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Comparison of Common Probiotic Products

Pre and Probiotics: Where the Strong Survive

Microorganisms are everywhere. The can protect us or make
us sick. The time has come to colonize our own microbes
against this pathogenic invasion. It is time to put nature back to
its original order and to employ the evolutionarily stronger
probiotic  bacteria— who have won the wars and battles against
pathogens for thousands of years.
We have excluded the
probiotics from our arsenal for too long. In fact, we have
unknowingly broken the backs of many of our probiotic
colonies. Our antimicrobial lifestyles have knocked probiotics
back a step and allowed the pathogens to get stronger.
However, it’s not too late.

This program clarifies not only what probiotics are and do, but
how they cooperate with our immune system to combat a
multitude of infections and diseases. Learn about: the history
of probiotics; what are prebiotics; what to look for on the
supplement label; how to find the best products; how foods can
be great probiotics; how to take probiotics and finally how our
health should improve when taking probiotics.
$40.00
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PL Detail-Document #280707
-This PL Detail-Document gives subscribers
additional insight related to the Recommendations published in-
PHARMACIST’S LETTER / PRESCRIBER’S LETTER
July 2012
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Copyright © 2012 by Therapeutic Research Center
P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com ~ www.pharmacytechniciansletter.com

  Probiotics are live organisms that provide therapeutic or preventative benefit for the host. The most commonly used probiotics are the lactic-acid producing bacteria bifidobacteria and lactobacilli. Probiotics also include the yeast
Saccharomyces boulardii.
  Probiotics are commonly promoted to strengthen the immune system or recolonize the gut or vagina with beneficial microbes. Accordingly, patients may express interest in using them to protect against infectious disease (e.g., influenza), antibiotic-Complimentaryd diarrhea, or vaginitis.  They are probably harmless in healthy patients.
76
  In rare cases (e.g., in immunocompromised patients), probiotics can cause infection.76,79 Avoid them in seriously ill patients unless there is a medical indication.79
 Treating 13 patients with a probiotic prevents one case of antibiotic-Complimentaryd diarrhea.
75 However, don’t rely on them to prevent C. difficile diarrhea.  
 
Also, they have not been proven as effective as antibiotics for prevention of recurrent UTIs.77 Efficacy of one probiotic product can’t be extrapolated to other products.76
  Use the chart below to help choose a product studied for the indication of interest.
**
See footnotes for definitions of efficacy designations.**
See footnotes for definitions of efficacy designations.

Product Contents Promoted Use Labeled Dose or Dose Used
in Studies
Efficacy
Activia yogurta
(Dannon/Danone [Canada])
Bifidobacterium lactis
DN-173 010b,4,5
At least 100 million live &
active bacteria per gram
Regulates digestive
system
4
Consume daily for two
weeks as part of balanced
diet and healthy lifestyle
4
Speeds gut transit time, but
has not been studied for
treatment or prevention of
constipation
1-4
Aligna (Procter & Gamble) Bifidobacterium infantis
35624
(Bifantis)
4 mg/capsule (1 billion
colony-forming units)
6
Promotes digestive
health
6
One capsule daily6 B. infantis is Possibly
Effective
c for abdominal
pain, bloating, and difficult
bowel movements
Complimentaryd with irritable
bowel syndrome
7,28
Bacid
(Erfa Canada Inc)
(Canada)
(Keep refrigerated.)
71
Lactobacillus rhamnosus70
One billion bacteria per
capsule
71
Restore and maintain
normal gastrointestinal
flora; prevent/treat oral
candidiasis and diarrhea
due to antibiotics;
management of
aphthous and herpes
stomatitis
70
Two capsules two to four
times daily, preferably with
milk or lactose
70
Insufficient Evidenceh when
used orally for any specific
symptom or disorder

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Product Contents Promoted Use Labeled Dose or Dose Used
in Studies
Efficacy
Bio-K+
(Bio-K+ International)
Lactobacillus acidophilus CL
1285,
L. casei LBC80R
12.5 billion (regular
strength), 25 billion (strong),
or 50 billion (extra strength)
live bacteria per capsule
9,84
50 billion active bacteria/98
g bottle fermented
beverage
49,51,83
Promotes and maintains
a healthy and balanced
digestive system
8
For digestive health:
one to two capsules daily,
46-
48,87-89
or one bottle (beverage)
daily for a month, then ½ to
one bottle daily (children one
to 12 years, one tablespoon to
½ bottle daily)(U.S.);
45 ½ to
one bottle daily one year and
older (Canada)
86
To prevent antibiotic
Complimentaryd diarrhea: one bottle
or two extra-strength capsules
daily within
24 to 48 hours of starting
antibiotic. Continue until five
days after stopping
antibiotic
49-51
Take two hours after
antibiotics
45-48,86-89
Possibly Effectivec for
reducing incidence and
duration of antibiotic
Complimentaryd diarrhea
(including
C. diff colitis) in
inpatients
49-51
Culturellea
(ConAgra Foods)
Continued…
Lactobacillus GG (a specific
strain of
L. rhamnosus)7
Culturelle Digestive Health
and
Culturelle Vegetarian
Health & Wellness:
10 billion bacteria plus inulin
200 mg per capsule
10,55,k
Culturelle Health &
Wellness: 10 billion bacteria
per capsule
54
Culturelle Kids Packets:
1.5 billion bacteria per
packet
52
Culturelle Digestive
Health: Improve
digestion and digestive
health, prevent gas and
bloating, support
immune system and
well-being, and reduce
travel-Complimentaryd
digestive complaints.
10
Culturelle Health and
Wellness and
Vegetarian Health &
Wellness: supports
immune system and
Culturelle Digestive Health
and
Culturelle Vegetarian
Health & Wellness:
To support immune and
digestive health: one
capsule daily
10,55
For digestive discomfort:
two capsules daily until
resolved
10,55
During travel (Digestive
Health product): two
capsules daily beginning
two to three days before
travel
10
Likely Effectived for
treatment of rotavirus
diarrhea in infants & young
children
7
Possibly Effectivec for
prevention of antibiotic
Complimentaryd diarrhea in
children,
e traveler’s
diarrhea,
e nosocomial
diarrhea in infants & young
children, & diarrhea in
malnourished children;
e as
an adjunct to treat and
prevent recurrence of
C.

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Product Contents Promoted Use Labeled Dose or Dose Used
in Studies
Efficacy
Culturelle, continued Culturelle Kids Chewables:
2.5 billion bacteria per
tablet
53
digestive health54,55
Culturelle Kids
products: Promote
health, support immune
system, and alleviate
occasional digestive
complaints
52,53
Children over one year old:
one capsule daily
10,55
Culturelle Health &
Wellness: one capsule daily
(adults and children over
one year old)
54
Culturelle Kids Packets (for
children 25 to 50 lbs):
To support immune and
digestive health: one
packet daily
52
For digestive discomfort:
up to seven packets daily,
spaced regularly through
the day
52
Culturelle Kids Chewables
(for children 50 to 100 lbs):
To support immune and
digestive health: one tablet
daily
53
For digestive discomfort:
two tablets twice daily
53
To prevent antibiotic
Complimentaryd diarrhea in
children: 10 to 20 billion
bacteria once daily
OR
20 billion bacteria twice
daily during treatment
7,e
difficile colitis;e for
treatment of eczema in
infants allergic to cow’s
milk; prevention of
allergies in infants when
taken during pregnancy and
lactation; and treatment of
chemotherapy-Complimentaryd
diarrhea
7

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Product Contents Promoted Use Labeled Dose or Dose Used
in Studies
Efficacy
DanActivea
(Dannon/Danone [Canada])
Lactobacillus bulgaricus
Streptococcus thermophilus
Lactobacillus casei
(strain
used in product is
trademarked
L. casei
Immunitas
[Defensis in
Canada])
11,12
Over 10 billion live and
active
L. casei per bottle12
Strengthen the body’s
defenses
56,12
Strengthen defenses: at least
one bottle daily
12
Prevention of antibiotic
Complimentaryd diarrhea
(hospitalized adults): one
bottle twice daily during
treatment and for one week
afterward
29,e
Possibly Effectivec for
preventing or reducing
severity of acute diarrhea in
infants and young children,
and prevention of
antibiotic-Complimentaryd
diarrhea (including
Clostridium difficile
diarrhea) in hospitalized
adults
7,13,14,29,e
Fem-dophilus: see RepHresh, below
Florajen
(American Lifeline, Inc.)
(U.S.)
(Refrigeration
recommended when
possible.)
73
Florajen:
Lactobacillus acidophilus66
20 billion live bacteria per
capsule
66
Florajen 3:
Lactobacillus acidophilus,
Bifidobacterium lactis, B.
longum
15 billion live bacteria per
capsule
67
Florajen4Kids:
Lactobacillus acidophilus, L.
rhamnosus
, Bifidobacterium
lactis
6 billion live bacteria per
capsule
68
Florajen Bifidoblend:
Bifidobacterium bifidum,
B. longum
10 billion live bacteria per
capsule
69
Florajen: restore and
maintain vaginal flora;
benefit intestinal health;
maintain immune
system
66
Florajen 3: restore and
maintain gastrointestinal
health; support immune
system; benefit vaginal
flora
67
Florajen4Kids:
maintain healthy
intestinal flora balance
68
Florajen Bifidoblend:
maintain healthy
intestinal flora balance
69
General use: One capsule
daily
66-69
Prevention of antibiotic
Complimentaryd diarrhea
(hospitalized adults): one
capsule three times daily
during treatment and for 14
days after the last dose of
antibiotic
72
Take one to two hours before
or after antibiotic (product
labeling).
73
(Note: Other sources
recommend separating from
antibiotics by at least two
hours.
7)
Possibly Effectivec for
preventing antibiotic
Complimentaryd diarrhea in
hospitalized adults
72

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Product Contents Promoted Use Labeled Dose or Dose Used
in Studies
Efficacy
Florastora,i (Biocodex)
(Do not refrigerate)
82
Saccharomyces boulardii lyo
250 mg per capsule or
packet
20
Protect against digestive
imbalance due to
antibiotics, travel, stress
diet, or other digestive
issues
20
Digestive health (two months
of age and older): one
capsule or packet twice
daily
81,82
Prevention of antibiotic
Complimentaryd diarrhea: two
capsules twice daily
beginning within three days
of antibiotics, and continuing
for three days after
discontinuation
15
Prevention of traveler’s
diarrhea: one or two
capsules daily beginning five
days before travel and
continued for duration of
trip
22
To prevent C. difficile
recurrence: two capsules
twice daily for four weeks
(with appropriate
antibiotics)
16
HIV-Complimentaryd diarrhea:
1 gram three times daily,
tapered to 1 gram daily to
control diarrhea
17
Tube-feed diarrhea: 500 mg
four times daily; has been
used for up to 28 days
18,19
Possibly Effectivec for
prevention of antibiotic
Complimentaryd diarrhea,
traveler’s diarrhea,
f and
diarrhea in tube-fed
patients; prevention of
recurrence of
C. difficile
colitis (adjunctive therapy);
treatment of HIV
Complimentaryd diarrhea; and
treatment of diarrhea in
infants
7,22

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Product Contents Promoted Use Labeled Dose or Dose Used
in Studies
Efficacy
Howaru
Howaru Protect
a
(Danisco)
(Refrigeration
recommended when
possible.)
74
Lactobacillus acidophilus
NCFM
Bifidobacterium lactis Bi-
07
31
10 billion live bacteria per
capsule or stick
30,33
5 billion live bacteria per
tablet
32
Strengthen natural
defenses
21
Capsules or sticks: one
daily
30
Tablets: two tablets per
day
32
Reducing cold and flu
symptoms in children:
5 billion bacteria twice
daily
31
Possibly Effectivec for
preventing & reducing
duration of cold and flu
symptoms, antibiotic use,
and absenteeism in children
3-5 years old when taken
for six winter months
31
Jamieson Probiotic Sticks
(Jamieson Natural Sources)
(Canada)
Lactobacillus helveticus and
Bifidobacterium longum41
1 billion colony-forming
units per powder stick
41
Balances gut flora to
maintain health,
decreases stress-related
digestive symptoms
41
One powder stick daily with
a meal
41
Possibly Effectivec for
stress-related digestive
symptoms (e.g., pain,
nausea, vomiting, etc)
41
Kefir
(Lifeway)
Lactobacillus lactis, L.
rhamnosus, L. plantarum, L.
casei, L. acidophilus, L.
reuteri, Leuconostoc
cremoris, Streptococcus
diacetylactis, Saccharomyces
florentinus, Bifidobacterium
longum, B. breve, B. lactis
39
7 to 10 billion colony
forming units per cup
39
Keep harmful bacteria
in check
39
Not stated Possibly Ineffectiveg for
preventing antibiotic
Complimentaryd diarrhea
40,e

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Product Contents Promoted Use Labeled Dose or Dose Used
in Studies
Efficacy
Lactinexa
(Becton, Dickinson and
Company)
(Refrigeration strongly
recommended.)
34
Lactobacillus acidophilus, L.
bulgaricus
(or helveticus)
1,000,000 colony-forming
unit/tablet; 100,000,000
colony-forming unit/packet
34
Not specified Four tablets three or four
times daily or one packet
three or four times daily
34,e
Lactinex is Possibly
Ineffective
g for antibiotic
Complimentaryd diarrhea,
e
infectious diarrhea, and
traveler’s diarrhea
23-25
Probaclac
(Nicar Laboratories, Inc)
Continued…
Adult, children’s (Canada),
and mild (Canada) formulas:
Lactobacillus acidophilus, L.
rhamnosus
, L. bulgaricus, L.
casei, Streptococcus
thermophilus
,
Bifidobacterium bifidum, B.
longum
(U.S. products also
contain inulin.
k)42,60
B. breve added to extra
strength formula, substituted
for
L. acidophilus in senior
formula (U.S.) and for
L.
casei
in
50+ formula (Canada);
B.
breve
and L. plantarum
added to traveler formula
(U.S.);
B. breve and
Saccharomyces boulardii
added to traveler formula
Canada)
57-60
Probaclac SB Medic
(Canada):
Saccharomyces
boulardii
, Lactobacillus
bulgaricus
, L. helveticus,
Streptococcus thermophilus
U.S.: Balance intestinal
flora, digestive health,
normal digestive
function, and support
body’s defenses
42,57-59
Canada (adult,
children’s, 50+,
travelers, extra-strength
formulas): Provide
bacteria that contribute
to healthy intestinal
flora
60
SB Medic formula
(Canada): for diarrhea
60
Adult, senior, extra-strength
formulas, U.S.:
Maintenance: one capsule
daily with a meal
42,57,58
To restore flora balance:
one capsule two or three
times daily
42,57,58
Travelers formula:
Beginning a week before
travel and while traveling,
take one capsule twice daily
with a meal
59
Adult, children’s, 50+
formulas, Canada: one
capsule once or twice daily
before breakfast and/or
supper
60
SB Medic formula, Canada:
one capsule twice daily with
breakfast and supper, or two
hours after taking antibiotic.
Continue for at least a week
after antibiotic use
60,e
Insufficient Evidenceh
when used orally for any
specific symptom or
disorder

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Product Contents Promoted Use Labeled Dose or Dose Used
in Studies
Efficacy
Probaclac, continued 3 billion active bacteria per
capsule (children’s and mild
formulas, [Canada]),
5 billion active yeast per
capsule (SB Medic and
traveler formulas, Canada), 6
billion active bacteria per
capsule (adult formula,
Canada),
8 billion active bacteria per
capsule (50+ formula,
Canada),
10 billion active bacteria per
capsule (traveler formula
[U.S.] and extra strength
formula [Canada]), 12 billion
active bacteria per capsule
(adult formula, U.S.), 15
billion active bacteria per
capsule (senior formula), 20
billion active bacteria per
capsule (extra strength
formula, U.S.)
42,57-60
Extra-strength formula,
Canada: one capsule two or
three times daily
60
Mild formula, Canada: one
capsule daily with breakfast
60
Take two hours after
antibiotics.
90
RepHresh Pro-Ba
(Lil’ Drugstore Products,
Inc)
Fem-dophilusa
(Jarrow Formulas)
(Also called
Urex-Cap-5.)64,65
(Keep refrigerated.)63
Lactobacillus rhamnosus
GR-1,
L. reuteri RC-1461,63
5 billion colony-forming
units per capsule
63,78
Promote vaginal health
and balance flora
(
RepHresh Pro-B and
Fem-dophilus)61,63
Support urinary tract
health (
Fem-dophilus)63
Maintain vaginal health:
One capsule daily
61,63
Support urinary tract health
(
Fem-dophilus): One
(increased to two, if needed)
capsule daily
63
Bacterial vaginosis: One
capsule twice daily
62
UTI prevention: One
capsule twice daily
77
Possibly Effectivec as an
adjunct to oral
metronidazole for treatment
of bacterial vaginosis,
62,e
and for prevention of
recurrent urinary tract
infections in
postmenopausal women
77

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Product Contents Promoted Use Labeled Dose or Dose Used
in Studies
Efficacy
VSL#3a,j
(Sigma-Tau
Pharmaceuticals)
(Requires refrigeration, but
can be kept at room
temperature for up to a
week with no potency
loss)
80
Lactobacillus acidophilus, L.
plantarum
, L. paracasei, L.
bulgaricus, Bifidobacterium
breve
, B. infantis, B. longum,
and
Streptococcus
thermophilus
35
450 billion live bacteria per
packet
35
225 billion live bacteria per
two capsules
35,36
NOTE: Dosing for children
based on age, weight, and
number of bowel
movements daily. See
product information.
Provide probiotics to
protect the
gastrointestinal tract and
modulate intestinal
inflammation to aid in
the management of
ulcerative colitis,
irritable bowel
syndrome, and ileal
pouch
36
Bloating and gas Complimentaryd
with diarrhea-predominant
irritable bowel syndrome:
½ to one packet or two to
four capsules daily
26,27,36
Pouchitis, remission
(maintenance): two to four
packets or six to 18 capsules
daily
26,36
Ulcerative colitis, remission
(maintenance): one to two
packets or four to eight
capsules daily
26,36
Ulcerative colitis, active
(adjunct): four to eight
packets or 16 to 32 capsules
daily
26,36
(In studies, total daily dose
divided [i.e., BID].)
7,44
Possibly Effectivec for
maintenance of remission
in pouchitis; bloating
Complimentaryd with diarrhea
predominant irritable bowel
syndrome; achievement and
maintenance of remission
in ulcerative colitis
7,27
Yakulta
(Yakult U.S.A. Inc.)
Lactobacillus casei Shirota37
8 billion active bacteria per
80 mL bottle
37
Balance digestive
system and maintain
health
37,38
Balance digestive
system/maintain health: One
to two bottles daily
37
Chronic constipation: One
bottle daily
43
Insufficient Evidenceh for
reducing constipation
severity, softening stool,
and increasing stool
frequency
43
Yogurt Content varies. Choose a
product with the National
Yogurt Association’s seal to
assure the product contains
100 million live and active
bacteria per gram (e.g.,
Dannon, Yoplait)7
N/A Prevention of antibiotic
Complimentaryd diarrhea: Four to
eight ounces twice daily
7,e
Yogurt is Possibly
Effective
c for prevention of
antibiotic-Complimentaryd
diarrhea
e or recurrent
vaginal candidiasis
7

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Definitions of Effectiveness Ratings and Helpful Notes:
a. Brand used in studies
b. Also referred to as
Bifidobacterium animalis, Bifidus Regularis (U.S. product), and BL Regularis (Canadian product).4,5
c. Possibly Effective: A randomized trial, meta-analysis, or at least two epidemiologic studies show positive outcomes without substantial
evidence to the contrary. The studies have low to moderate risk of bias and moderate to high validity. However, the evidence is limited by
quantity, quality, or contradictory findings.
There is insufficient high-quality evidence to recommend for most people.
d. Likely Effective: Two or more randomized trials or meta-analyses including several hundred patients consistently show positive outcomes.
The studies have low risk of bias and high validity.
Evidence supports recommending.
e. Separate from antibiotics by at least two hours. Antibiotic may kill bacterial probiotics.7
f. Study used Perenterol, a similar product not readily available in North America.
g. Possibly Ineffective: A randomized trial, meta-analysis, or at least two epidemiologic studies show negative outcomes without substantial
evidence to the contrary. The studies have low to moderate risk of bias and moderate to high validity.
Use should not be advised.
h. Insufficient Evidence: There is not enough reliable scientific evidence to provide an Effectiveness Rating.
i. Systemic antifungals (e.g., fluconazole, itraconazole, ketoconazole, posaconazole, voriconazole) could reduce efficacy.
7
j. A medical food intended for use under the supervision of a physician.36
k. Inulin is a nonabsorbable oligosaccharide found in many fruits and vegetables. Commercially, it is usually obtained by hot water extraction
from chicory root. It is used as a prebiotic, a “food” for probiotics.
7
Users of this document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical
judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national
organizations. Information and Internet links in this article were current as of the date of publication.

(PL Detail-Document #280707: Page 11 of 14)
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Project Leader in preparation of this PL DetailDocument: Melanie Cupp, Pharm.D., BCPS
References
1. Marteau P, Cuillerier E, Meance S, et al.
Bifidobacterium animalis strain DN-173 010 shortens
the colonic transit time in healthy women. A doubleblind randomized controlled study.
Aliment
Pharmacol Ther
2002;16:587-93.
2. Meance S, Cayuela C, Turchet P, et al. A fermented
milk with
Bifidobacterium animalis strain DN-173 010
shortened oro-fecal gut transit time in elderly.
Microb
Ecol Health Dis
2001;13:217-22.
3. Meance S, Cayuela C, Raimondi A, et al. Recent
advance in the use of functional foods: effect of the
commercial fermented milk with
Bifidobacterium
animalis
strain DN-173 010 and yogurt strains on gut
transit time in the elderly.
Microb Ecol Health Dis
2003;15:15-22.
4. Dannon. Get answers to frequently asked questions
about
Activia. http://www.activia.us.com/activiabenefits/faqs. (Accessed June 7, 2012).
5. Danone.
Activia FAQ.
http://www.danone.ca/en/products/activia/faq.
(Accessed June 7, 2012).
6. Procter & Gamble.
Align product information.
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(PL Detail-Document #280707: Page 12 of 14)
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www.pharmacistsletter.com ~ www.prescribersletter.com ~ www.pharmacytechniciansletter.com
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2012).

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42. Nicar laboratories.
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58. Nicaro laboratories.
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(PL Detail-Document #280707: Page 13 of 14)
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Copyright © 2012 by Therapeutic Research Center
P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com ~ www.pharmacytechniciansletter.com
59. Nicaro Laboratories. Probaclac Traveler Probiotic.
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60. Nicaro Laboratories.
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79. Marteau P, Seksik P. Tolerance of probiotics and
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87. Bio K+ International Inc. Regular probiotic capsules.
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88. Bio-K+ International Inc. Strong probiotic capsules.
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89. Bio-K+ International Inc. Extra strength probiotic
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90. Nicar laboratories.
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http://www.probaclac.com/faq. (Accessed June 20,
2012).

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Cite this document as follows: PL Detail-Document, Comparison of Common Probiotic Products. Pharmacist’s
Letter/Prescriber’s Letter. July 2012.

(
PL Detail-Document #280707: Page 14 of 14)
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