Table 3.

Efficacy of microflora modulation by combined probiotics in multiple sclerosis - results of the clinical studies.

Study Sample		Probiotics		Main Findings	Refs.
n=9 in the treatment group, patients with relapsing-remitting MS, n=13 in the healthy control group (pilot study) The dynamics of the studied parameters was determined in each group (prior to, at discontinuation of therapy, and 3 months thereafter)		Probiotic mixture VSL3 containing 3×1011/g of viable lyophilized bacteria including four strains of Lactobacillus (Lactobacillus paracasei DSM 24734, Lactobacillus plantarum DSM 24730, Lactobacillus acidophilus DSM 24735, and Lactobacillus delbrueckii subspecies bulgaricus DSM 24734), three strains of Bifidobacterium (Bifidobacterium longum DSM 24736, Bifidobacterium infantis DSM 24737, and Bifidobacterium breve DSM 24732), and one strain of Streptococcus (Streptococcus thermophilus DSM 24731).		Increased abundance of many species predominated by Lactobacillus, Streptococcus, and Bifidobacterium was seen in both healthy controls and MS patients. In controls, the significant increase in the relative abundance of these strains resulted in the reduced evenness (as the measure of representation of all species) due to the possible competitive interaction. At the immune level, the probiotic effect was predominantly seen on monocytes and dendritic cells. The decreased frequency of intermediate monocytes (CD14highCD16low) was seen in MS subjects (9.07% vs. 7.58%, p = 0.039), while decreased mean fluorescence intensity of costimulatory marker CD80 on classical monocytes was registered in controls (88 vs. 80.6, p=0.048). These changes were considered by the authors as an anti-inflammatory peripheral innate immune response, as well as the decreased mean fluorescence intensity of human leukocyte antigen-antigen D related (HLA-DR) on myeloid derived dendritic cells (CD45+LIN− CD11c+) following administration of the probiotic (1890 vs. 1510, p = 0.016) in MS patients. These immunomodulatory effects did not persist after discontinuation of the probiotic.	[135]
Study Sample	Probiotics		Main Findings		Refs.
n=30 per group, patients with relapsing-remitting MS (receiving interferon beta-1α therapy), comparison of the results of probiotic treatment with the results in placebo group	Probiotic containing Lactobacillus acidophilus, Lactobacillus casei, Bifidobacterium bifidum and Lactobacillus fermentum (each 2×109 CFU/g) daily for 12 weeks		The improvement in expanded disability status scale dynamics was registered after the probiotic use compared with placebo (-0.3 ± 0.6 vs.+0.1 ± 0.3, p = 0.001), as well as inflammatory factors such as high-sensitivity CRP serum level (-1.3 ± 3.5 vs. +0.4 ± 1.4 mg/mL, p = 0.01). These parameters were considered as the primary outcomes. The positive changes in the secondary outcomes were also seen, including mental health parameters - Beck Depression Inventory (-5.6 ± 4.9 vs. -1.1 ± 3.4, p < 0.001), general health questionnaire (9.1 ± 6.2 vs. 2.6 ± 6.4, p < 0.001) and depression anxiety and stress scale (16.5 ± 12.9 vs. 6.2 ± 11.0, p = 0.001). The additional benefits were the improvements of the metabolic profile, among which the serum insulin and the calculated values of assessment-estimated insulin resistance, beta cell function was the most favorably changed (in all cases p≤0.001).		[136]
n=24 per group, patients with relapsing-remitting MS (receiving interferon beta-1α therapy), comparison of the results of probiotic treatment with the results in placebo group	Probiotic containing Bifidobacterium infantis, Bifidobacterium lactis, Lactobacillus reuteri, Lactobacillus casei, Lactobacillus plantarum and Lactobacillus fermentum (each 2 × 109 CFU/d) for 16 weeks		The positive effect was reached after the probiotic use in the primary outcomes, namely the expanded disability status scale dynamics (-0.52 ± 0.04 vs. +0.17 ± 0.07, p < 0.001), as well as the reduction in IL-6 (-0.2 ± 0.1 vs. 0.07 ± 0.08, pg/mL; P = 0.01) and a significant increase in IL-10 (+0.46 ± 0.16 vs. -0.3 ± 0.22, pg/mL; p< 0.001) plasma levels. These shifts were considered as balancing the inflammatory and anti-inflammatory responses. The other biomarker of inflammatory processes activation - high-sensitivity CRP level in serum - was also decreased (p = 0.03). Among the secondary outcomes pronounced decrease was observed in the plasma concentration of MDA (-0.31 ± 0.75 vs. +0.15 ± 0.79, µmol/L; p < 0.001) as well as 8-hydroxy-2′-deoxyguanosine (-6.72 ± 2.03 vs. +3.15 ± 1.57, ng/mL; P < 0.001) in the probiotic compared to placebo group. These oxidative stressors are expected to be significant for the symptoms reduction in MS patients. The mental health parameters (as the secondary outcomes) were also improved by the probiotic, namely Beck Depression Inventory (-5.08 ± 0.71 vs. -2.62 ± 0.78, p = 0.026), general health questionnaire-28 (-6.7 ± 1.17 vs.-3.04 ± 1.13, p = 0.03) and depression, anxiety, and stress scale (-12.5 ± 1.81 vs. -3.33 ± 2.26, P = 0.003).		[137]
n=20 per group, patients with relapsing-remitting MS, comparison of the results of probiotic treatment with the results in placebo group	Probiotic containing Lactobacillus acidophilus, Lactobacillus casei, Bifidobacterium bifidum, and Lactobacillus fermentum (each 2 × 109 CFU /g)		Compared with placebo, probiotic supplementation downregulated gene expression of the pro-inflammatory cytokines IL-8 (p < 0.001) and TNF-α mRNA (p < 0.001) in peripheral blood mononuclear cells of patients with MS.		[138]