baseline and 6 wk UCDAI scores were determined
by a single experienced IBD physician at each site. The secondary objective was the detection of bacterial species contained in the VSL#3 product in association with biopsies
collected after treatment with the probiotic, and to determine whether their detection was associated with remission of
disease.
MATERIALS AND METHODS
Participants
The study was performed between June 2002 and July 2003.
Patients were eligible to participate if they were between 18
and 65 yr of age; had an endoscopic and histologic confirmed
diagnosis of UC for at least 1 yr; and had at least a 2 wk history
of active UC that had not responded to mesalamine therapy.
The following patients were not eligible: disease less than
25 cm from the anal canal, active enteric infection, evidence
of severe disease characterized by hemoglobin <8.0 g/dl,
white blood cell count >20,000 cells/mm3 , temperature
>38.5◦ C, albumin <25 g/dl, active disease >2 months, UCDAI < 2 or >9 (see description of scoring system below).
Patients with a history of dysplasia of the colon or any
cancer within 5 yr, clinically significant hematologic values
(see above) or biochemical values (serum creatinine concentrations >1.5 times the upper limit of normal or alkaline
phosphatase, aspartate aminotransferase, or alanine aminotransferase concentrations >2.5 times the upper limit of
normal) were also ineligible. Each patient provided written,
informed consent before participation. Approval for the study
protocol was granted by the appropriate institutional human
subject review board at each participating site.
Concomitant Therapy
Continued treatment with oral or rectal mesalamine, oral or
rectal corticosteroids was allowed, provided the dose had been
stable for at least 2 wk. Patients receiving stable doses of
6-mercaptopurine, or azathioprine for at least 8 wk were eligible. Patients who had received infliximab or cyclosporine
within 12 wk were not eligible. Treatment with antidiarrheal agents (loperamide, diphenoxylate, and opiates) were
allowed, provided doses remained stable during the 6-wk evaluation period. No other medications for UC were permitted.
No patient had received investigational therapies within 30
days preceding randomization.
Study Medication
VSL#3 (VSL Pharmaceuticals, Inc., Ft Lauderdale, FL)
sachets contained 900 billion viable lyophilized bacteria
consisting of four strains of Lactobacillus (L. casei, L. plantarum, L. acidophilus, and L. delbrueckii subsp. bulgaricus),
three strains of Bifidobacterium (B. longum, B. breve, and B.
infantis), and one strain of Streptococcus salivarius subsp.
thermophilus. 3,600 billion bacteria (four sachets) of VSL#3
were administered orally each day for 6 wk in two divided
doses (1,800 billion bacteria twice each day).
Interventions
The 6-wk study was an open label trial performed at three
IBD referral centers (University of Alberta, Canada, University of Bologna, Italy, and University of North Carolina at
Chapel Hill, USA). After a 1-wk screening period, eligible
patients received open label VSL#3, 3,600 billion bacteria, in
two divided doses, for 6 wk. At entry (screening visit), each
patient’s demographic characteristics, medical history, and
current medications were recorded. Disease activity was assessed at the baseline visit and after 3 and 6 wk. At each visit a
physical examination and history was performed. At baseline
and at 6 wk a sigmoidoscopy with endoscopic and histologic
assessment of the mucosa at the site of most severe disease
activity was determined. All laboratory tests were performed
at local laboratories. All adverse events were classified and
graded according to the consort dictionary criteria.
Outcome
The intention-to-treat population included all patients who
were evaluated at the screening and baseline visits and who
received at least one dose of study medication. The sole primary outcome measure, as specified in the study protocol
before initiating the study, was number of patients entering
remission (UCDAI ≤2). The secondary outcome measures
that were specified in the study protocol before initiating the
study were as follows: (1) number of patients with a response,
but not entering remission, (decrease in UCDAI ≥3 points,
but final score ≥3), (2) mean decrease in UCDAI, (3) number
of patients worsening (UCDAI increasing >3 points), and (4)
number of patients exhibiting toxic effects of the study medication. Disease activity was assessed using the previously
described UCDAI (Table 1) (34). The UCDAI is the sum of
the scores from four criteria, ranked zero to three for each
criteria, including stool frequency, rectal bleeding, mucosal
appearance, investigator’s rating of disease of activity, with a
maximum of 12 points. Disease in remission is defined as two
VSL#3 for Treatment of Ulcerative Colitis
Table 1. Ulcerative Colitis Disease Activity Index (34)
Variable
1. Stool frequency
Normal
1–2 stools/day > normal
3–4 stools/day > normal
>4 stools/day > normal
2. Rectal bleeding
None
Streaks of blood
Obvious blood
Mostly blood
3. Mucosal appearance
Normal
Mild friability
Moderate friability
Exudation, spontaneous bleeding
4. Physician’s rating of disease activity
Normal
Mild
Moderate
Severe
Score
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
or lower points. Severe disease is defined as greater than nine
points. Patients were permitted enrollment with a UCDAI of
3–9.
Extraction of Bacterial DNA from Biopsies and VSL#3
Preparation
In a subset of 11 patients mucosal biopsies were obtained at
the time of sigmoidoscopy (0 and 6 wk) from 40 cm proximal
to the anal verge. Biopsies were immediately frozen in liquid
◦
nitrogen and then stored at −80 C prior to analysis. Of the
11 patients sampled, 8 showed remission of disease, and 3
remained with active disease after 6 wk of treatment.
DNA was extracted from biopsies, the VSL#3 powder and
the individual bacterial strains that make up the VSL#3 product, as described elsewhere (35). Briefly, 15–30 mg of tissue
specimens, or 35 mg of the VSL#3 powder were incubated
with lysozyme (25 mg/ml) for 30 min at room temperature.
In the case of the individual VSL#3 strains, overnight cultures in Lactobacilli MRS broth (Difco) were centrifuged
and the pellets were washed twice before the lysozyme treatment. Samples were transferred to sterile tubes containing
0.3g of sterile zirconium beads, and disrupted in a Mini-bead
beater. Then, samples were treated with a series of phenolchloroform extractions. DNA was precipitated overnight at
−20◦ C in isopropanol, washed with 80% ethanol and airdried at room temperature. Finally, DNA pellets were dissolved in TE buffer (pH 7.5) and stored at −20◦ C.
Detection of Bacteria by PCR–DGGE
Amplification of the V3 region of the 16S rRNA gene of
biopsy-associated bacterial DNA and of VSL#3 DNA was
carried out using the universal bacterial primers HDA1-GC
and HDA2, as described previously (36) and the Taq PCR
Core Kit (Qiagen Inc., Ontario, Canada). PCR products were
checked by electrophoresis in a 2% agarose gel stained with
3
ethidium bromide and viewed by UV transillumination. Amplicons were analyzed by DGGE performed with a DCode
apparatus (Bio-Rad, Hercules, CA) as described previously
(37). An identification ladder was prepared by extracting
DNA from the individual components of VSL#3 and then
by PCR amplification using the same pair of primers and
amplification kit.
Cloning DNA Fragments Eluted from DGGE Gels to
Identify Bacterial Origin
DNA fragments were cut from the polyacrylamide gel using a sterile scalpel blade, and DNA was eluted and purified
using a commercial kit (Qiagen Inc., Ontario, Canada) according to the manufacturer’s instructions. Purified fragments
were digested with S1 nuclease (Roche) to remove single
stranded DNA as described previously (37). S1-nucleasetreated DNAs were used as templates in PCR reactions
with the HDA primers prior to ligation. The resulting PCR
products were cloned in Escherichia coli TOP10 using the
pCR 2.1-TOPO vector system (Invitrogen, Carlsbad, CA).
Recombinant plasmids were purified from colonies grown in
LB broth (Difco) supplemented with 100 µg ampicillin/ml,
using the Wizard Plus SV minipreps DNA purification system (Promega, Madison, WI). The migration of the amplified
inserts was checked using DGGE by comparison to the original profile from which the fragments had been obtained.
Cloned inserts were amplified from the cloning vector using
M13 primers for sequencing. Sequences were compared to
those in the GenBank database using the BLASTn algorithm.
Similarities between the DGGE profiles were determined by
calculating similarity indices of the densitometric curves of
the profiles using Dice’s correlation with the aid of computer software (Bionumerics, Applied Maths, Texas, USA).
An unweighted pair group method using an arithmetic averages (UPGMA) algorithm was performed.
Role of the Funding Source
The investigators designed the study, recruited the patients,
managed the data, performed the statistical analysis, and
wrote the manuscript detailing the results of the study. The
completed case report forms were sent by the investigators to
the principal investigator, where the statistical analysis was
performed. The study was funded by research grants from the
CCFC and CCFA and VSL Pharmaceuticals, Inc., Study drug
was supplied by VSL Pharmaceuticals, Inc., Representative
from VSL Pharmaceuticals, Inc., had the opportunity to review and comment on the study design and on the manuscript,
but the principal investigator made the final decisions regarding the design of the study and the content of the manuscript.
RESULTS
Forty-six patients were screened for entry into the trial, from
which 34 (16 female, 18 male) were randomized to 6 wk of
open label VSL#3. The baseline characteristics of the patients
4
Bibiloni et al.
Table 2. Patient Demographic and Baseline Characteristics
Variable
Male/Female gender
Mean (SD, range) age at entry (yr)
Maximum disease extent
(no. of patients) (%)
Rectum, sigmoid
Distal to the mid transverse colon
Pancolitiss
Concomitant medications (%)
Corticosteroids oral∗
Corticosteroid enema∗
Azathioprine or 6-mercaptopurine∗
Antibiotics
Mesalamine oral∗
Mesalamine enema∗
None
VSL#3-Treated Group
16 (47) / 18(53)
35 ± 13
4 (12)
23 (67)
7 (21)
5 (15)
4 (12)
6 (18)
None
25 (74)
4 (12)
1 (3)
∗
Duration on concomitant medication prior to study entry; oral corticosteroid
(range 22–15 wk day), rectal corticosteroid (range 12–4 wk), azathioprine or
6-metcaptopruine (range 116–13 wk), oral mesalamine (range >104–27 wk), rectal
mesalamine (range >52–5 wk).
are shown in Table 2. Patients screened but not randomized
were excluded for not matching the inclusion criteria or for
having exclusion criteria at the time of screening.
Clinical Effectiveness
Intent to treat analysis demonstrated that remission was
achieved in 53% (n = 18) of patients; response in 24%
(n = 8) of patients; no response in 9% (n = 3) of patients;
(Fig. 1); worsening in 9% (n = 3) of patients; and 5% (n = 2)
did not have the final sigmodmioscopy assessment. Of those
patients with no response baseline UCDAI was 8, 6, and 8,
and all patients were on baseline mesalamine 2 g/day. Of those
patients with worsening of the disease baseline UCDAI was
7 in each patient and all were on baseline corticosteroids and
mesalamine. Results of UCDAI scores at baseline study entry
and following 6 wk of VSL#3 therapy are shown in Table 3.
There was no difference in baseline mean UCDAI scores
among those patients who achieved remission or response and
Figure 1. Intent to treat analysis following 6 wk of VSL#3 treatment
in patients with active ulcerative colitis. Remission was achieved in
53% (n = 18), response in 24% (n = 8), no response in 9% (n = 3),
and worsening of disease activity in 9% (n = 3). Two patients did
not complete the final endoscopic assessment.
Table 3. Ulcerative Colitis Disease Activity Index Scores for Each
Responding Group
UCDAI Score
Patient response to
VSL#3
Remission
Response
No change
Worsened
Baseline
Following 6 wk
of VSL#3 therapy
p-Value
6.33 ± 0.41
7.63 ± 0.42
6.67 ± 0.33
6.67 ± 0.33
1.06 = 0.19
4.25 ± 0.49
6.00 ± 058
9.67 ± 0.33
p < 0.001
p < 0.001
p = 0.188
p < 0.001
Values are mean ± SEM relative to baseline.
those with no change or worsening of their disease activity.
However, there were highly significant changes in UCDAI
from baseline to study completion in those patients entering remission or responding (Table 3), implying not only a
biologic but also a clinical effect of VSL#3 therapy. Eight
patients continued their rectal therapy (Table 3) throughout
the study period. Rectal therapy also did not appear affect
the VSL#3-induced efficacy results as 5 of these patients
demonstrated disease remission, while 2 had no change and
1 worsened, reflecting a similar proportion of response to
those without rectal therapy.
Per-protocol analysis for the 32 patients that completed
6 wk of VSL#3 treatment demonstrated that remission was
achieved in 56% (n = 18) of patients; response in 25%
(n = 8) of patients; no response in 9% (n = 3) of patients;
and worsening in 9% (n = 3) of patients.
Adverse Events
There were no biochemical adverse events related to VSL#3.
Twenty-nine percent of patients (n = 10) reported increased
bloating that they attributed to the VSL#3. In no cases was
the bloating severe enough to stop the study medication.
BACTERIOLOGICAL ANALYSIS. All eight components
of the VSL#3 preparation could be detected using a nucleic
acid-based method to analyze the bacterial content of a sachet
similar to that provided to the patients (Fig. 2). The bacterial
components of VSL#3 could be differentiated, except that
the 16S rRNA gene fragments from L. acidophilus and L.
delbrueckii subspecies bulgaricus had the same migration
properties in the DGGE gel. Similarly, B. infantis and B.
longum DNA fragments could not be differentiated.
The presence of specific components of VSL#3 could be
detected in DGGE profiles from patients by comparing the
migration distances of their DNA fragments to the identification ladder. The bacterial origin of these fragments was
subsequently determined by cloning and sequencing DNA
fragments cut from the gel. Two bacterial species, S. salivarius subspecies thermophilus, and B. infantis were detected in
association with biopsies collected after (but not before) the
administration of VSL#3 in the case of 3 patients in remission. VSL#3 components were not detected in the profiles of
the remaining 8 patients (Fig. 3).
Comparison of DGGE profiles generated from biopsies
collected from patients before and after VSL#3 administra-
VSL#3 for Treatment of Ulcerative Colitis
1
2
3
4
5
6
7
8
9
Figure 2. PCR–DGGE profiles generated from bacterial DNA extracted from the VSL#3 product and its eight individual components.
Lane 1: VSL#3; lane 2: Lactobacillus plantarum MB452; lane 3:
Lactobacillus acidophilus MB443; lane 4: Lactobacillus delbruekii
subsp. bulgaricus MB453; lane 5: Streptococcus salivarius subsp.
thermophilus MB455; lane 6: Bifidobacterium breve Y8; lane 7:
Lactobacillus casei MB451; and lane 8: Bifidobacterium infantis
Y1; lane 9: Bifidobacterium longum Y10.
tion could be made for a subset of 7 patients. The DGGE
profiles of 4 out of 5 patients in remission were considerably
different after VSL#3 administration, whereas the 2 patients
with continued active disease had high similarity before and
after the consumption of VSL#3 (Fig. 3; Table 4). However,
the study was not controlled with respect to temporal changes
that might occur in biopsy profiles in the absence of probiotic
treatment, or for the effect of concurrent medication, although
the latter were administered in the same doses before and after
therapy.
DISCUSSION
Treatment of patients with mild to moderate UC, not responding to conventional therapy, with the probiotic mixture
VSL#3 results in a combined induction of remission/response
rate of 94% in patients that completed the study; 77% of patients responded when analyzed in an intent to treat fashion.
No adverse events were noted other than mild bloating.
Only a minority of patients were using concomitant
mesalamine, corticosteroids, and purine anitmetabolites
(Table 2) prior to VSL#3 treatment. It is unlikely that these
5
medications played a significant role in disease response since
patients had been on oral therapies for a minimum of 13 wk
and rectal therapies a minimum of 4 wk (both long enough
for a therapeutic effect to the concomitant therapy to be identified before VSL#3 was started), indeed the majority had
been on these agents much longer.
These results are relatively unique in that they examined
the use of a highly concentrated mixture of probiotic bacteria to induce remission in patients with active UC. The only
similar study in the management of active UC reported that
uncontrolled administration of Saccharomyces boulardii for
4 wk induced clinical remission in 71% of 24 patients with
mild to moderate UC (26). Previous studies have reported that
E. coli 1917 Nissle was as effective as low dose mesalamine
in preventing relapse of quiescent UC (22, 23). Similarly,
an uncontrolled pilot study demonstrated that VSL#3 maintained remission over an interval of 12 months in 75% of
UC patients (24). Bifidobacteria-fermented milk decreased
the relapse rate of UC from 90 to 27% (28). These studies
suggest that several probiotic preparations may have a role
in treating and preventing relapse of UC. In contrast to the
evidence for VSL#3 in prevention and maintenance of remission the role of VSL#3 in acute active disease remains to be
determined.
Unlike most probiotics products that are composed of either single microbes or a combination of a few, VSL#3 is a
mixture of eight probiotic lyophilized bacteria consisting of
four strains of L. casei, L. plantarum, L. acidophilus, and L.
delbrueckii subsp. bulgaricus, three strains of B. longum, B.
breve, and B. infantis, and one strain of S. salivarius subsp.
thermophilus. VSL#3 has been convincingly demonstrated,
in randomized controlled clinical trials, to prevent the recurrence pouchitis following antibiotic-induced remission (29,
30) and postoperatively (31). In pouchitis, VSL#3 appears
to exert several antiinflammatory mechanisms of action, including alteration in cytokine profile, and expression of nitric
oxide and matrix metalloproteinases (32). Where the efficacy
of VSL#3 is attributable to these antiinflammatory mechanisms and whether all eight bacteria are required remains
under investigation.
PCR/DGGE provides a rapid screening method that is suitable for the analysis of bacterial communities (35–37), including the detection of altered in microbiota composition.
The method can be applied to biopsies collected from the
human gut as well as feces (38). The method permits the
detection of not only normal inhabitants of the gut, but also
bacteria that have been consumed with food (39). PCR based
methods have also been employed for the detection and quantification of the bifidobacterial strains in the VSL#3 product
(40, 41); however, nucleic acid-based detection of the full
bacterial mixture in the product has not been reported. We
were able to detect all eight components of the product using
a combination of PCR and DGGE.
Two of the components of VSL#3, S. salivarius subspecies
thermophilus and B. infantis, were detected in 3 of the patients
in remission, demonstrating that these bacteria reach the
6
Bibiloni et al.
1
2
b a
3
b a b a
4
5
b a
b a
6
b a VSL#3
7
8
b a
b
a
9
10
b a
b
a
b a1 a2 VSL#3
A
A
B
B
C
C
2
11
3
5
D
E
F
D
E
F
G
1
4
G
Figure 3. PCR–DGGE gels generated with DNA extracted from biopsies collected before (b) and after (a) the administration of VSL#3
in a subset of 11 patients. Ladder profile obtained with DNA extracted from the VSL#3 is shown in the last lane on the right of each gel.
Numbered/lettered fragments were identified as described in the text. Fragment A: Lactobacillus plantarum; fragment B: L. acidophilus/L.
delbruekii subsp. bulgaricus; fragment C: Streptococcus salivarius subsp. thermophilus; fragment D: Bifidobacterium breve; fragment E:
L. casei; fragment F: L. casei; and fragment G: B. infantis/B. longum. Fragments 1 and 4: Bifidobacterium infantis Y1 (97.4% identity),
fragment 2, 3, and 11: Streptococcus themophilus/Streptococcus salivarius (99.5–100% identity).
diseased bowel site. Similarly, B. infantis Y1 and B. breve Y8
have been transiently detected previously by specific PCR in
the feces of IBD patients and normal subjects who had consumed the product (40). Despite of the sensitivity of PCR,
very low concentrations of the target gene (few bacteria)
might not be detected in the DGGE gels. For instance, in the
case of the VSL#3 preparation, the L. plantarum strain was
poorly detected in the product and its association with biopsies might escape detection. However, it could be questioned
whether such low numbers of bacteria in association with
the gut mucosa would be of biological significance. We did
not attempt to measure VSL#3 components in fecal samples,
since mucosal association may be more relevant to local biologic activity (6, 42). S. salivarius subspecies thermophilus
and B. infantis may be of particular interest in future studies
of probiotic treatment of active mild to moderate UC. They
were the only two components of VSL#3 that were detected
in association with biopsies and may therefore be the active
ingredients of the bacterial mixture in vivo.
Our results suggest that oral administration of high doses of
VSL#3 may effectively treat active UC and is associated with
no serious adverse effects. A randomized placebo-controlled
trial is currently underway to confirm the efficacy of VSL#3
in treating active UC.
Table 4. Comparison of the DGGE Profiles Generated from Biopsies
from Ulcerative Colitis Patients Before and After the Administration
of VSL#3. Concurrent Medication is also Indicated
ACKNOWLEDGMENT
Primary Dice’s Similarity
Patient No. Outcome Coefficient (%)
2
R
57.9
3
A
89.4
4
5
7
R
R
R
85.2
56.5
70.8
8
R
79.1
10
A
95.2
Primary outcome; remission, R; active, A.
Concomitant
Medication
Pentasa (4 g),
betnesol (daily)
Salofalk (4 g),
asacol (1.2 g)
Pentasa (4 g)
None
Pentasa (4 g),
betnasol (daily)
Salofalk
(4 g, daily)
Asacol (1.6 g),
prednisone (10 mg)
This work was partially supported by Crohn’s and Colitis
Foundation of Canada. VSL#3 provided by VSL#3 Inc.
Reprint requests and correspondence: Richard N. Fedorak, M.D.,
Division of Gastroenterology, University of Alberta, Suite 205 College Plaza, 8215–112 Street, Edmonton, Alberta, Canada T6G 2C8.
Received November 9, 2004; accepted January 19, 2005.
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Queries
Q1 Author: Please provide degree for all authors.