SIBO Treatment

1. Starve or kill the overgrowth. (elemental diet • antibiotics • herbals)

2. Strengthen defenses to prevent relapse. (prokinetics • meal spacing)

3. Give the gut time to heal. (transition diet)

4. Stay vigilant.

Note about hydrogen vs methane

Hydrogen SIBO is the easiest to eradicate and is usually associated with diahrhea. Methane SIBO is harder to treat, is often associated with constipation, and requires a different protocol, as do SIFO and hydrogen sulfide SIBO.

Elemental diet vs. prescription antibiotics vs. herbal antibiotics

Which treatment is right for you?

• Elemental diet

• Prescription antibiotics

• Herbal antibiotics

Severe cases and those on a tight timeline will probably benefit from the elemental diet as a first-line approach, while more moderate cases may choose prescription or herbal antibiotics.

Each person responds differently. You may need to experiment to see what works best for your specific case of SIBO.

Main treatment options:

Elemental Diet

Summary:

The elemental diet is extremely effective at reducing methane and hydrogen gas counts. It essentially starves the bacteria until they die. Some people have seen their gas numbers drop from over 100ppm within two weeks, while others will need three weeks for the best impact.

Elemental diet instructions are linked here.

How it works:

This liquid diet has all the nutrients that a person needs, broken down into their simplest, most digestible forms. It is so easily absorbed that your body is able to process the food before the bacteria have a chance to get to it for themselves. Without a food source, most bacteria are not able to survive past two to three weeks.

Things to consider:

• This option is not for the feint of heart. It tastes foul and requires serious commitment, but there is an 80%+ success rate for just two to three weeks of hard work.

• Due to the high simple sugar content, there is an increased chance of yeast overgrowth. Some people supplement with anti-fungal drugs (nystatin mainly since it stays in the gut) or supplements during treatment. If you decide to do that, just be careful that the supplements don't contain any complex carbs that could help the otherwise starving bacteria survive.

• This unfortunately starves the large intestine too, potentially harming microbiome health.

• If you don't feel 80-90% better and/or test results aren't negative, move on to other treatment methods until you achieve that result, but remember to stay on a SIBO diet and prokinetic between rounds of treatment to prevent recolonization (read more about this below).

• There is limited added benefit past three weeks.

• Die-off symptoms can be severe and can last for the entirety of treatment.

Prescription Antibiotics

Summary:

Prescription antibiotics can effectively treat SIBO. They take a little longer versus an elemental diet, but they are quicker than herbal antibiotics. The downside for many is cost / insurance coverage.

Top prescription antibiotic options:

Things to remember:

• Treat no longer than two weeks at a time, then take a couple of weeks off to prevent clinical resistance and to test for progress.

• Keep treating with any method until you feel 80-90% better and/or test results are negative.

• Multiple rounds are often required. The higher your gas numbers on the SIBO breath test, the longer your expected total treatment time is.

• Stay on the diet and take a prokinetic agent between rounds to prevent backsliding (more on prokinetics in section 2 below).

• With the exception of rifaximin, be careful using the same prescription antibiotics over and over for each subsequent round of treatment as the risks grow with long term use. Maybe sub in a round of herbals to keep the bacteria guessing, especially if prescription antibiotics didn't help much.

Herbal Antibiotics

Summary:

Herbal antibiotics work more gradually but can be just as effective as prescription antibiotics. For someone with really high methane or hydrogen gas levels, this could mean six months or more of treatment. The main benefits to herbal antibiotics is that they are available without a prescription, often cost less, and provide additional benefits such as mild anti-fungal and anti-biofilm activity.

Herbal antibiotic options:

Things to remember:

• Pick two of these at a time! And if you have methane predominant or constipation SIBO, you absolutely have to include allicin (beware of garlic supplements containing anything but allicin or "allisure"... need it pure, not with all those FODMAPS typically found in whole garlic!).

• Use a SIBO diet while treating.

• Treat no longer than six weeks at a time, then take a couple of weeks off to prevent clinical resistance and to test for progress.

• Stay on the diet and take a prokinetic agent between rounds to prevent backsliding (more on prokinetics in section 2 below). Keep treating with any method until you feel 80-90% better and/or test results are negative.

• Multiple rounds are often required. The higher your H2 or CH4 numbers on the SIBO breath test, the longer your expected total treatment time is, especially with herbal antibiotics.

• Cycle through different herbs on each round of treatment, especially if your progress is stalling. Unfortunately there aren't many herbal antibiotic alternatives to allicin for methane.

• There is usually only downside to using more than two herbs at the same time.

Other eradication tips

• Hydrogen sulfide SIBO often doesn't respond to any of the treatments above. Bismuth (as in Pepto Bismol or bismuth sub nitrate or citrate) at 2000mg/d for two to four weeks is supposed to help (if OTC, go with capsules and try to find them without sugar alcohol like Target's Up & Up brand).

• Fungal SIBO also known as SIFO is fairly common. While many of the herbal antibiotics listed here are also anti-fungal, something stronger is usually called for, such as a prescription anti-fungal (nystatin) or targeted herbal anti-fungal formulas. Anti-fungal treatments can benefit from anti-biofilm agents.

• While it may be best to avoid probiotics (especially those with prebiotics as a main ingredient ex: FOS), there is some evidence that lactobacillus reuteri 17938 can help treat methane-predominant SIBO.

• Similarly, Atrantil is an over the counter supplement that helps reduce methane SIBO symptoms. The reason I didn't feature it more prominently is because it doesn't get rid of the methane as much as it just manages it. Many people swear by Atrantil, so go ahead and try it out, but it ultimately needs to be taken on an ongoing basis to continue to work (not too different from prokinetics for chronic SIBO suffers).

• Anti-biofilm agents generally aren't supposed to help that much, and a lot of herbal antibiotics actually have anti-biofilm mechanisms of their own. However, for tough cases, I've read that bismuth can be an effective anti-biofilm treatment addition (as well as a good treatment for hydrogen sulfide SIBO).

• Trials are going on for SYN-010, a statin-like drug that is supposed to inhibit methane production in the gut.

• Online Canadian pharmacies like Mark's Marine are often much cheaper for prescription drugs and are easy to use.

Gut motility is your friend.

We've heard this over and over from Dr. Siebecker, the #1 defense against SIBO is a strong migrating motor complex (MMC).

Most cases of SIBO stem from a dysfunctional MMC, and there are two things that can really help:

• Prokinetics

• Meal Spacing

Prokinetics

Prokinetics keep things moving along in your digestive system. They are extremely useful in both constipation and diarrhea SIBO cases.

Prokinetic options:

Important things to know:

• Prokinetics work best for SIBO when taken right before bed on an empty stomach with no eating at least 2 hours before. No eating overnight either for a minimum of 10 hours fasting after dinner.

• Use prokinetics between rounds of treatment and ongoing for at least for at least a month after SIBO eradication. For me it is a no-brainer cheap insurance policy against relapse even if you aren't sure that your SIBO is chronic.

• Natural prokinetics aren't as effective as prescription. And sometimes even prescription prokinetics are not enough. You can combine them for additive effects. The OTC combo I'd try first is Iberogast + Ginger + 5HTP combo.

• Higher doses = stronger effect. Constipation cases might dose in the upper range (ex: 1-2mg for rx). If you get worsening diarrhea for more than a few days, reduce the dose and/or try something different.

• Effectiveness can fade over time, especially for erythromycin.

• You can use online pharmacies for these too. See Resources.

• There are other prescription options such as low dose naltrexone and domperidone (not available in US due to safety concerns).

• Erythromycin is easier to get insurance coverage for right now in the US. If you want prucalopride to be covered by insurance, I've heard that idiopathic constipation that hasn't responded to prescription laxatives is the best angle to take.

Meal Spacing

Extremely important along with prokinetics to keep the MMC healthy and to keep SIBO at bay. The MMC doesn't kick in until a few hours after a meal, so if you snack all day, you really don't get any significant gut motility while the sun is up. That's what meal spacing is trying to combat.

This one is easy to explain with a few simple rules:

• Meals 4-5 hours apart. Shoot for 5 hours if possible.

• No snacking, calories, or large volumes of liquid between meals.

• No eating or large volumes of liquid within at least 2 hours of bed.

Example schedule = Breakfast 8AM, Lunch at 1PM, Dinner at 6PM

Other things to consider

• Addressing the underlying cause as much as possible (i.e. avoiding another round of food poisoning)

• HCL supplements

• Digestive enzyme supplements

• Stress reduction / exercise

• And more

Stay on a SIBO diet for at least a month after eradication

Now that SIBO is gone and we've propped up the MMC-led SIBO defenses, your GI tract needs time to heal. The small intestine lining in particular needs to be restored for proper digestive functioning, which can take up to four weeks or more.

Slowly start to introduce more foods as you heal. Proceed with caution, noting which foods and portion sizes do and don't bother you. It is an individualized trial-and-error approach; there is no one-size-fits-all.

Eventually you may be able to return to 100% normal eating, but staying a little carb-conscious would probably benefit all SIBO sufferers in the long run.

Diet makes a huge difference with symptom management- one of the best tools out there and easiest levers to pull.

You can also consider supplements like resveratrol, L Glutamine, IgG / colostrum, turmeric, quercetin, lion's mane aqueous extract, and many others to accelerate healing.

See the Resources page for more details on various SIBO diets.

Try to live normally, but don't get too cozy.

As of now, the majority of SIBO cases are chronic, so a relapse is likely.

Stay with the prokinetic, stay carb-conscious, keep fasting between meals, etc. Enjoy the newfound freedom from SIBO, but don't let your guard down too much.

If you begin to relapse, try to catch it early to make re-treatment less onerous.

If you do relapse...

Now that you know what treatments work for you, it will be easier this time around. The trend is for people to have longer and longer periods of remission as they learn how to read the signs and better manage and treat their SIBO condition.

Who knows you... might be one of the lucky ones that is cured forever. And even if you aren't, there are hopeful new research developments occurring on a seemingly monthly basis.

Most all of the over the counter supplements discussed on this page are available on Amazon. I purposely didn't put affiliate links in here because ethically I think it makes it all a lot simpler if I'm not trying to make money off you.

Otherwise you'll need prescriptions from a doctor and either good health insurance / drug coverage or be willing to pay out of pocket (my choice is this Canadian pharmacy because it was cheap and easy).