SIBO 4: How is it Treated? General Principles.
In this series on SIBO (Small Intestinal Bacterial Overgrowth), the previous topics have been relatively straight forward without much controversy. However, when it comes to the treatment of SIBO--it's a completely different story. As one of my medical mentors said so long ago: "It's not a good sign when there's a lot of different treatments for a single condition. It means there's not ONE good way to treat it." And he was right. There's no standardized treatment that works in every case, and when you find something that works for one person, the same treatment may be a failure for the next. Therefore, in my experience, the adage stands true: "If at first you don't succeed, try, try again." I have divided the treatment considerations into 4 categories below.
Starve the Overgrowth
A major aspect of treatment, as always, is the diet. We'll be dealing with each individual dietary approach in coming posts, so for now I'll just give a thumbnail sketch of each approach because they all have the same general purpose: Limit the food that the bacterial overgrowth loves to "eat." The low fermentable diet (a.k.a. low FODMAP diet) limits the foods that are highly fermentable in the GI tract. The Specific Carbohydrate Diet (SCD) has a slightly different protocol. The GAPS diet, SIBO specific diet, BiPhasic diet, etc. can all be researched online.
Kill (or suppress) the Overgrowth
The mainstay of the conventional medical approach remains the antibiotic Rifaximin for standard cases with the addition of Neomycin in cases of methane predominant SIBO. With this initial treatment, 40% will have persistent symptoms, and in those who respond, the recurrence rates at 3, 6, and 9 months have been shown to be 13, 28, and 44% respectively in the larger studies. With numbers like that, you might begin to get a picture of how difficult it is to treat SIBO--even with pharmaceutical antibiotics. Many, if not most of you who are reading this are probably thinking, "But standard antibiotics kill both beneficial and undesirable organisms--isn't there a gentler alternative that might spare most of the beneficials?" Well, you're right, standard antibiotics are like napalm: they can wipe out the entire bacterial landscape in the gut, and that might have a future effect on your optimal microbiome. The good news is that there are some effective natural (botanical) alternatives. These can be given either with or without pharmaceutical antibiotics. In some difficult cases, the combination of pharmaceutical and botanical may be what's necessary to achieve a response, but most of the time the botanicals are administered without the pharmaceutical. There are many categories of botanical antimicrobials including those with high berberine content (e.g. Gentian and Goldenseal), some with compounds such as allicin (e.g. garlic), and others with extracts from herbs such as oregano. These have been studied extensively for potential effectiveness in both bacterial and fungal infections. We'll get into specific product combinations in coming posts.
Replete Micronutrient Deficiencies
Another factor in the optimal treatment of SIBO is correction of any micronutrient deficiencies that may be the result of the condition. Testing of, and correction to optimal levels may be necessary for nutrients such as B12, fat-soluble vitamins (A, D, E, K), iron, thiamine, niacin, and others. In addition, many times there is an inflammatory component as well, and anti-inflammatory dietary measures as well as nutrient supplementation should not be neglected in these cases.
Motility of the small bowel and colon should always be addressed since "stagnation" is a major perpetuating factor in SIBO. If the contents of the small intestine are not "waved" on down the tract, the overgrowth is exacerbated. Prokinetic agents stimulate the "wave" called the migrating motor complex (MMC) that helps clear the small intestine. We are very thankful that Prucalopride (Motegrity is the trade name) is now available by prescription in the U.S.--but alas, it's very expensive and many insurance carriers don't cover it. Low dose naltrexone (also prescription) is also effective in some SIBO sufferers. I'm not a fan of full dose erythromycin because it causes nausea in many patients, but low dose is worth a try. There are also non-prescription motility enhancing agents that can be helpful including ginger root, Iberogast, SIBO-MMC, and (my favorite) Motil-Pro. All prokinetic (motility) agents should be taken at bedtime. Optimizing the MMC is crucial for the prevention of SIBO relapses.
There are other modalities that need to be incorporated into the treatment of SIBO and we'll address those in the future. There's a lot of info for you to digest for now. I hope this helps you on your quest to conquer SIBO!