Prevention of SIBO Relapse

SIBO is a disorder that relapses [1] [2] because bacterial eradication itself does not always correct the underlying cause(s).[3] In a multi-center study, two-thirds of cases relapsed at an average of 2.5 months after successful treatment.[2] Therefore, prevention of relapse is just as important as antibacterial treatment (antibiotics, herbal antibiotics, elemental diet) to stay well long-term. Use of a prokinetic and a SIBO diet are two of the most important prevention strategies.

Why Does SIBO Relapse?

SIBO is a condition that is caused by something else. Antibacterial treatment (antibiotics, herbal antibiotics, elemental diet) treats the overgrown bacteria, but doesn't treat the reason why the bacteria overgrew in the first place. This means that SIBO will relapse if the cause of the SIBO has not been addressed.[3] Unfortunately, some of the causes of SIBO currently have no cure and/or cannot be resolved. In these cases, prevention of relapse is especially important to extend remission periods.
However, not everyone with SIBO relapses. About one third of cases don’t relapse at all, need no further treatment, and are not chronic. But about two-thirds of SIBO cases relapse [2] which makes them chronic cases. It’s important to note that for the two-thirds with chronic SIBO, "chronic" doesn’t mean no improvement: symptoms are typically reduced by 70% to 90% with antibacterial treatment. It just means SIBO is not gone forever and prevention strategies are needed to maintain improvement and delay relapse. How quickly SIBO relapses varies widely, from weeks to years, based on underlying cause, previous SIBO treatment, prevention strategies, and individual factors.  
Rate of Chronic SIBO Cases

Main Prevention Strategies

  • Prokinetics
    Agents that stimulate the migrating motor complex (the cleansing wave of the small intestine), to move bacteria down and out of the small intestine. Depending on the prokinetic used, studies show they can delay SIBO relapse by 5-8.5 months.[4]
  • SIBO Diet 
    Standard SIBO diets are usually expanded to include more carbohydrates, as tolerated, during the prevention phase.  
  • Meal-Spacing
    Space meals 4-5 hours apart and fast 2 hours before bedtime (with a 12 hour overnight fast), to allow the migrating motor complex (MMC) time to clear bacteria out of the small intestine. (the MMC works during fasting)
See "Other Strategies" below for additional preventions.

Prokinetics for SIBO Prevention

Pharmaceutical
  • Prucalopride
  • Erythromycin
  • Low Dose Naltrexone (LDN)
Herbal
  • Iberogast / IBSShield
  • Ginger / Ginger containing formulas
  • Bitter Orange containing formula

See "Where to Get Prokinetics" below for products.
Prokinetics can significantly prevent the recurrence of symptoms after antibacterial treatment compared to no prevention.[4]
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Prucalopride has replaced the original prokinetic studied for SIBO (tegaserod), due to it's superior safety and effectiveness with the same mechanism of action [4] [5] [6] [7] and is considered the most effective prokinetic for SIBO. Tegaserod showed greater success than erythromycin at delaying SIBO relapse (8.5 months).[4] It has many benefits, including the ability to heal intestinal nerves, [19] [20] making it a good choice for SIBO from food poisoning (which damages GI nerves). 

Erythromycin is a antibiotic but in low-dose, has prokinetic activity with less antibacterial effects. It is commonly used for gastroparesis (slow stomach emptying). It is contraindicated with pre-existing heart conditions and has drug interactions that must be accounted for when prescribed.[28] Erythromycin delayed SIBO relapse by 5 months.[4] 

Low-Dose Naltrexone (LDN) is not technically a prokinetic, but has prokinetic effects [29] and delayed SIBO relapse in 62%.[8] It also improved GI symptoms mildly to markedly in 68%.[8] LDN has many benefits, including balancing the immune system, reducing inflammation and pain, helping mood and more.[21] [22] [23] [24] [25] It's used to help autoimmunity, making it a good choice for SIBO from food poisoning (which is autoimmune mediated).   

Herbal prokinetics have not been studied for SIBO. However, Iberogast [9] [10] [11] [12], Ginger [13] [14] [15] [16], Prodigest® (ginger + artichoke leaf) [17] [18] and Bitter Orange [26] [27] have been studied as effective prokinetics in other conditions. Herbal prokinetics have proven effective in clinical use for SIBO, but may not be strong enough in all cases of SIBO vs. pharmaceutical prokinetics.


Prokinetics are not laxatives, they primarily work on the esophagus, stomach and small intestine, and in SIBO, are used to stimulate the migrating motor complex (MMC) in the small intestine. Laxatives (i.e. magnesium, polyethylene glycol, senna, cascara, bisacodyl, linaclotide, lubiprostone, plecanatide) do not stimulate the MMC and thus cannot be used for SIBO prevention. However, GI side effects can occur from any medicine - if a prokinetic has a laxative effect, lower the dose or switch prokinetics.

When to Use Prokinetics 

1. Between antibacterial treatment rounds - to keep the improvements made and prevent backsliding while assessing if another treatment round is needed.

2. After successful antibacterial treatment to maintain and extend remission.

Prokinetics are started within a few days after antibacterial treatment ends, and as soon as the day after treatment ends. 

Prokinetic Duration

Prokinetics are typically used for at least 3 months after successful eradication. For chronic SIBO cases, they are used ongoing, long-term. 

They may be continued during Antibiotic or Herbal Antibiotic treatment rounds if desired. LDN dose is typically titrated up and thus is not started and stopped intermittently.

Prokinetics can be discontinued at any time - the only risk is SIBO relapse (in chronic cases). Decreasing the dose over time, allows monitoring of potential relapse. If a relapse occurs after discontinuation, prokinetics are indicated for longer duration (as is looking for the underlying cause if not known). 
Prokinetic Dosages
Prokinetics are taken at bedtime to stimulate the MMC overnight while fasting.

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Where to Get Prokinetics

Pharmaceutical prokinetics are available by prescription at pharmacies (compounding pharmacies for LDN). Herbal prokinetics are widely available commercially. 
Iberogast IBShield Gut Motivator MMC Restore Ginger/Ginger Prokinetic Formulas
Iberogast Herbal Prokinetic for SIBO
Iberogast / IBShield for SIBO
Ginger as a Prokinetic for SIBO
Ginger as a Prokinetic for SIBO

Combination Prokinetic Dosing

Prokinetics can be combined for greater effect since they have different mechanisms of action. This is especially helpful in tough cases of SIBO and when herbal prokinetics are not effective enough. They can be taken together at bedtime or apart at morning and bedtime. For example Prucalopride + LDN at night; Prucalopride p.m./erythromycin a.m.; Iberogast/IBShield + Ginger/Ginger formula; LDN with any other prokinetic while titrating dose up.
Exception: erythromycin with domperidone (or cisapride)

Diet for SIBO Prevention

While a SIBO Diet doesn't prevent relapse in itself, it can help delay it by reducing fuel for bacteria, like reducing fuel on a fire. For those with chronic SIBO, it's an essential tool for managing ongoing symptoms. After successful treatment, bacteria have been reduced, allowing more foods to be tolerated. Though experts have different opinions, my opinion is that SIBO diets can be expanded to include any tolerated foods during the prevention phase. Personal experimentation is needed to ascertain which foods may now be tolerated (don't create or aggravate symptoms) after successful antibacterial treatment.

When expanding diet, one can start with a) whatever food is most desired, b) would make recipes and eating out easier (i.e. onions and garlic), or c) is medically helpful (i.e. for weight gain, if underweight). Serving size makes a difference - smaller amounts may be tolerated while larger amounts may not. Many choose to begin with a small amount (1/8 to 1/4 a serving) and increase slowly, others prefer to start with a full serving size and stop if symptoms are aggravated.

Meal-Spacing
In addition to expanding foods, spacing meals 4-5 hours apart (no food or calorie-containing beverages) and fasting 2 hours before bed, is another key prevention. Meal-spacing allows the migrating motor complex time to clear bacteria out of the small intestine on a daily basis, helping to maintain post-treatment lower bacteria levels.

Other Strategies for Prevention

  • Support hydrochloric acid, the antibacterial acid of the stomach (if deficient) with Betaine HCl, Herbal/Digestive Bitters or apple cider vinegar (1 tsp in 1 cup water) before meals.
  • Consider discontinuing proton pump inhibiting drugs (PPIs) which reduce hydrochloric acid and are a risk factor for SIBO relapse[1]
  • Visceral Manipulation can help with motility and structural issues, as can other body work. (International Visceral Manipulation Practitioner Directory) 
  • Address Ileocecal Valve Syndrome if present, the physical barrier to bacterial back-flow from the large intestine. See chapter 15, Functional Gastroenterology by Dr. Sandberg-Lewis.
  • Address neurological deficits and dysfunctions, including sympathetic dominance (chronic stress) 
  • Treat any concomitant diseases that contribute to SIBO
For more details about prokinetics, diet and relapse prevention, see Courses, join a Q&A and join Dr. Siebecker's newsletter.
More Resources: SIBO Relapse Prevention playlist on my YouTube  
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