Ask the Pharmacist – July 3, 2018

Q) You’ve written a lot about probiotics in the last year. The two I hear recommended the most are Align and Florastor. What are the differences and which is better?

A) Just about every pharmacy (and health food store, and grocery store and…) carries a wide variety of probiotics that can fit just about every budget and are labeled in ways that often make it challenging (more so than it needs to be) to tell the difference between them.

 Probiotics differ from each other in four main ways. They may contain different species of bacteria, each dosage form (i.e. capsule, pill. sachet…) contain a widely varying numbers of bacteria cells, they can be manufactured by different processes and of course there are large discrepancies in cost.

Let’s start with the last differentiator mentioned. Costs can vary widely and do not always reflect the quality of the product you are purchasing. As I mentioned last week, probiotics as a category are worth billions of dollars globally and there are always going to be companies and individuals looking to take advantage of those in uncertain or poor health.

The two products featured here tend to be on the more expensive end and are more costly than most. Many stores have private label versions which run just over $10 a bottle and also sell multiple versions made by the usual natural health companies (Jamieson, Swiss, Webber…) for somewhat (to quite a bit!) more.

There is very little evidence to support this, but if you are of generally good health, are taking a probiotic as a preventative measure for a low risk medical intervention (i.e. a healthy 30 year old taking their first antibiotic in the last year for a bladder infection) who is not prone to having side effects (e.g. diarrhea, upset stomach, yeast infections..) when taking antibiotics in the past, I am fine with recommending the least expensive option for the time that they are on the antibiotic and for perhaps another week after that. Of course, there’s nothing “wrong” with buying one of the Cadillac versions, it just may not be worth the extra cost.

For those who do not meet all of the qualifications just stated, then Florastor or Align may well be worth the added dollars. Before focusing on these however, here is a brief summary on the other ways probiotics differ in the interests of keeping this article to a single hours read.

Most types have the number of cells they contain listed on the bottle (which can vary from millions to billions). The assumption seems to be that more is better since they compete with bad bacteria and yeast cells but it’s more complicated than that as many of the cells within these pills do not survive the acid in our stomach to make it to your intestines or vaginal tract.

As to how they are made, the vast majority are freeze- dried and then one or more “techniques” are performed to keep the bacteria alive and stable in their capsule. They may be coated with a “cryoprotectant” (such as sugar) to protect the cells from harsh temperatures or stored with vitamin C and probiotic fibers (which protect them from oxidation and allow the bacteria to continue to reproduce in the pill form) or mixed with digestive enzymes (that help shield them from the destructive nature of our stomach acids).

All together, research shows that probiotics maintain 90-95% of their cell count 6 to 12 months after they have been packaged and about 1-3 months after the bottle has been opened. It also means that the days when the only good probiotics had to be bought from and stored in a fridge are long gone and is now only a marketing gimmick rather than a reason to buy one brand over another.

Lastly, they differ in the species they may contain and this is where the two featured products may shine (we can say ‘may’ since we do not have true head-to-head comparisons amongst brands so we can only go off the proof that these two products have managed to provide us through trials).

 Align uses a unique patented strain of Bifidobacterium infantis 35624 (BI) which is not found in any other products that I am aware of.  BI is found naturally within our intestines and is one of the few types of bacteria (lactobacillus is the other) that can be contained in a pill and make it through the acidic environment of our stomach completely unharmed.

Florastor in contrast does not contain any bacteria whatsoever.  Its active ingredient is a probiotic yeast, Saccharomyces boulardii (SB) which can also make it through the stomach acid relatively unharmed.

While it is not a normal inhabitant of our gut, it has been used for a very long time in Asia (by chewing the skin of lychee & mangosteen) to treat intestinal troubles. Being yeast, it has the added benefit of not being harmed by antibiotics (unlike all the other probiotics on the market, including Align) and, therefore, its niche role has been in the prevention and treatment of side effects that may occur when we take a course (or multiple courses) of antibiotics.

While Florastor seems to perform this role very well, it cannot live long in our intestines. This means that shortly after you stop taking it, its benefits will be over. That’s just fine for its intended purpose of making antibiotic treatment safer and more pleasant, but is not ideal for people who have long term intestinal issues such as irritable bowel syndrome (IBS). Ideally, with Florastor, you take it for the prescribed time (or until your symptoms have gone away for at least a few days) then you just stop or lower the dose and stop somewhere down the line depending on patient specific issues.

Align conversely has been shown to stay in your intestines (one study showed it could still be found in our gut two weeks after stopping the supplement) for a prolonged period of time. This can be beneficial for those who need to take it chronically and are likely to forget to take their dose once in a while. It is also important to remember that despite the fact that it can survive for awhile, research seems to indicate that stopping the therapy will eventually lead to the end of its benefits.

Align seems to be better for fighting Candida overgrowth (which is yeast, Align can actually kill this organism) and food intolerance related to irritable bowel syndrome (IBS). There is some evidence that with continued use of Align, some foods that were previously challenging can be enjoyed once again easing up on the dietary restrictions so many of have to live with. While Align is not indicated for inflammatory bowel disease, this would still be the supplement I would choose to help control the chronic symptoms (note it cannot cure these) associated with Crohn’s and colitis.

Doses between the two products differ as well. Align is a simple one capsule a day regimen whereas Florastor doses have varying recommendation ranges. For normal digestive help, it is suggested to use 1 capsule or packet twice a day. For prevention of antibiotic associated diarrhea the recommendation is 2 capsules twice daily while on the antibiotic and for at least 3 more days after stopping.

For the prevention of a recurrence of a Clostridium difficile infection (this is a brutal intestinal infection usually caused by using antibiotics which can leave you sick for months) it is suggested to use 2 capsules twice daily for 4 weeks.

Side effects with either product tend to be minimal, they are not affected by a full or empty stomach and some people find they work better when used in larger than the suggested doses while still maintaining their excellent record of safety.

For more information about this or any other health related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination in Port Elgin and Kincardine.