Probiotics provide net health benefits in preventing allergic disease, according to the World Allergy Organisation (WAO) which recommends the use of probiotics in pregnant and breastfeeding mothers whose offspring are at increased risk of developing allergies.¹ More specifically, probiotics are effective in relieving allergic symptoms in those suffering from allergic rhinitis (AR, hayfever).²

According to the Australasian Society of Clinical Immunology and Allergy (ASCIA) - a peak professional body of clinical immunology and allergy specialists in Australia and New Zealand³ - one in five people develop an allergy during their lifetime, of which AR is one of the most common presentations. In fact, in 2017/2018, an estimated 19% (more than 4.6 million) of Australians presented with AR, of which the highest rate (29%) was seen in the Australian Capital Territory (ACT).⁴ Moreover, AR is one of the two leading chronic allergic disorders in children aged 0 to 14 years.⁵

Clinical Application of Research

A summary of the essential take-away messages of the most relevant resent research on a specialised probiotic mixture is detailed below to assist practitioners in their clinical use of probiotics in AR patients: 

• Clinical Use: Allergic rhinitis
• Clinically Effective Dose: 2 billion (2x109) CFU twice daily of a formulation containing Bifidobacterium (B.) bifidum W23, B. lactis W51, Lactobacillus (L.) acidophilus W55, L, casei W56, L. salivarius W57, Lactococcus (Lc) lactis W58, plus vitamin B2 35 mg/100 g and biotin 750 mcg/100 g (Ecologic® AllergyCare).⁶
• Duration & Expected Results: Individual symptoms and overall symptoms were significantly reduced over the course of eight weeks, while a moderate reduction in frequency of allergy-related medication use can be expected in the final four weeks of supplementation.⁶
• Drug Interactions & Safety Concerns of Probiotics: Probiotics are generally regarded as safe in most populations. However, they should be used with caution or avoided in immune-compromised patients (i.e. in those with AIDS, lymphoma, or those receiving long-term corticosteroid therapy, anti-rejection medication, injectable immunosuppressive drugs, chemotherapy or radiation) as well as the critically ill.^7-10 Avoid in those with cow’s milk allergy.

Research Update- Study Details

A recent Australian clinical trial has by Watts et al from 2018 demonstrated the effectiveness of a specialised probiotic mixture in relieving several symptoms associated with AR, including: 

• ‘nose symptoms’ such as nasal itch, sneezing, stuffy blocked nose, runny nose and post-nasal drip
• ‘eye symptoms’ such as itchy eyes, sore eyes, and watery eyes

The trial was based on a Simon Two-Stage Design to account for seasonal variation in symptoms requiring > 10 patients to exhibit an improvement in quality-of-life scores to determine sufficiency of activity for the supplement to be considered effective. Forty-four participants from Australia (aged 17 to 65 years; 16 males and 24 females) with a history of > 2-years of allergic rhinitis then received the probiotic supplement described above twice daily for 8 weeks. The primary outcome measure was based on a change in Quality of Life Questionnaire (mRQLQ) scores following supplementation, while secondary outcomes included assessment of a change in symptoms and medication usage with a twice-weekly symptom and medication diary, nasal congestion by rhinomanometry, and total serum Immunoglobulin E (IgE) and specific IgE for Bermuda grass. A total of 40 participants completed the study, of which 25 participants (63%, 49–76%, p < 0.001; mean, 95% confidence interval, p-value) had a clinically meaningful response to treatment based on assessment of mRQLQ. On average, mRQLQ scores changed from 2.83 – 1.51 at baseline to 1.66 – 1.36 at week 4 and 1.38 – 1.13 at week 8 (p < 0.01) (mean – SD, p-value). The sum of individual symptom scores and overall symptom scores were significantly reduced over the course of treatment (p = 0.036 and p = 0.039, respectively). A moderate reduction in frequency of allergy-related medication use was also observed in the final 4 weeks of supplementation (52.5% weeks 0–4 to 41.4% weeks 4–8; average proportion of total diary responses, p = 0.085).

Background: Mechanisms of Action of Probiotics Mitigating Allergic Response

Probiotics exert specific cell-mediated and humoral immune responses via the immunological gut barrier where they stimulate gut associated lymphoid tissue or ‘GALT’ and induce the maturation of antigen-presenting cells or ‘dendritic cells’ (DC). DCs play a critical role in modulating-helper (Th) cell responses and the restoration of Th1/Th2 balance,² which in turn prevents the development of allergy.¹¹ Probiotics also work via non- or aspecific mechanisms of action.^2,12-16 In summary, specific and non-specific mechanisms of action by which probiotics help avert allergic responses include:

•  Regulating cell-mediated and humoral immune response
  • Inducing CD and Treg cells
  • Stimulating Th1 / suppressing Th2
  • Increasing IgA and decreasing IgE
• Restoring gut wall integrity / intestinal permeability
  • Increasing TJs and decreasing mucins
• Competitively inhibiting adhesion of harmful bacteria
• Modifying the local microenvironment
• Reducing intestinal inflammation

 

 References

1. Fiocchi A, Pawankar R, Cuello-Garcia C, Ahn K, Al-Hammadi S, Agarwal A, et al. World Allergy Organization-McMaster University Guidelines for Allergic Disease Prevention (GLAD-P): Probiotics. World Allergy Organ J. 2015 Jan 27;8(1):4.
2. Güvenç IA, Muluk NB, Mutlu FŞ, Eşki E, Altıntoprak N, Oktemer T, Cingi C. Do probiotics have a role in the treatment of allergic rhinitis? A comprehensive systematic review and meta-analysis. Am J Rhinol Allergy. 2016 Sep 1;30(5):157-175.
3. Australasian Society of Clinical Immunology and Allergy (ASCIA). Allergy and Immune Diseases in Australia (AIDA) Report 2013. 2013. Available from: https://www.allergy.org.au/?view=article&id=530:allergy-and-immune-diseases-in-australia-2013&catid=97
4. Australian Institute of Health & Welfare (AIHW). Allergic Rhinitis (‘Hay Fever’). 2020. Available from: https://www.aihw.gov.au/reports/chronic-respiratory-conditions/allergic-rhinitis-hay-fever/contents/allergic-rhinitis
5. Australian Institute of Health & Welfare (AIHW). Australia’s Children. 2020. Available from: https://www.aihw.gov.au/reports/children-youth/australias-children/contents/health/chronic-conditions-and-burden-of-disease
6. Watts AM, Cox AJ, Smith PK, Besseling-van der Vaart I, Cripps AW, West NP. A Specifically Designed Multispecies Probiotic Supplement Relieves Seasonal Allergic Rhinitis Symptoms. J Altern Complement Med. 2018 Aug;24(8):833-840.
7. Guarner F, Khan AG, Garisch J, Eliakim R, Gangl A, Thomson A, et al. World Gastroenterology Organization. World Gastroenterology Organisation Global Guidelines: probiotics and prebiotics October 2011. J Clin Gastroenterol. 2012 Jul;46(6):468-81.
8. Doron S, Snydman DR. Risk and safety of probiotics. Clin Infect Dis. 2015 May 15;60 Suppl 2(Suppl 2):S129-34.
9. Health Canada. Probiotics. Monograph. 2019. Available at: http://webprod.hc-sc.gc.ca/nhpid-bdipsn/atReq.do?atid=probio&lang=eng
10. Braun L. and Cohen M. Herbs and Natural Supplements, 4th Edition, Volume 2, Churchill Livingstone, Sydney, 2015, pp.771-796.
11. Toh ZQ, Anzela A, Tang ML, Licciardi PV. Probiotic therapy as a novel approach for allergic disease. Front Pharmacol. 2012 Sep 21;3:171.
12. Iacono A, Raso GM, Canani RB, Calignano A, Meli R. Probiotics as an emerging therapeutic strategy to treat NAFLD: focus on molecular and biochemical mechanisms. J Nutr Biochem. 2011 Aug;22(8):699-711.
13. Sanders ME, Merenstein DJ, Reid G, Gibson GR, Rastall RA. Probiotics and prebiotics in intestinal health and disease: from biology to the clinic. Nat Rev Gastroenterol Hepatol. 2019 Oct;16(10):605-616.
14. Sampson HA, O'Mahony L, Burks AW, Plaut M, Lack G, Akdis CA. Mechanisms of food allergy. J Allergy Clin Immunol. 2018 Jan;141(1):11-19.
15. Pascal M, Perez-Gordo M, Caballero T, Escribese MM, Lopez Longo MN, Luengo O, Manso L, Matheu V, Seoane E, Zamorano M, Labrador M, Mayorga C. Microbiome and Allergic Diseases. Front Immunol. 2018 Jul 17;9:1584.
16. Ipci K, Altıntoprak N, Muluk NB, Senturk M, Cingi C. The possible mechanisms of the human microbiome in allergic diseases. Eur Arch Otorhinolaryngol. 2017 Feb;274(2):617-626.