Prevention
SIBO is a disorder that relapses because eradication itself does not always correct the underlying cause, which is thought to be a deficiency of the migrating motor complex (MMC) in many cases. The MMC moves bacteria down into the large intestine during fasting at night and between meals, clearing them from the small intestine (SI) on a daily basis. Bacteria can repopulate the SI within 2 weeks of finishing antibiotics, herbal antibiotics or elemental diet, without prevention, though it may take longer. If diet alone is used as treatment, the underlying causes must still be addressed for optimal improvement.
In 2006 Dr Pimentel shared his prevention protocol which includes a prokinetic drug (motility agent) and a lower carbohydrate diet. The combined use of these two (#'s 1 & 2 below) are of key importance for prevention.
The main strategies for prevention are:
For more details on prevention, please see the prevention section of my article Small Intestine Bacterial Overgrowth: Often Ignored Cause of IBS (page 2), and my class videos.
In 2006 Dr Pimentel shared his prevention protocol which includes a prokinetic drug (motility agent) and a lower carbohydrate diet. The combined use of these two (#'s 1 & 2 below) are of key importance for prevention.
The main strategies for prevention are:
- Stimulate the migrating motor complex (MMC), the bacterial cleansing wave of the SI, with a prokinetic drug
- Follow a SIBO diet ongoing
- Supplement with Hydrochloric Acid (HCl), the antibacterial acid of the stomach, if deficient
- Remove proton pump inhibiting drugs (PPI's), and antacids, a cause of reduced HCl and risk factor for SIBO
- Correct Ileocecal Valve Syndrome (IVC), the physical barrier to bacterial backflow from the large intestine (LI)
- Correct neurological deficits and dysfunctions, including sympathetic dominance
- Treat any concomitant diseases that contribute to SIBO
For more details on prevention, please see the prevention section of my article Small Intestine Bacterial Overgrowth: Often Ignored Cause of IBS (page 2), and my class videos.
Prokinetic Dosing
The following information is provided for physicians. A trial removal of the prokinetic after at least 3 months is suggested, but continued long-term use may be needed. Prokinetics studied for SIBO include:
Low-dose Naltrexone (LDN)- 2.5 mg for diarrhea types or 5 mg for constipation types, at bedtime (Ploesser et al)
Low-dose Erythromycin- 50 mg at bedtime (Pimentel et al). Compounding necessary for this low dose, or quarter a 250mg pill to get 62.5 mg.
Tegaserod (Zelnorm)- 2-6 mg at bedtime (Pimentel et al)
Tegaserod has a higher success rate for SIBO prevention than erythromycin (Pimentel et al) but has been withdrawn
from the US market for safety reasons.
Prucalopride (Resolor/Resotran) .5-1 mg at bedtime (not available in the United States but available in Canada and some European countries) is a safer alternative to tegaserod (Manabe et al) but has not been directly studied for SIBO.
Low-dose Naltrexone (LDN)- 2.5 mg for diarrhea types or 5 mg for constipation types, at bedtime (Ploesser et al)
Low-dose Erythromycin- 50 mg at bedtime (Pimentel et al). Compounding necessary for this low dose, or quarter a 250mg pill to get 62.5 mg.
Tegaserod (Zelnorm)- 2-6 mg at bedtime (Pimentel et al)
Tegaserod has a higher success rate for SIBO prevention than erythromycin (Pimentel et al) but has been withdrawn
from the US market for safety reasons.
Prucalopride (Resolor/Resotran) .5-1 mg at bedtime (not available in the United States but available in Canada and some European countries) is a safer alternative to tegaserod (Manabe et al) but has not been directly studied for SIBO.
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