Today we’re back and finishing my SIBO series with part 3! If you haven’t already, go back to parts 1 and 2 for the 101 on SIBO (small intestinal bacterial overgrowth), testing, and causes. Right now, we’ll be diving into different treatment options for SIBO, as well as ways to prevent it. Just remember, none of this information is meant to replace your doctor. It’s just for you to look over to make the best choices for your health! If you suspect you have SIBO, then please work with a functional medicine doctor or GI specialist. Now, let’s not waste any more time and get started!

First, Get to the Root Cause

I recommend understanding the cause of your SIBO before trying to remove it. Why? Because you’re more likely to cause a relapse. Not only that, your symptoms may come back with a vengeance. If you want to go back and forth between expensive tests, supplements, and antibiotics, then, by all means, ignore the causes. In all seriousness, though, to make sure your SIBO doesn’t come back, you need to identify the culprits. It may be due to low thyroid, estrogen excess, poor bile flow or stomach acid, a stealth infection (H. Pylori, Lyme, mono, etc.), motility disorder (gastroparesis, vagus nerve dysfunction), extreme stress, or low immune function. I cover these causes more in part 2, but these are all known for creating an overgrowth.

Second, Consider Your Options

When getting rid of SIBO, you have a few options. These are based on insurance, budget, how extreme or mild your symptoms are (look back at part 1), and even your root causes. Here’s an overview of treatment strategies for SIBO:

Antibiotics

If you remember in part 1, there are different types of SIBO. The type of SIBO you’ve been diagnosed with will determine the prescription you’ll be given.

Hydrogen-predominant SIBO-D is given rifaximin (xifaxan).

Methane-predominant SIBO-C is trickier to remove and requires a combination of rifaximin and either neomycin or metronidazole.

Hydrogen-sulfide is a newer type of SIBO; from what I’ve read, it’s treated similarly to the other types. A dead giveaway for hydrogen sulfide overgrowth is a “rotten egg”-like smell to your gas and stools. [1]

The antibiotics used to treat SIBO target the small intestine, so they have fewer side effects. Surprisingly, they may also help to promote the growth of healthy new bacteria once they’re gone! They also work fast and have plenty of research to support their effectiveness. However, they’re not cheap, costing up to $1,500 without insurance, and many companies don’t cover them. Some people report feeling nausea and dizziness, but these symptoms aren’t common. [2]

Antimicrobials 

Then there’s the natural route. Whether it’s due to insurance or wanting to avoid antibiotics altogether, they’re a legitimate alternative. Research shows that they’re as effective (though not as quick) as rifaximin (see above). The downside to antimicrobials is that they’re obviously not covered by insurance and can also be expensive. You also need to be careful where you buy them online since many companies sell diluted or even fake versions of the ones used in the research. Ordering through your doctor is best. People often need to do several rounds of antimicrobials to see any benefits, which can take months. Finally, antimicrobials may cause side effects. People with a sensitive or inflamed gut should be slow and careful. Other symptoms include more bloating, gas, fullness, diarrhea or constipation, and stomach upset. Finally, if you’re not a fan of taking a lot of pills, you may want to consider simplifying things by going the antibiotic route. [1] [2] [3]

The most common antimicrobials used for SIBO include Atrantil (a supplement designed for SIBO-C by a GI doctor), Biotics FC Cidal with Dysbiocide, Metagenics Candibactin AR with Candibactin BR, allicin (from garlic), oil of oregano, berberine, neem, and cinnamon. [2]

Elemental Diet

This is one diet you MUST do under medical supervision. The Elemental Diet is a 2-3-week diet that replaces all meals with Elemental Formula, which is a powdered meal replacement supplement providing essential nutrients, amino acids (protein), carbs (glucose or maltodextrin), and fat. Other than consuming the Elemental Formula and water, you’re abstaining from all other foods and drinks. It’s almost like a fast.

On the one hand, the Elemental Diet was shown to have an 80-84% success rate in eliminating SIBO. It works fast and is effective for people with extreme gut sensitivities and poor reactions to both antibiotics and antimicrobials. But on the other hand, the Elemental Diet is not cheap- whether you buy the actual formula or make one yourself- and is very hard to follow. You won’t be having any solid food for at least half a month. And the actual formula itself isn’t very tasty. A side note about the formulas is that many of them are very high in sugar, which can lead to an overgrowth of yeasts like Candida (which is why many practitioners end up prescribing an antifungal like Nystatin to go along with the formula). [2] [4]

Or, Get to the Root Cause

In some cases, all you need to do to reverse SIBO is to fix the root cause. For example, if a slow thyroid (hypothyroid) is causing slow bowel movements (motility), then fixing it might speed up digestion, and eliminate SIBO. Like I mentioned before, getting to the root cause should be your priority. Not only can it prevent a recurrent overgrowth, but it may also keep you from having to take antibiotics, antimicrobials, or the Elemental Formula.

A Note on FODMAP

While the FODMAP diet keeps the bacteria from overgrowing, it’s not going to fix SIBO directly. The diet itself is only meant to be followed for a short period of time since removing beneficial fibers from the diet can starve the gut and cause dysbiosis (bacterial imbalances). FODMAP is meant to provide symptomatic relief; it doesn’t fix the problem or get to the root cause. [5]

Preventing SIBO

To prevent SIBO, you need to maintain a healthy lifestyle. This includes managing your stress, supporting the gut, and keeping a close eye on hormones. Many doctors also have their patients regulate their motility through the use of prokinetics, which keep bowel movements consistent and prevent another overgrowth. The use of prokinetics is usually between 1-3 months. You’ll either be using a pharmaceutical (low-dose erythromycin, naltrexone, prucalopride) or supplement (5-HTP, ginger, Iberogast). It’s also recommended that you leave 4-5 hours between meals and avoid snacking. [1] [2]

Probiotics are not a tried-and-true treatment for SIBO. They can either make symptoms worse or help improve them. Not only that, there are different types of probiotics to use. [6] There’s soil-based probiotics, lacto or bifido ones, and saccharomyces boulardii, a probiotic-like yeast. Your doctor will determine whether probiotics are right for you during treatment. Digestive enzymes, bile salts, and HCL (acid) may also be used to improve digestion and allow the gut to heal. Other recovery supplements include prebiotic powders, l-glutamine, DGL (deglycyrrhizinated licorice), and aloe vera.

Over and Out

Whew! And there you have it, everyone. Probably one of the longest gut health posts I’ve made in a while. I hope this information has helped and would love your feedback!

Sources:

[1] https://www.hopkinsmedicine.org/gastroenterology_hepatology/diseases_conditions/small_large_intestine/small-intestinal-bacterial-overgrowth.html
[2] https://www.charteredwellness.com/blog/how-to-get-over-sibo/
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030608/
[4] https://www.ncbi.nlm.nih.gov/pubmed/14992438
[5] https://www.monashfodmap.com/blog/faq-low-fodmap-diet-is-helping-to/
[6] https://www.health.com/digestive-health/sibo-causes-digestive-issues