
A Promising Pill, Not So Hard to Swallow - dnetesn
http://www.nytimes.com/2014/10/12/us/a-promising-pill-not-so-hard-to-swallow.html?ref=science
======
Klinky
I've dealt with IBS symptoms for 17 years. I would love to try one of these
pills. Digestive maladies can really hamper a person's life. The digestive
system is poorly understood, and there aren't a lot of effective treatment
options for IBS & IBDs like Crohn's & Ulcerative Colitis. The treatments which
are effective for IBD are often invasive or can have serious side effects.

~~~
300bps
_there aren 't a lot of effective treatment options for IBS & IBDs like
Crohn's & Ulcerative Colitis_

I had IBS from the age of 10 to the age of 30. First off I have to say that
IBS is not even remotely comparable to IBD. For most people, IBS is a very
inconvenient life-altering syndrome. IBD is often 100x worse, increases the
risks of colon cancer and can be life threatening. I wouldn't wish ulcerative
colitis or Crohn's disease (IBD) on my worst enemy.

Beyond that, I'm not sure why you think this pill would help your IBS. It is
specifically meant to treat one particular problem - a clostridium difficile
infection. Typically the colon is populated by helpful or otherwise non-
harmful bacteria. Clostridium difficile is an opportunistic infection that
often takes hold after someone takes a course of antibiotics that kills all
the helpful bacteria. The fecal transplant puts back the normal bacteria into
your colon, attempting to crowd out the clostridium difficile bacteria. There
is anecdotal evidence of fecal transplants helping IBS or IBD but it has not
been studied well. Source: [http://www.mayoclinic.org/medical-
professionals/clinical-upd...](http://www.mayoclinic.org/medical-
professionals/clinical-updates/digestive-diseases/quick-
inexpensive-90-percent-cure-rate) I would suspect much of the benefit to IBS
from a fecal transplant (or fecal transplant pill) derives from the placebo
effect.

After 20 years of having IBS, the best cure I found for myself was to eat a
lot of dietary fiber and drink a lot of water. I haven't had symptoms of IBS
for over 12 years now since doing that. Unfortunately I find I have to eat
about 40 grams of dietary fiber and drink about a gallon and a half of water
per day. That takes actual work, but it's worth it. Source on dietary fiber
treating IBS: [http://www.aboutibs.org/site/treatment/diet/dietary-
fiber](http://www.aboutibs.org/site/treatment/diet/dietary-fiber)

~~~
Klinky
Perhaps you are too distant from your experience of IBS, or your symptoms were
not as severe as some, but IBS can destroy someone's life just as well as an
IBD can. Someone in remission with an IBD may have better quality of life than
someone with uncontrollable IBS. Severity varies by patient, and while IBDs
are usually more severe, that isn't always the case. Mentioning the two
together does not mean that I am indicting they are equally severe. C.diff,
IBS and IBD are all ailments with the potential to be treated via fecal
transplantation.

The IBS issues I've dealt with have lead to some catastrophic effects. Twice
after dealing with stomach flu/food poisoning I developed gastroparesis or
severe gastric motility issues. I lost 60 lbs during the first bout in 2006
and 45 lbs during a second bout in 2012. My quality of life was horrible
during these periods of time. I basically lost a year of my life each time.

Luckily you found a solution for your IBS, many people have not. If simply
upping my fiber solved the problem then I would be set, but fiber lead to more
gas and pain for me. Probiotics on the market often leave me constipated and
nauseated. Even if I stick to a regimen irregularities continue, and my body
still seems to ebb and flow. So far regular strenuous exercise seems to help
me, but IBS often leads to fatigue.

This all happened to me after I went swimming in a river with friends and got
ill later in the evening. I may have swallowed river water contaminated with
agriculture run off. Nothing has been the same since then. This is similar to
many people's stories about IBS. The hope is that the pill would restore
whatever was killed off due to the initial illness, which might result in
regulation and relief. Yeah it's a shot in the dark and not officially meant
to treat ~anything~, but at least it's something with some promise. The
doctors over the years haven't had an answer for me. Treatments are also used
off label all the time and trials are often very narrow in scope to meet
regulatory guidelines. Somehow I think you know this already and are being a
bit of a smartass.

~~~
300bps
From the little you've written here, it doesn't sound to me like you have
typical IBS or perhaps even IBS at all. The diagnostic criteria for IBS are
here:

[http://www.aboutibs.org/site/what-is-ibs/intro-to-
ibs/diagno...](http://www.aboutibs.org/site/what-is-ibs/intro-to-
ibs/diagnosis)

Dramatic weight loss as you've outlined is a sign you're suffering from
something more serious than IBS. That makes sense since you list several other
non-IBS related disorders ("stomach flu (sic) / food poisoning" as well as
gastroparesis). The thing that doesn't make sense to me is why you attribute
these things to IBS?

 _If simply upping my fiber solved the problem then I would be set, but fiber
lead to more gas and pain for me._

There is nothing "simple" about increasing your fiber in a manner to solve
IBS. As I mentioned in my original comment, it takes actual work. First, you
have to eschew eating anything at all throughout the day that doesn't have
dietary fiber. Second, you must gradually increase your fiber intake over a
period of a year to avoid gas buildup and pain. Third, you must actively seek
out fiber rich foods to eat throughout the day. As I said, there is absolutely
nothing simple about it.

 _This all happened to me after I went swimming in a river with friends and
got ill later in the evening._

Again, I'm questioning why you think this has anything to do with IBS. You
don't catch IBS by swimming in a river.

~~~
Klinky
I had IBS symptoms well before my severe issues with gastroparesis and
digestive motility in 2006 and 2012. I feel my underlying issues with IBS made
me more predisposed to additional further complications brought on by severe
gastroenteritis from viral or bacterial origin. Often most people do not know
what caused their "24 hour stomach flu", if it was something they ate or a
virus.

I am not doubting the work it's taken you to achieve your remission of IBS,
but I am saying your cure may not be the cure for others dealing with IBS.

 _> >You don't catch IBS by swimming in a river._

In a contaminated river you certainly can.

Have you really researched IBS fully? Post-infectious IBS is quite common.
There have been major studies on it.

[http://www.aboutibs.org/site/what-is-ibs/intro-to-
ibs/post-i...](http://www.aboutibs.org/site/what-is-ibs/intro-to-ibs/post-
infectious-ibs)

[http://fhs.mcmaster.ca/main/news/news_2010/walkerton_study.h...](http://fhs.mcmaster.ca/main/news/news_2010/walkerton_study.html)

------
the_rosentotter
We use something similar when we go traveling, basically tablets made from
feces (active ingredient is
[http://en.wikipedia.org/wiki/Enterococcus_faecium](http://en.wikipedia.org/wiki/Enterococcus_faecium)),
as a probiotic to prevent stomach infections and diarrhea. They are extremely
effective and a very good alternative to having to go on antibiotics while on
vacation. Available in pharmacies over the counter.

On another note I have a pet theory that the increasing prevalence of IBS is
caused by the widening use of antibiotics everywhere, both as medicine but
also in food production.

~~~
vegardx
Where on earth do you travel if you have to go on antibiotics, just for
traveling? Some people get a little sick from the different kind of bacteria
cultures in different part of the world, but not something a doctor would put
you on antibiotics for. A lot of people die every year for taking antibiotics
they didn't necessarily need to take, so if your doctor prescribes antibiotics
for a simple "vacation stomach", I'd change him or her out pretty quickly. [1]

[1] [http://www.nytimes.com/2012/05/17/health/research/popular-
an...](http://www.nytimes.com/2012/05/17/health/research/popular-antibiotic-
may-raise-risk-of-sudden-death.html)

~~~
Mikeb85
> Where on earth do you travel if you have to go on antibiotics, just for
> traveling?

Anywhere in the 3rd world, especially around the equator. Not everywhere is
too concerned with cleanliness and food safety, and even if it's OK for the
locals, coming from a foreign country/continent you won't have immunity...

~~~
DangerousPie
Even for these places I have never heard of doctors prescribing antibiotics
simply as a precaution when traveling. Is this commonly done in the US?

At least to me this idea seems very strange. Not only are there side effects
and antibiotic resistance to consider, but they also won't help you at all
against viral diseases or protozoans (unless you take special antibiotics).

~~~
Mikeb85
I know for the country I travel to, the doctors in that country will give you
antibiotics if you go into the jungle. If you stay on the coast you might be
OK, but they still recommend having antibiotics on you. The first time I went
I didn't take antibiotics, and even though I was careful, I had an infection
within a week...

------
JetSpiegel

        "If you can just open a freezer and take out a poop pill, that’s wonderful.”
        While the pills are not being marketed yet
    

Jee, I wonder why. Selling a poop pill is a proper way to see if a marketer is
worth their value.

~~~
shill
I would start with the slogan "Eat Shit and Live!" and then fine tune the
campaign from there.

------
drcode
I find the framing of this nytimes article to be rather condescending, as if a
reasonable person should have a problem with taking such a pill, if it is
actually effective.

(though the science behind it, in itself, also still seems shaky at this
point)

------
logn
It seems like we could refine the fecal matter further until we get down to
the active ingredient(s). Penicillin is made from mold, but we don't get
repulsed by that, since it's so processed and pure.

~~~
Klinky
The active ingredient is "unknown" at this point. Work is being done to figure
out which microbes are useful, and in some cases you may need an orchestration
of many different types.

[http://www.hmpdacc.org/](http://www.hmpdacc.org/)

[http://en.wikipedia.org/wiki/Human_microbiome](http://en.wikipedia.org/wiki/Human_microbiome)

------
lesterbuck
Ari Meisel's Less Doing podcast devoted one episode to an interview with an
expert in this procedure:

Podcast #59 Glenn Taylor - Fecal Microbiota Transplants

>For more info visit [http://lessdoing.com/](http://lessdoing.com/) Ari's book
[http://www.lessdoingbook.com](http://www.lessdoingbook.com) In this episode
Ari talks with Glenn Taylor of the Taymount Clinic. Glenn specializes in
applying Fecal Microbiota Transplant (FMT) techniques to a broad range of gut
conditions. FMT restores normal gut microbiota by implanting Standardized Gut
Flora from tested and optimized sources. Listen to how Glenn has seen patients
literally cured from debilitating illness such as Crohn’s, Ulcerative Colitis,
IBS, Multiple Sclerosis, Rheumatoid Arthritis and other disease simply by
restoring their gut bacteria to a normal balance.

[http://podbay.fm/show/605938952/e/1397717818](http://podbay.fm/show/605938952/e/1397717818)

------
ilaksh
I have no problem with probiotics. But this is _not_ an easy pill for me to
swallow.

Can they please figure out which bacteria are actually important and then I
will take that? Instead of eating actual shit. Thanks.

~~~
mabbo
The problem is that the answer may be "literally thousands of different types
of bacteria".

Your digestive tract is a jungle, with more species than man will ever fully
know about. When too many of certain types go extinct, the ecosystem breaks
down, and bad shit starts to happen (come to think of it, literally).

It may take decades to figure out all of the specific species that matter
most, and in what proportions. We aren't even certain which bacteria are
common to all people, and which are specific to certain cultures / races /
geographies / genders / who-knows-what-else. I bet people who eat a lot of KFC
have a very different personal biome than I do.

In the meantime, here's 'one weird trick' that seems to just work.

~~~
maerF0x0
>" than man will ever fully know about"

The more this works, the more we'll be inclined to study it. We'll know
eventually.

~~~
jaggederest
Bacteria evolve faster than we can isolate and sequence them.

Even brewer's yeast is discarded after a few generations, usually, since it
mutates enough to change the flavor of the resulting beer, and that's in an
extremely well controlled environment.

Imagine that happening every six weeks in your gastrointestinal tract.
Multiply by 6 billion people. I'd guess it's extremely unlikely we're going to
thoroughly investigate all of those different variations on the theme.

~~~
giblaz
Take a large sample of people and find out patterns in their gastrointestinal
bacteria, and run the numbers.

Is it out of the question for people to be consistently pooping & supplying
this data so we have ongoing tracking of the ratios of the various bacteria
present in the population? Some clear patterns may arise.

~~~
dlss
Clear patterns did arise when the Human Microbiome project did this :)

[http://academy.asm.org/images/stories/documents/FAQ_Human_Mi...](http://academy.asm.org/images/stories/documents/FAQ_Human_Microbiome.pdf)

That represents the consensus view (ie no exotic theories). The really good
stuff starts on page 10.

~~~
ssully
This is actually really interesting, thanks for sharing.

They talk about mother's milk/breast milk being a source of microbes for
babies at birth. I have heard this before and I wonder if it could be an
alternative to this pill/fecal transplants?

~~~
dlss
It depends what you're using the feces to accomplish. Usually FMT is done for
people suffering from CDiff infections. The healthy gut flora outcompete the
CDiff, causing the infection to go away.

Mother's milk is mostly viruses, so it's unlikely this would work against
CDiff. For other users is sounds interesting though!

------
PaulAJ
We're clearly at the very beginning of this. Using someone else's gut flora in
the hope that it will sort out yours is on a par with pre-scientific herbal
medicine: trial and error, and it often worked, but you don't know why.

In the future the medical system will analyse your gut flora and identify the
specific mix of strains you need to take to remedy the situation.

------
api
Are probiotics bunk? Or do they only include a few species and not the
complete biodiversity really needed in the human digestive system?

~~~
derefr
Probiotics contain individual bacterial species, to help people who might be
missing that one species, where we know that species serves an important
function—they make sense for the same reason people missing one nutrient would
take a supplement for that one nutrient (e.g. vitamin C.)

The alternative to taking one of these foecal pills would be to take lots of
_different_ probiotics, in appropriate portions, over time. This is, after
all, what animals do naturally to create gut microbiomes in the first place.
(It's hypothesized that this is why we like the taste of things like blue
cheese: maximizing gut-biome biodiversity is apparently good for reproductive
fitness, so we've evolved to enjoy the taste of things with novel bacteria on
them.)

------
cpncrunch
Yet another open-label study posted on HN. The placebo effect will play a
large part in every patient treated with this, so how do we know if the pill
had any effect over and above placebo? Really, this study is a waste of time
and money.

~~~
kevinalexbrown
It's a first step. Preliminary studies like this are important: before
investing a huge amount of money into proper studies, it's fiscally prudent to
take smaller steps.

Instead of going straight for the generic criticism, you might ask "what's
cool about this study?"

~~~
cpncrunch
It doesn't really tell us anything, like all open-label studies (except
perhaps whether or not the treatment is dangerous and whether it _might_
provide a benefit). Also it doesn't really cost any more to do a small-scale
placebo-controlled trial vs an open-label study.

Overall open-label studies just give false hope to people who don't understand
science and the placebo effect (i.e. most people).

~~~
refurb
I've never seen (although it might be possible) the placebo effect cure a
bacterial infection. C. difficle infections are notoriously difficult to
treat, even with specific drugs like Dificid.

If an open-label, uncontrolled study of fecal transplants cures a ton of
people, that's very strong evidence that it works.

Closed, double-blinded clinical trials offer different value for different
diseases.

That's why the FDA will accept an open-label, uncontrolled clinical trial for
a drug that treats cancer.

~~~
cpncrunch
The study didn't show that the treatment cured the infection. It just found
that bowel movements decreased, and patient self-rated health increased. The
placebo effect has been shown to have a significant effect on diarrhea for
IBS:

[http://www.webmd.com/ibs/news/20101221/secrecy-may-be-
unnece...](http://www.webmd.com/ibs/news/20101221/secrecy-may-be-unnecessary-
for-placebo-effect)

Also, there are currently no RCTs showing the effectiveness of fecal
transplant for C difficile, and a Nature review cautions that there will be a
strong placebo effect for invasive procedures:

[http://tcminfection.com/pdf/5%20(119).pdf](http://tcminfection.com/pdf/5%20\(119\).pdf)

(This particular study isn't invasive, but it is highly novel, and that has
also been shown to correlate with a large placebo effect).

~~~
refurb
I didn't look into the details of this particular trial, so if in fact it did
just look at patient self-rated health then yes, placebo effect could be a big
factor.

I have seen other open-label uncontrolled studies for fecal transplant that
had some pretty spectacular outcomes. Is such a trial as rigorous as a RCT?
No, but it's a pretty positive signal.

