Disclaimer: As I have said in the past, I’m not a research blogger. I’m here to mix “data with soul” and give you useful info, but only in the context of my real, human experience. That is not to say that citation on my part and proper follow-up on your part are not important. Everything I wrote about in this blog was presented by Dr. Mark Pimentel, Dr. Leonard Weinstock, and Dr. Alison Siebecker at the SIBO Symposium during June 2015 and you can pay to have access to those presentations through the National College of Natural Medicine’s website.
More great, useful information coming at you thanks to the excellent presentations at this year’s SIBO Symposium! I decided for this Part 3 update to the series, to focus on prokinetic drugs used in the treatment of SIBO. I’ll be outlining what I learned from Dr. Pimentel, Dr. Weinstock, and Dr. Siebecker through their presentations on prokinetics.
First thing first, what the heck are prokinetics? Prokinetics are drugs or herbal compounds that stimulate the migrating motor complex (MMC), which is the naturally occurring cleansing wave motion of our intestines.
Second thing, why in world would you need to use a prokinetic? The MMC needs to occur in between meals and over night, basically any time we are fasting, in order to move food along the GI tract and sweep out bacteria. Sometimes motility (movement) of the intestines can, for a variety of reasons, go off-track; perhaps the muscle contractions don’t happen frequently enough or they aren’t strong enough or they don’t last long enough. This is where prokinetics can help.
Finally, how does this apply to SIBO? There is very often a problem with the MMC in SIBO patients, particularly those with methane-dominant or constipation SIBO. In those with diarrhea, the MMC is too fast, but in those with constipation, it is too slow. This slowness prevents that sweeping, cleansing action, which is crucial to conquering the SIBO. If you’re body is unable to move food along and move waste out appropriately, bacteria can easily overgrow.
It is thought that methane has an effect on serotonin production in the gut. Serotonin is a neurotransmitter that affects intestinal motility. In those with methane-dominant SIBO, serotonin production may not be adequate to get the MMC working properly. Constipation SIBO cases are notoriously much harder to treat and relapse is really common. The missing piece in these cases is probably a prokinetic, which ideally needs to be a part of the treatment and prevention regimen. That leads to the next question, which prokinetic is best?
The doctors each gave presentations covering basically all the prokinetic options available for a patient. I’ll discuss them by doctor, starting with Dr. Mark Pimentel. He mentioned a few that he felt were poor choices, so I’ll just list his top three.
- Low-dose Erythromycin: Dr. Pimentel indicated erythromycin is a good choice for SIBO. It is an antibiotic, but when taken for SIBO it is given at a very low dose of 50 mg/day, which is not harmful. The drawback according to Dr. Pimentel is that patients can develop a diminishing response to erythromycin and have to take “holidays” from it.
- Tegaserod (Zelnorm): Dr. Pimentel indicated that Tegaserod is a very good choice for SIBO at about 2-6 mg/day; however, it was taken off the market in the U.S. He does have patients that occasionally work to source it from other countries. Of note is that it is also very useful for gastroparesis.
- Prucalopride (Resolor/Resotran): Dr. Pimentel indicated that Prucalopride is an excellent choice for SIBO at 0.5-1 mg/day, however, like Tegaserod it was taken off the market in the U.S. It is available nearly everywhere else in the world and Dr. Pimentel’s clinic works with patients to get prescriptions from Canada. He did note that it is important to start at a low dose, because it is a strong prokinetic.
Next up to present was Dr. Leonard Weinstock. Dr. Weinstock focused on one drug, which was not actually developed specifically as a prokinetic.
- Low-dose Naltrexone (LDN): Many autoimmune folks are already familiar with LDN as an immune system regulating and balancing drug, but it was first developed as way for opiate addicts (like heroin users) to recover. At a low dose it can also act as a prokinetic. Dr. Weinstock indicated it was useful for SIBO and he saw the additional benefits being that it also reduces both inflammation and pain, which he thought might in and of themselves help motility.
Finally, Dr. Alison Siebecker presented. Dr. Siebecker in a naturopath, so although her clinic does also use drugs such as erythromycin, Prucalopride, and LDN, I’ll focus on some of the natural options she finds useful.
- Iberogast: Dr Siebecker indicated that Iberogast, a combination of nine herbs used in Europe for over 40 years, was a good choice for SIBO. She favors it because it is adaptogenic and can be used to treat both diarrhea and constipation, there are low to no side effects, and it is a proven prokinetic. She stated that she has very good results in about 80% of IBS patients (remember, many IBS patients actually have SIBO as a cause of their IBS). She uses a dose of 20 drops 3 times/day. She did mention that some patients are sensitive to it and it can help to start with a lower dose and work up for them.
- Ginger: Dr. Siebecker did not spend a lot of time talking about ginger, but she uses a dose of 1,000 mg/day. The caution is that ginger is not appropriate for patients on blood thinners.
It’s important to say here that most prokinetics are given at bed time, since this is the longest fast in a 24-hour period and provides the most opportunity for the MMC to do its work.
So there you have it! Prokinetics are pretty important to treating and preventing relapse of SIBO. I did not use prokinetics in my own treatment process, but in hindsight, I definitely think I could have benefitted and probably would not have had to treat it three times! What about you? Have you used prokinetics as part of a SIBO protocol? Do you feel this information could be helpful to you and your doctor as you seek to treat SIBO?