In this article, we will discuss integrative medicine modalities for treating SIBO (small intestinal bacterial overgrowth). To learn more about SIBO symptoms and testing, bookmark this article.
There are several categories of therapies that we will focus on:
- Prescription antibiotics
- Antimicrobial herbs
- Additional agents
Low FODMAPs diet
Low FODMAPs diet stands for a diet low in fermentable oligo-saccharides, di-saccharides, mono-saccharides and polyols. These fermentable carbohydrates are food for bacteria that are overgrowing in the small intestine. If we cut the food supply for the bacteria, we are going to prevent further growth and re-population. Low FODMAPs diet is typically recommended between 4-12 weeks, after treatment of SIBO, before a gradual re-introduction of foods.
As it can be difficult to prepare meals that strictly adhere to low FODMAPs, I often recommend Epicured food delivery to patients, to supplement their home-cooked low FODMAPs meals. The Monash University low FODMAP diet app can also be helpful in providing guidance with low FODMAPs diet. Note that this is not intended to be a long term diet, not only because it is impractical, but also because it is restrictive and, as a result, can lead to nutritional deficiencies.
SIBO Info website has a wealth of information on dietary protocols for SIBO. Given that the low FODMAPs diet is restrictive, it is important to work with your healthcare provider on the timeline and strategy of food re-introduction.
Elemental diet for 14-21 days has also been shown to be effective in improving bowel symptoms and eradicating SIBO. It is usually recommended for individuals who cannot tolerate antibiotics or who do not respond to antibiotic therapy. To learn more about it, continue to read here.
As a longer-term dietary solution, that is not as restrictive as low FODMAPs, Dr. Mark Pimentel and his team developed a low fermentation diet at Cedars-Sinai. This diet is more practical to maintain long term.
For hydrogen sulfide SIBO, a low sulfur food plan is recommended. This involves reducing foods such as cruciferous vegetables, dried fruits, papaya, pineapple, grapes, legumes, onions, peas, meat, eggs, and dairy products.
The recommended therapy for hydrogen positive SIBO is rifaximin. The typical regimen is 550mg by mouth three times daily for 14 days.
The recommended therapy for intestinal methanogenic overgrowth is combination therapy of rifaximin and neomycin for 14 days. The rifaximin dose is the same as above, and the neomycin dose is 500mg by mouth twice daily.
For patients who have a contraindication to neomycin, rifaximin in combination with metronidazole 250mg by mouth three times daily is often used.
Patients who experience no improvement in symptoms or worsening symptoms after two courses of antibiotics, should be evaluated by a gastroenterologist for alternative diagnoses.
Due to the cost of rifaximin, intolerance to certain antibiotics, or lack of efficacy of antibiotic treatment, some individuals may turn to antimicrobial herbs.
One retrospective study where data was reviewed from over 100 patients found that efficacies of both the combination of Candibactin BR and Candibactin AR and the combination of FC-Cidal and Dysbiocide (2 capsules twice daily of each supplement) supplements were equivalent to the efficacy of rifaximin for the treatment of SIBO. Forty six percent of those taking herbal therapy had a subsequent negative breath test, while 34% of those on rifaximin had a subsequent negative breath test, but this difference was not statistically significant. In this study, the supplements and rifaximin were administered for 4 weeks after a positive breath test for SIBO. Note that the dose of rifaximin was slightly lower than the currently prescribed dose (1200mg/day total dose vs currently prescribed dose of 1650mg/day total dose). The herbal preparations mentioned above contain a mixture of herbs have anti-microbial properties, and thereby act together to eradicate the thriving populations of bacteria in the small intestine. Interestingly, when the patients who failed rifaximin treatment were subsequently subjected to a course of triple antibiotic therapy vs a course of the above regimens of antimicrobial herbs, both groups had the same response rate (approximately 60%). Of note, this is a small study, and not a randomized-controlled trial. It is important to obtain more high-quality evidence, from large randomized-controlled trials to gain more insight into efficacy of these supplements.
Allicin is the biologically active component of garlic and is recommended for methane-positive SIBO. It can be added to rifaximin alone, or to antimicrobial herbs. While the duration of supplemental support can vary, it is typically 1 month. It is important to note that unlike garlic itself, allicin is low FODMAPs.
Other Supplemental Regimens
Neem is potent antimicrobial herb, which can be used for SIBO.
Berberine complex also has antimicrobial activity and can be used for SIBO.
Oregano is another antimicrobial herb often used for SIBO.
It is important to note that herbal supplements, just like medications, can interact each other, with medications, as well as cause adverse and unintended side effects, which can be serious. Some herbal supplements are contraindicated in certain disease states. It is important to seek guidance from a qualified, licensed healthcare provider, when considering starting a supplemental regimen. Note that the antimicrobial herbs do not have the same level of scientific evidence for their use as antibiotics do for the treatment of SIBO.
While treating SIBO by using nutritional and antimicrobial therapies, it is important to address any potential predisposing factors for SIBO.
Prokinetic medications (such as erythromycin or metoclopramide) or supplements (such as MotilPro or Motility PRO), which promote gastrointestinal motility, may be helpful after antimicrobial treatment to maintain remission. Pancreatic insufficiency can be addressed with the use of pancreatic enzymes, and hypochlorhydria or achlorhydria can be addressed by addressing its root cause.
What About Probiotics?
A meta-analysis found that probiotics do not prevent SIBO but that they can reduce hydrogen gas concentration, reduce abdominal pain and reduce daily stool frequency. A small study of individuals with functional constipation found that when probiotic Lactobacillus reuteri was administered for 4 weeks, methane production on lactulose breath test significantly decreased from baseline.
Additional Herbs for Symptom Support
Iberogast and Atrantil are two additional herbal preparations that have been found to alleviate symtpoms of SIBO.
Iberogast contains angelica archangelica, caraway, peppermint oil and chamomile, which relax the intestinal smooth muscle. In addition, digestive bitters contained in it promote digestion by causing stimulation of the vagus nerve. These herbs in Iberogast help improve wave-like muscle contractions that move food down the digestive tract.
Atrantil is a product made of three botanical extracts: Quebracho Colorado, Horse Chestnut, and Peppermint. It has been found to relieve bloating and abdominal discomfort by relaxing the muscles of the GI tract, killing overgrowing bacteria, using up hydrogen gas (so that there is less of it to be made into methane), and shutting down methanogenic archaea’s fuel source.
When Should I Be Retested After Treatment?
This is typically done 2-4 weeks after completing the antimicrobial protocol.
It is important to note that 40% of people with SIBO have persistent symptoms after the initial course of antibiotics. Individuals who do not respond to two courses of antibiotics should be further worked up for gastrointestinal pathologies by a gastroenterologist.
If you live in NY, CA, CT or NJ and have documented SIBO or have symptoms of it, including bloating, gas, nausea, abdominal discomfort or cramping, diarrhea, or constipation, call our practice at 646.627.8000 or contact us here for a complimentary discovery call with Dr. Bojana Jankovic Weatherly.