SIBO Treatment Protocol

[EIRE24]

My mom was the one with SIBO but she tells me the SIBO symptoms are gone but tend to come back if she stops the herbs. I think it takes some 1 year of herbs to get rid of it. She had tried the antibiotic route with no luck.

Can you advise me which herbs to take that worked for your mother?

 

[Queequeg]

Can you advise me which herbs to take that worked for your mother?

sure
"1-3 of the following herbs x 4 weeks per course, at highest levels suggested on product labels.
Allicin from Garlic (the highest potency formula I know of is Allimed)
Oregano
Berberine- found in Goldenseal, Oregon Grape, Barberry, Coptis, Phellodendron
Neem
Cinnamon"
Herbal Antibiotics

and never take probiotics again. I think that is a big reason for the huge increase in people with SIBO.

 

[EIRE24]

sure
"1-3 of the following herbs x 4 weeks per course, at highest levels suggested on product labels.
Allicin from Garlic (the highest potency formula I know of is Allimed)
Oregano
Berberine- found in Goldenseal, Oregon Grape, Barberry, Coptis, Phellodendron
Neem
Cinnamon"
Herbal Antibiotics

And this is all at once I take them?

 

[Queequeg]

And this is all at once I take them?

"1-3 of the following herbs x 4 weeks per course, at highest levels suggested on product labels." she takes 3 but i think needs to mix it up so you dont get any resistant strains

 

[EIRE24]

"1-3 of the following herbs x 4 weeks per course, at highest levels suggested on product labels." she takes 3 but i think needs to mix it up so you dont get any resistant strains

Ok thank you. I'm guessing the garlic would be the strongest

 

[Queequeg]

Ok thank you. I'm guessing the garlic would be the strongest

To b e clear you want allicin which is made from garlic. I think oregano is actually stronger. I would get all of them and rotate them. Take 3 at a time and switch every 4 weeks. from my reading SIBO is very hard to get rid of.

 

[EIRE24]

To b e clear you want allicin which is made from garlic. I think oregano is actually stronger. I would get all of them and rotate them. Take 3 at a time and switch every 4 weeks. from my reading SIBO is very hard to get rid of.

But this does seem to get rid of it?

 

[Queequeg]

there is a study i linked to in the thread that shows herbs work as good or better than the standard treatment. If this doesnt work there are dietary changes etc to try

 

[Prosper]

sure
"1-3 of the following herbs x 4 weeks per course, at highest levels suggested on product labels.
Allicin from Garlic (the highest potency formula I know of is Allimed)
Oregano
Berberine- found in Goldenseal, Oregon Grape, Barberry, Coptis, Phellodendron
Neem
Cinnamon"
Herbal Antibiotics

and never take probiotics again. I think that is a big reason for the huge increase in people with SIBO.

Are these oils or what?

 

[TheBeard]

As far as minimizing gut bacteria to limit endotoxins, would it be better to take penicillin and doxicycline on empty stomachs?

The leaflets mention to take them with food to increase absorption, but absorption is not our goal here, we want a localized gut action.

If there is no food in the way, they could potentially act more efficiently?

 

[LUH 3417]

As far as minimizing gut bacteria to limit endotoxins, would it be better to take penicillin and doxicycline on empty stomachs?

The leaflets mention to take them with food to increase absorption, but absorption is not our goal here, we want a localized gut action.

If there is no food in the way, they could potentially act more efficiently?

I think the idea is you want an acidic environment in your stomach when you take them.

 

[TheBeard]

I think the idea is you want an acidic environment in your stomach when you take them.

What the reason behind this?

 

[LUH 3417]

What the reason behind this?

Well for tetracyclines specifically the calcium binds the medication from what I understand...for other meds recommended to be taken on an empty stomach the reasoning is that an alkaline environment will inactivate the drug. Sorry don’t know anything beyond that and it’s not a very good reason after all.

 

[Amazoniac]

It was nice to find this because it confirms many suspicions through a doctor's experience, you must've heard of him.

- Insights from Mark Pimentel on the treatment of SIBO

"I was recently diagnosed with a severe case of methane SIBO (which I’ve had for ~10 years without realizing that it was causing me to bloat constantly) and did a lot of research on what to do about it. By far, the most interesting insights came from about 100 emails plus a 1 hour in-person discussions with Mark Pimentel, who is arguably the world’s #1 expert on SIBO.

Because Mark was so generous of his time with me, and because there is so much misinformation on the web about SIBO, I wanted to document the unique insights I learned from him that I didn’t find elsewhere in the hopes that it will help others with this condition.

I’ve reviewed the contents of this summary with Mark for accuracy; he thought it was a great addition to the material he’s put on the web.

This article is concise because it is written for someone who already knows about the SIBO basics, but has more than likely been horribly misinformed along the way in one or more aspects. So this is like an erratum list for the stuff you’ve read so far.

Unfortunately, there is a lot of misinformation out there so this is a 26 minute read. But trust me, you’ll be glad you did! Even if you’ve read a lot about SIBO, you are almost certain to learn some new info that may lead to a much more successful outcome, with fewer side effects, and, in some cases, substantially lower out of pocket costs.

To save time, I’ve summarized the most important points at the top.

1. SIBO is basically a condition that is, in almost all cases, caused by poor gut motility (failure of the MMC to clean out your small intestine between meals). You cannot get SIBO unless you have a motility problem. Therefore, “curing SIBO” is only curing the symptom, not the disease.
2. If you don’t want it to reoccur, you must find out and fix the root cause of the motility problem. Finding out the root cause means a series of tests which may or may not include physical exam (especially listening to your stomach, upper endoscopy (with biopsies), intestinal MRI and CT scan, smartPill, IB smart blood test, etc). The list of disease states leading to SIBO are listed in Table 1 of Mark’s paper. So if you aren’t following a logical process to find the root cause, it’s going to keep happening and you’ll be stuck on taking a prokinetic each night for a long long time. Finding the root cause is most often a process of hypothesis and eliminating possible causes.
3. The 2 “golden rules” in order to get rid of SIBO and minimize recurrence are: 1) take a prokinetic pill and 2) eat discrete meals (for example at 8am, 1pm, and 6pm; ideally at least 4 hours between meals, and you do not want to eat right before bedtime).
4. You can “kill your way” out of SIBO with antibiotics, but that is only recommended at the very start to get to remission faster. Fix your motility is key. It’s way easier to flush the stuff out with a prokinetic than to kill it.
5. In most all cases, until you discover the underlying cause, the only thing you really need is a prokinetic. Mark’s favorite for the prokinetic is prucalopride taken at a low dose (typically .5mg each night before bedtime on an empty stomach, but for some can be less or more). For prucalopride, eat nothing for at least 4 hours before taking the pill at bedtime. Then, after taking the pill, try to fast as long as you can before eating something. The longer you fast, the greater the benefit. But don’t try to be a hero. There is no award for fasting for all 12 hours and nobody is going to test you and see how you are doing. The drug wears off in 12 hours so no point in fasting longer. Personally, i just eat when I wake up and don’t optimize the fasting period. NOTE: Prucalopride is now available in the US (as of April 2019)!
6. If you cannot tolerate prucalopride, there are other drug options (mentioned in Table 1 in Mark’s paper below): erythromycin and domperidone.
7. Using only these the two golden rules in #2 above, most people should be able to completely get rid of SIBO and keep it from recurring; one drug and one eating pattern. Total drug cost (if not covered by insurance): typically a little more than $1/day (if you are clever and buy the 2mg pill and split it into 4 pieces like I do).
8. Most people don’t know the 2 golden rules, so they relapse, sometimes quickly. I hear stories of people taking multiple rounds of antibiotics then herbs in between the antibiotics. This is insane. You really only should have one round of antibiotics tops, and then the pro-kinetic.
9. Mark’s Low-Fermentation Diet (LFD) guide [uploaded the file] is highly useful for understanding SIBO and how the digestive system works. It’s a short read, and full of great info and insights you won’t find anywhere else. Mark’s LFD is much easier to adhere to than any of the other SIBO diets (like SCD and FODMAP diets) because it allows a more options so you don’t feel deprived. The whole point of the diet is to identify foods that can be more fully digested and thus minimize bacterial growth. Some foods may not agree with you; avoid them. Some foods may be inappropriate for you, e.g., white bread and rice if you are a diabetic. The foods are simply a list of “relatively safe” foods in general. And you can cheat since the golden rules are the main drivers, not diet. The diet minimizes food for the bacteria if you have not yet addressed the underlying cause of your SIBO. Something is wrong to have caused you to get SIBO in the first place. The LFD is just meant as a stopgap until you discover the root cause of your SIBO. If the root cause is incurable, the the motility is key and the LFD becomes more important. However, if you can restore normal motility overnight through a prokinetic, the LFD is irrelevant since you are fully cleaned out every night. I did the LFD for awhile, but I now eat normally. Absolutely no change in symptoms. So be practical: try the LFD diet and if there are no changes in your symptoms, you have Mark’s permission to give it up.
10. While you are on the antibiotic regimen, you should ignore the diet. The bacteria are more easily killed when they are replicating so you want to feed them. Mark says, “I have told my patients from day one of rifaximin or treating with antibiotics — and this goes back to the 1980s; this is an old microbiological concept — happy bacteria, happy and well-fed bacteria, are more sensitive to antibiotics and are easier to kill. What that means is that most antibiotics work on the replicating cell wall of bacteria. When bacteria are in hibernation, starving, distressed, they wall off, don’t replicate, and they just sit there, waiting for conditions to improve. That’s a survival mode. So when the bacteria are in survival mode, antibiotics won’t penetrate and won’t work as well.”
11. While you can get rid of SIBO with ONLY a good prokinetic, you may be able to get rid of SIBO faster by starting with a 2 week antibiotic regimen. For methane dominant SIBO, the recommended treatment is 550 Rifaximin (Xifaxan)+ 250mg Metronidazole (Flagyl) taken 3 times a day for at least 14 days. This is slightly better than the combo with neomycin. Some people get stressed out about not tolerating the drugs. No problem. The antibiotics are optional.
12. A lot of people may make the mistake of upping the dosage of prucalopride which may lead to undesirable side effects. Also, note that Prucalopride will induce phase III MMCs only when taken in a fasted state. The whole point of prucalopride is give your intestines an extra “boost” during the longest fast of the day (overnight); therefore for SIBO it is prescribed at 25% of the “standard dosage” because the “standard dosing” for prucalopride is set by the labelled use (chronic idiopathic constipation (CIC)), not for SIBO patients. Personally, I found nearly zero difference in how I feel at .5 mg to 2 mg. So stick with the .5 mg unless you have a good reason to go higher. Always take fasted (>4 hours since last meal), right before bed. In my case, if I eat at 7pm, I’ll take the pill at bedtime. Otherwise, if I wake up at night, I’ll take the pill. The pill lasts for 12 hours so ideally you should not eat anything (including pills/medication!!) for 12 hours after taking the pill to get the fastest improvement and the most bang for your buck. If you can’t last 12 hours, don’t sweat it. I’m just citing the ideal. There is no benefit to fasting longer than 12 hours after taking the pill. So far, no side effects whatsoever doing it this way.
13. I asked Mark if you can simply flush the bacteria out of your small intestine by drinking a lot of water. NB: A lot of water will kill you so don’t do this! He said hydration makes no difference because water is absorbed very quickly so it’s not like you have any chance of “flushing” out the bacteria by supplementing with water. The small bowel when spread out is about half the size of a badminton court (previously they thought it was the size of a tennis court).
14. You can monitor your progress during treatment by doing “fasting” breath test. No substrate ingestion is required. Just fast overnight, brush your teeth, and take the breath test. This is not super accurate but is reasonably useful to see if you are making solid progress in the right direction as you consume the drugs. See below on the cheat that you can use to do this very economically. But I basically monitor symptoms. Doing “at home” breath tests is really over the top…suitable for analytical types like me and even I don’t do it.
15. You can NEVER win the war against bacteria by trying to starve it. Bacteria multiply by 2 every 12 hours. So if you could wipe out 99.9% of bacteria with an antibiotic, it will all return in just 5 days. So if you starve the bacteria, the stuff that grows back will be all replicas of the bacteria that is immune to starvation. This is evolution at its finest (especially so if you have methane SIBO; methanogens are very primitive and very hard to kill). This is why all the clever, innovative approaches people have proposed (Iodine, chlorine, ozone, …) are simply never going to work. You won’t kill it all and it comes back way too fast. Your ONLY hope of winning is to sweep it out of the small intestine with mechanical action, like a broom sweeping out debris. This is what the Migrating Motor Complex (MMC) is all about. MMC refers to the “gut clearing” waves that happen every 45–180 minutes between meals. If the gut clearing is weak, you get trash left over in the gut, i.e., SIBO.
16. About half the time, elemental diets do work, but they only work because they partially restore MMC function! Per Pimentel: “I think the elemental diet is working because it is absorbed in the first 3 feet of small bowel. So the latter 12 feet of small bowel do not see food and bacteria die and dramatically reduce in number. You might say “but in the first 3 feet there is all that good elemental stuff”. That area is tough for bugs because they get bombarded with acid (kills them). They get bombarded with bile (it’s a detergent and kills them) and they get bombarded with enzymes that try to digest them, from the pancreas (which can kill them). Also, If 12/15 feet of small bowel no longer have bacteria (starved out), that’s an 80% reduction in bacterial load.” But there has to be more going on than this. As noted even the previous point, even if you killed 99.9% of the bacteria this way, it will all come back in just 5 days! So what’s going on? Mark wrote, “We did see in a 2003 paper we wrote that when you get rid of SIBO, MMC are halfway normal. Not perfect. So still could use prokinetic in order to stay in remission.” In short, when you eradicate the SIBO, your MMC comes back halfway which can keep you from a remission and this remission is even more likely if you take a prokinetic. That’s why the Elemental Diet works for some people… kill + partial restoration of MMC.
17. Probiotics and prebiotics: Avoid. Probiotics have mixed results and prebiotics (fiber) is something you want to avoid since it ferments. But like I said, this is fine tuning. I pretty much ignore this myself and there is no symptomatic difference.
18. Methane from methanogens can cause constipation. So type of bacteria you have can cause C or D. But since we do not yet have hydrogen sulfide on the breath test, it’s still confusing because this gas can cause diarrhea. In short, you can have a normal-looking breath test and D, and be confused; the cause may be the gas you can’t (yet) measure (but that test is coming in May 2019 from Gemelli Biotech)."

 

[Osteo33]

This is fantastic info..just a question on prucalopride...are you sure its ok as its is a selective, high-affinity serotonin (5-HT4) receptor agonist

 

[accelerator]

It was nice to find this because it confirms many suspicions through a doctor's experience, you must've heard of him.

- Insights from Mark Pimentel on the treatment of SIBO

"I was recently diagnosed with a severe case of methane SIBO (which I’ve had for ~10 years without realizing that it was causing me to bloat constantly) and did a lot of research on what to do about it. By far, the most interesting insights came from about 100 emails plus a 1 hour in-person discussions with Mark Pimentel, who is arguably the world’s #1 expert on SIBO.

Because Mark was so generous of his time with me, and because there is so much misinformation on the web about SIBO, I wanted to document the unique insights I learned from him that I didn’t find elsewhere in the hopes that it will help others with this condition.

I’ve reviewed the contents of this summary with Mark for accuracy; he thought it was a great addition to the material he’s put on the web.

This article is concise because it is written for someone who already knows about the SIBO basics, but has more than likely been horribly misinformed along the way in one or more aspects. So this is like an erratum list for the stuff you’ve read so far.

Unfortunately, there is a lot of misinformation out there so this is a 26 minute read. But trust me, you’ll be glad you did! Even if you’ve read a lot about SIBO, you are almost certain to learn some new info that may lead to a much more successful outcome, with fewer side effects, and, in some cases, substantially lower out of pocket costs.

To save time, I’ve summarized the most important points at the top.

1. SIBO is basically a condition that is, in almost all cases, caused by poor gut motility (failure of the MMC to clean out your small intestine between meals). You cannot get SIBO unless you have a motility problem. Therefore, “curing SIBO” is only curing the symptom, not the disease.
2. If you don’t want it to reoccur, you must find out and fix the root cause of the motility problem. Finding out the root cause means a series of tests which may or may not include physical exam (especially listening to your stomach, upper endoscopy (with biopsies), intestinal MRI and CT scan, smartPill, IB smart blood test, etc). The list of disease states leading to SIBO are listed in Table 1 of Mark’s paper. So if you aren’t following a logical process to find the root cause, it’s going to keep happening and you’ll be stuck on taking a prokinetic each night for a long long time. Finding the root cause is most often a process of hypothesis and eliminating possible causes.
3. The 2 “golden rules” in order to get rid of SIBO and minimize recurrence are: 1) take a prokinetic pill and 2) eat discrete meals (for example at 8am, 1pm, and 6pm; ideally at least 4 hours between meals, and you do not want to eat right before bedtime).
4. You can “kill your way” out of SIBO with antibiotics, but that is only recommended at the very start to get to remission faster. Fix your motility is key. It’s way easier to flush the stuff out with a prokinetic than to kill it.
5. In most all cases, until you discover the underlying cause, the only thing you really need is a prokinetic. Mark’s favorite for the prokinetic is prucalopride taken at a low dose (typically .5mg each night before bedtime on an empty stomach, but for some can be less or more). For prucalopride, eat nothing for at least 4 hours before taking the pill at bedtime. Then, after taking the pill, try to fast as long as you can before eating something. The longer you fast, the greater the benefit. But don’t try to be a hero. There is no award for fasting for all 12 hours and nobody is going to test you and see how you are doing. The drug wears off in 12 hours so no point in fasting longer. Personally, i just eat when I wake up and don’t optimize the fasting period. NOTE: Prucalopride is now available in the US (as of April 2019)!
6. If you cannot tolerate prucalopride, there are other drug options (mentioned in Table 1 in Mark’s paper below): erythromycin and domperidone.
7. Using only these the two golden rules in #2 above, most people should be able to completely get rid of SIBO and keep it from recurring; one drug and one eating pattern. Total drug cost (if not covered by insurance): typically a little more than $1/day (if you are clever and buy the 2mg pill and split it into 4 pieces like I do).
8. Most people don’t know the 2 golden rules, so they relapse, sometimes quickly. I hear stories of people taking multiple rounds of antibiotics then herbs in between the antibiotics. This is insane. You really only should have one round of antibiotics tops, and then the pro-kinetic.
9. Mark’s Low-Fermentation Diet (LFD) guide [uploaded the file] is highly useful for understanding SIBO and how the digestive system works. It’s a short read, and full of great info and insights you won’t find anywhere else. Mark’s LFD is much easier to adhere to than any of the other SIBO diets (like SCD and FODMAP diets) because it allows a more options so you don’t feel deprived. The whole point of the diet is to identify foods that can be more fully digested and thus minimize bacterial growth. Some foods may not agree with you; avoid them. Some foods may be inappropriate for you, e.g., white bread and rice if you are a diabetic. The foods are simply a list of “relatively safe” foods in general. And you can cheat since the golden rules are the main drivers, not diet. The diet minimizes food for the bacteria if you have not yet addressed the underlying cause of your SIBO. Something is wrong to have caused you to get SIBO in the first place. The LFD is just meant as a stopgap until you discover the root cause of your SIBO. If the root cause is incurable, the the motility is key and the LFD becomes more important. However, if you can restore normal motility overnight through a prokinetic, the LFD is irrelevant since you are fully cleaned out every night. I did the LFD for awhile, but I now eat normally. Absolutely no change in symptoms. So be practical: try the LFD diet and if there are no changes in your symptoms, you have Mark’s permission to give it up.
10. While you are on the antibiotic regimen, you should ignore the diet. The bacteria are more easily killed when they are replicating so you want to feed them. Mark says, “I have told my patients from day one of rifaximin or treating with antibiotics — and this goes back to the 1980s; this is an old microbiological concept — happy bacteria, happy and well-fed bacteria, are more sensitive to antibiotics and are easier to kill. What that means is that most antibiotics work on the replicating cell wall of bacteria. When bacteria are in hibernation, starving, distressed, they wall off, don’t replicate, and they just sit there, waiting for conditions to improve. That’s a survival mode. So when the bacteria are in survival mode, antibiotics won’t penetrate and won’t work as well.”
11. While you can get rid of SIBO with ONLY a good prokinetic, you may be able to get rid of SIBO faster by starting with a 2 week antibiotic regimen. For methane dominant SIBO, the recommended treatment is 550 Rifaximin (Xifaxan)+ 250mg Metronidazole (Flagyl) taken 3 times a day for at least 14 days. This is slightly better than the combo with neomycin. Some people get stressed out about not tolerating the drugs. No problem. The antibiotics are optional.
12. A lot of people may make the mistake of upping the dosage of prucalopride which may lead to undesirable side effects. Also, note that Prucalopride will induce phase III MMCs only when taken in a fasted state. The whole point of prucalopride is give your intestines an extra “boost” during the longest fast of the day (overnight); therefore for SIBO it is prescribed at 25% of the “standard dosage” because the “standard dosing” for prucalopride is set by the labelled use (chronic idiopathic constipation (CIC)), not for SIBO patients. Personally, I found nearly zero difference in how I feel at .5 mg to 2 mg. So stick with the .5 mg unless you have a good reason to go higher. Always take fasted (>4 hours since last meal), right before bed. In my case, if I eat at 7pm, I’ll take the pill at bedtime. Otherwise, if I wake up at night, I’ll take the pill. The pill lasts for 12 hours so ideally you should not eat anything (including pills/medication!!) for 12 hours after taking the pill to get the fastest improvement and the most bang for your buck. If you can’t last 12 hours, don’t sweat it. I’m just citing the ideal. There is no benefit to fasting longer than 12 hours after taking the pill. So far, no side effects whatsoever doing it this way.
13. I asked Mark if you can simply flush the bacteria out of your small intestine by drinking a lot of water. NB: A lot of water will kill you so don’t do this! He said hydration makes no difference because water is absorbed very quickly so it’s not like you have any chance of “flushing” out the bacteria by supplementing with water. The small bowel when spread out is about half the size of a badminton court (previously they thought it was the size of a tennis court).
14. You can monitor your progress during treatment by doing “fasting” breath test. No substrate ingestion is required. Just fast overnight, brush your teeth, and take the breath test. This is not super accurate but is reasonably useful to see if you are making solid progress in the right direction as you consume the drugs. See below on the cheat that you can use to do this very economically. But I basically monitor symptoms. Doing “at home” breath tests is really over the top…suitable for analytical types like me and even I don’t do it.
15. You can NEVER win the war against bacteria by trying to starve it. Bacteria multiply by 2 every 12 hours. So if you could wipe out 99.9% of bacteria with an antibiotic, it will all return in just 5 days. So if you starve the bacteria, the stuff that grows back will be all replicas of the bacteria that is immune to starvation. This is evolution at its finest (especially so if you have methane SIBO; methanogens are very primitive and very hard to kill). This is why all the clever, innovative approaches people have proposed (Iodine, chlorine, ozone, …) are simply never going to work. You won’t kill it all and it comes back way too fast. Your ONLY hope of winning is to sweep it out of the small intestine with mechanical action, like a broom sweeping out debris. This is what the Migrating Motor Complex (MMC) is all about. MMC refers to the “gut clearing” waves that happen every 45–180 minutes between meals. If the gut clearing is weak, you get trash left over in the gut, i.e., SIBO.
16. About half the time, elemental diets do work, but they only work because they partially restore MMC function! Per Pimentel: “I think the elemental diet is working because it is absorbed in the first 3 feet of small bowel. So the latter 12 feet of small bowel do not see food and bacteria die and dramatically reduce in number. You might say “but in the first 3 feet there is all that good elemental stuff”. That area is tough for bugs because they get bombarded with acid (kills them). They get bombarded with bile (it’s a detergent and kills them) and they get bombarded with enzymes that try to digest them, from the pancreas (which can kill them). Also, If 12/15 feet of small bowel no longer have bacteria (starved out), that’s an 80% reduction in bacterial load.” But there has to be more going on than this. As noted even the previous point, even if you killed 99.9% of the bacteria this way, it will all come back in just 5 days! So what’s going on? Mark wrote, “We did see in a 2003 paper we wrote that when you get rid of SIBO, MMC are halfway normal. Not perfect. So still could use prokinetic in order to stay in remission.” In short, when you eradicate the SIBO, your MMC comes back halfway which can keep you from a remission and this remission is even more likely if you take a prokinetic. That’s why the Elemental Diet works for some people… kill + partial restoration of MMC.
17. Probiotics and prebiotics: Avoid. Probiotics have mixed results and prebiotics (fiber) is something you want to avoid since it ferments. But like I said, this is fine tuning. I pretty much ignore this myself and there is no symptomatic difference.
18. Methane from methanogens can cause constipation. So type of bacteria you have can cause C or D. But since we do not yet have hydrogen sulfide on the breath test, it’s still confusing because this gas can cause diarrhea. In short, you can have a normal-looking breath test and D, and be confused; the cause may be the gas you can’t (yet) measure (but that test is coming in May 2019 from Gemelli Biotech)."

Did you try the prokinetic?

 

[Amazoniac]

Did you try the prokinetic?

I'm not familiar with it, but there's '(5R)-[(1S)-1,2-dihydroxyethyl]-3,4-dihydroxyfuran-2(5H)-one'.

Levothyroxine therapy and impaired clearance are the strongest contributors to small intestinal bacterial overgrowth: Results of a retrospective cohort study

"Hypothyroidism and levothyroxine therapy are the most strongly associated to SIBO in our cohort. A case control study by Lauritano et al[27] has already revealed a high prevalence of SIBO in patients with autoimmune thyroiditis and hypothyroidism, but the influence of the autoimmune process was a questionable biasing factor. Multivariate analysis confirmed that levothyroxine therapy is a stronger predictor of SIBO than hypothyroidism. The underlying mechanism is unclear. One might speculate that hypothyroidism leads to hypomotility, but, surprisingly, levothyroxine therapy was even more associated to SIBO and not able to reverse the effect of hypothyroidism."​

@Collden @Wilfrid

 

[accelerator]

I'm not familiar with it, but there's '(5R)-[(1S)-1,2-dihydroxyethyl]-3,4-dihydroxyfuran-2(5H)-one'.

Vitamin C? What do you mean by that comment?

 

[Amazoniac]

Vitamin C? What do you mean by that comment?

If you dose it right, it can improve motility (main goal) without being disruptive.

 

[Wilfrid]

I'm not familiar with it, but there's '(5R)-[(1S)-1,2-dihydroxyethyl]-3,4-dihydroxyfuran-2(5H)-one'.

"Hypothyroidism and levothyroxine therapy are the most strongly associated to SIBO in our cohort. A case control study by Lauritano et al[27] has already revealed a high prevalence of SIBO in patients with autoimmune thyroiditis and hypothyroidism, but the influence of the autoimmune process was a questionable biasing factor. Multivariate analysis confirmed that levothyroxine therapy is a stronger predictor of SIBO than hypothyroidism. The underlying mechanism is unclear. One might speculate that hypothyroidism leads to hypomotility, but, surprisingly, levothyroxine therapy was even more associated to SIBO and not able to reverse the effect of hypothyroidism."​

@Collden @Wilfrid

Thanks @Amazoniac.
I’m not sure about my following hypothesis....
We know that when someone is taking too much exogenous T4, an anti-thyroid effect is almost always present. When hypothyroid people are treated by T4, the goal for the endocrinologist is to treat the TSH not the patient and its clinical manifestation of the disease. I think that everyone here knows at least someone who has been treated “right” (by that, I mean a well suppressed TSH) by conventional T4 treatment only (and always with supra-physiological dose) and still suffering from constipation, cold extremities, slow digestion, hair loss etc... And I think that the problem here rises from the suppressed TSH and the consequently T3 underproduction/depletion in the thyroid gland as well as in other body tissues....In fact, we know that other tissues than the thyroid have TSH receptors too. For example, brown adipose tissue, found in various parts of the body also contains TSH receptors. This tissue will also up-regulate its deiodinase enzyme production with higher TSH and down-regulate it with lower TSH. The conversion rate from T4 to T3 will be adjusted in the same way as in the thyroid gland, i.e. less T3 will be produced from conversion with lower TSH, and more T3 will be produced with higher TSH.
And T3 is a very effective intestinal alkaline phosphatase regulator/enhancer. I think that long term treatment by T4 alone has the potential to down-regulate IAP and thus to enhance gut permeability and susceptibility to LPS translocation. If T4 was taken in a more physiological dose, perhaps TSH would have been rise, like in Dr Blanchard clinical observation, and then the correlation between SIBO and levothyroxine intake would have been different too.