Probiotics for SIBO

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While the main strategy for treating SIBO is with antibacterials, probiotics, which are beneficial bacteria, may be supportive in various ways, such as decreasing SIBO, symptom management, decreasing the risks of antibiotics, increasing antibiotic effectiveness and helping the microbiome. Studies show probiotics can reduce SIBO symptoms up to 71%, decrease leaky gut, lower SIBO gas levels, and even eradicate SIBO as the only treatment used, with a pooled eradication rate of 62.8%.[1] [2] [3] [4] [23] However overall, study data on this topic is considered low quality, and is inconsistent, with no benefit and symptom worsening also seen.[2] [5] Clinically, results differ individually, spanning a spectrum from symptom aggravation to symptom benefit. These differences may be due to which probiotic was used and how well it suits that individual. Probiotics can be used before, during or after antibacterial treatment.

Affiliate links include Amazon and Fullscript.

Which Probiotics Are Used For SIBO

Probiotics can be divided into three categories.[9] All three categories of probiotics have shown benefit for SIBO in studies, as single species, combinations from the same category and combinations from different categories.[2] 

Three Categories of Probiotics used in SIBO Studies
The following species have been studied for SIBO:
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1. Lacto-Bifido

• Lactobacillus - acidophilus, bulgaricus, casei, delbrueckii, longum, paracasei, pentosus, plantarum, reuteri, rhamnosus
• Bifidobacterium - bifidum, breve, infantis, lactis, longum
• Streptococcus - faecalis, thermophilus
• Enterococcus - faecium

2. Yeast - Saccharomyces boulardii 

3. Spore/Bacillus (soil-based)

• Bacillus - clausii, coagulans (L. sporogenes)

If one category or strain of probiotic doesn't help, or worsens symptoms, another category or strain might be tolerated and may help symptoms.

Are Probiotics OK for SIBO?
Many are concerned probiotics could worsen SIBO or cause a relapse. SIBO experts have different opinions about using probiotics for SIBO. My opinion is that while probiotics are not required or mandatory for SIBO, the potential benefits, outweigh the potential risks.

Potential risks can be decreased by first trying probiotics before or along with antibacterial treatment rounds, since antibacterials decrease bacterial load. And if a probiotic worsens symptoms, effects can be reversed by simply discontinuing the probiotic. [1] In this case, a different probiotic strain or category may still be tolerated.

What about Bifidus?
The SCD diet, often used for SIBO, specifies no bifidus in supplements or yogurt. However for SIBO, bifidus tends to be very helpful and well tolerated, and additionally is often tolerated by those with Histamine Intolerance/MCAS (common in SIBO). 

Why Symptoms Can Get Worse With Probiotics

• Histamine: probiotics can contain or produce histamine and histamine intolerance is common in SIBO.
• Gas: probiotics can indirectly lead to gas production through cross-feeding: other bacteria can turn the acids probiotics make into gas. 
• Prebiotics: many probiotic supplements contain prebiotics, which can worsen SIBO symptoms. As a precaution, avoid probiotics with prebiotics as a main ingredient with a mg listing. However, prebiotics in the "other ingredients" are often tolerated due to their small amount. Download my free Problematic Supplements for SIBO Handout.

Probiotics for SIBO Masterclass with Dr. Hawrelak

Watch Here

Probiotic Resources

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See a list of my favorite probiotics for SIBO carried at Fullscript (professional supplement dispensary U.S.)

Probiotics Studied for SIBO
Lacto-Bifido single-species

• Biogaia: Protectis Baby Drops or larger size (L. reuteri DSM 17938) - 2 x day x 4 weeks significantly decreased methane with eradication in 55% and increased BM frequency in constipation cases,[12] also reduces pain and manages diarrhea [13] [21] [22]    
• Yakult (L. casei Shirota) - 65 ml/day x 6 weeks reversed hydrogen SIBO in 64%, decreased "wind" and overall symptoms [16] 

Yeast single-species

• Florastor or exclusive pricing at Fullscript (Saccharomyces boulardii) - eradicated hydrogen SIBO in 80% [19] and 33% with reduced diarrhea, pain, bloating and flatulence [18] and reduced hydrogen.[17] Studies use "Florastor" and unnamed brands/strains of S. boulardii.

Spore single-species

• Enterogermina or exclusive pricing at Fullscript (Bacillus clausii) - 56% eradication of hydrogen SIBO [14] [PDF], improves constipation, diarrhea, bloating with 90% satisfied to extremely satisfied [20]
• Thorne Bacillus Coagulans or exclusive pricing at Fullscript (Bacillus coagulans) - eliminated hydrogen SIBO in 93%, eliminated pain, decreased bloating, belching and diarrhea.[24] (Study used B. coagulans + FOS after 2 weeks antibiotics.) Best probiotic for reducing pain in IBS. [25]

Combo

• Lactolevure (S. boulardii, B. lactis, L. acidophilus, L. plantarum) - 1 cap 2 x day x 4 weeks decreased total symptoms by 71% [15]
  - ProbioMax DF or exclusive pricing at Fullscript (ProbioMax DF has the same ingredients as Lactolevure)
• L. acidophilus + L. casei (cerela 431 + 730) - decreased daily number of stools and significantly reduced hydrogen.[23] Studied strains unavailable but species are common in multi probiotics.
  - any multi probiotic listed here (Fullscript)
  - Ultimate Flora 15 Billion or exclusive pricing at Fullscript    
• Various lacto-bifido combos - show overall good results for SIBO.[2] Strains/brands unlisted but species are common in multi probiotics. 
  - any multi probiotic listed here (exclusive pricing at Fullscript)   
  - Ultimate Flora 15 Billion or exclusive pricing at Fullscript
• MegaSporeBiotic or exclusive pricing at Fullscript (B. clausuii + B. coagulans) - studied separately for SIBO (see above). Megaspore studies show decreased overall IBS symptoms, improved quality of life [26], increased bacterial diversity [27], protects against antibiotic induced dysbiosis, supports intestinal immunity, decreases intestinal inflammation [28]
• Triple Therapy Probiotic (15% off code ALLISON15) - all 3 categories in one (lato-bifido + yeast + spore)

​Probiotics Studied for GI (IBS) Symptoms (alphabetical)

• Align - improves bloating and normalized BM frequency [59] [62]
• Bio K - improved: stool consistency 91%, stool frequency 154%, bloating 89%, quality of life 65%. For constipation: improved stool consistency 71%, stool frequency 185%, satisfaction with bowel habit 32% [50]
• Bio Kult - significantly reduced BM frequency, pain, and improved quality of life [51]
• Culturelle Health & Wellness or exclusive pricing at Fullscript - reduces antibiotic associated and infectious diarrhea [53] [54]
• Ideal Bowel Support or exclusive pricing at Fullscript - improves pain, bloating, reduces BM frequency, prevents GI symptoms from antibiotics [63] [64]
• Life Extension - Bifido GI Balance or exclusive pricing at Fullscript - significantly improves stool consistency and BM frequency in constipation cases [57] [58] [65]
• VSL#3/#4 (Amazon: pills, packets) or (exclusive pricing at Fullscript) - reduces diarrhea from various causes and bloating [55]. Constipation improvements: increased BM frequency, consistency, bloating [61]
• Gut-Brain Reset (formerly ZenBiome Dual) - significantly reduced symptom severity, including pain/discomfort, bloating, distension, urgency, straining, gas, depression, anxiety and improved sleep quality. [29] Often tolerated by those with histamine sensitivity/MCAS.

Probiotic Food
The SCD diet popularized 24-hour lactose free yogurt as helpful for SIBO and other GI conditions. Then Dr. Davis added a twist, by specifying certain starter cultures for added benefit and called it "SIBO Yogurt" (see below for more info).  

Lactose Free Yogurt 
Low fat for diarrhea/high fat for constipation (fat can stimulate large intestine motility)

• Commercial: i.e. “Green Valley”, "Fage lactose free", "White Mountain 24 hour" or non-dairy yogurt
• Homemade: 24-hour Yogurt recipe 
  Starter for 24-hour yogurt: Yogurmet or Yogurmet Probio
• Homemade: "SIBO Yogurt" recipe  
  Starters for "SIBO Yogurt"
  • 1. BioGaia Gastrus + 2. Mercola Biothin (or exclusive pricing at Fullscript) + 3. Digestive Advantage or HU 58 (or exclusive pricing at Fullscript) + 4. Dextrose 
    
  • SIBO Yogurt explanation, and video recipe (note: dextrose can be used vs inulin)

Lactose Free Kefir

• i.e. “Lifeway”, "Green Valley"

Real fermented sauerkraut juice or other fermented vegetable juice (from the jar)

• i.e. "Bubbies", "Firefly", "Cleveland"

Probiotics with Antibiotics
Studies show probiotics actually enhance the effect of antibiotics.[33] [34] [35] [36] Additionally, probiotics are often taken with antibiotics to prevent yeast overgrowth, microbiome disruption [11] and antibiotic associated symptoms (like diarrhea). [52] [53] [54]
Studied options for this include: 

• Saccharomyces boulardii - "Florastor" (Amazon) or Various (exclusive pricing at Fullscript)
• Culturelle Health & Wellness (Amazon or exclusive pricing at Fullscript)  
• MegaSporeBiotic (Amazon or exclusive pricing at Fullscript) [27]

Dose: taken during antibiotics, and for 6 weeks after for microbiome protection

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More Resources - Microbiome playlist on my YouTube  

Probiotic Resource - Probiotic Advisor by Dr. Jason Hawrelak, is a great resource to look up which probiotics have been studied for specific conditions and symptoms 

For more details about probiotics and SIBO, see Courses, join a Q&A, and sign up for Dr. Siebecker's newsletter .

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