SIBO Update 2015: Pt. 3


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?

You can read Part 1 of this update series here, Part 2 here, or start with the original series here.

About Angie Alt

Angie Alt is a co-founder here at Autoimmune Wellness. She helps others take charge of their health the same way she took charge of her own after suffering with celiac disease, endometriosis, and lichen sclerosis; one nutritious step at a time. Her special focus is on mixing “data with soul” by looking at the honest heart of the autoimmune journey (which sometimes includes curse words). She is a Certified Health Coach through the Institute for Integrative Nutrition, Nutritional Therapy Consultant through The Nutritional Therapy Association and author of The Alternative Autoimmune Cookbook: Eating for All Phases of the Paleo Autoimmune Protocol and The Autoimmune Wellness Handbook. You can also find her on Instagram.


  • Shebank says

    Thanks for this helpful series. Can I start to use a prokinetic while I am taking natural antibiotics for SIBO or do I need to wait until I complete treatment?

    • Angie Alt says

      Shebank, it would really be best to make those choices w/ the help of your practitioner. Unfortunately, I can’t give you any advice on that. Thanks for reading!

  • Jess says

    Hi Angie,

    I noticed you had mentioned in one of these posts that you did not tolerate Berberine. I am curious about this. I have been taking Berberine 5x per day, oregano oil 5x per day, peppermint oil 5x per day, and lions mane 2 caps at night for about two weeks now. My naturopath plans on having me on this for a few more weeks. Last week I began to lose my appetite which eventually turned into nausea. I have just not been eating much at all the past week or so and I generally do not feel well. My naturopath said it could be due to die off of the bacteria or I could be fighting off a virus. I guess I am wondering what your experience was with Berberine and how it made you feel as maybe we had the same side effects. I am wondering if there is a better treatment for me if this is causing my problems. Thank you for sharing so much important info!!


    • Angie Alt says

      Hi Jess! Thanks for reading! I didn’t have a problem w/ Berberine specificially, but to an herbal antibiotic mixture. It was just far too strong for my system. I knew w/in a few days that it didn’t agree w/ me, because I got nauseated, dizzy, & had a skull splitting headache (like the kind that Advil doesn’t help & left me bed-ridden for two days). To my knowledge die off symptoms shouldn’t last more than about 3 days. I’d work w/ your ND to determine if you can see the treatment course through or if what you are experiencing is too uncomfortable & perhaps another treatment option would be better suited. We always have the impression that herbals are gentle, but the truth is that they can be very, very strong. Good luck!

  • Melissa says

    Very interesting & actually uplifting to see docs recommend meds that are off the market, especially when they shouldn’t be, IMO. Did any of the doctors mention Domperidone (Motilium) or Cisapride (Propulsid)?

    • Angie Alt says

      I agree Melissa!! I don’t remember those drugs being mentioned, but I feel like I recognize the names. They may have been on the list of “poor” choices according to Dr. Pimentel, but don’t quote me on that. 😉

  • Jason Cornish says

    Do you know how people are getting Resolor/Resotran from Canada?

  • Lisa says

    You mentioned that Dr. Siebecker doses the Iberogast as 20 drops, 3x/day. Does that mean before or with two meals and then the third dose before bed?

    • Angie Alt says

      Hi Lisa-
      I believe that means w/ Iberogast, that is also how it is directed on the bottle. Thanks!

  • Toni says

    My naturopath has me taking Candibactin AR and BR, Metagenics products. We’re these mentioned at all? If so, we’re they mentioned favorably or not? Thanks!

    • Angie Alt says

      Hi Toni, thanks for reading. They were not mentioned, so I can’t comment.

  • Tracey says

    Should I take a prokinetic as part of my SIBO treatment/prevention, if I have diarrhea SIBO or is it only for constipation SIBO?

    • Angie Alt says

      Tracey, prokinetics are only for use w/ constipation SIBO. They would make diarrhea worse.

      • Murry says

        Are you sure about this? I see on Siebecker’s site under prevention that they suggest Naltrexone but at a lower dose. Everything I have read and cross referenced about treating SIBO seems to indicate this is an important step in the healing process. Please cite your resources for not using a prokinetic for SIBO-D. Thank you.

        • Angie Alt says

          Hi Murry-
          You’ll notice that the answer to this question was in 2016. You are correct that information seems to be changing and in some cases prokinetics are being used for SIBO-D as well. Thanks!

  • Sbua says

    Thanks for the info!
    If it’s SIBO with diarrhea, not constipation, I guess a prokinetic isn’t needed? What is usually the underlying cause of SIBO if it’s diarrhea/not a MMC problem?

  • […] can read Part 2 of this update series here, Part 3 here, or start with the original series […]

  • Cherise says

    Thankyou for this imformation. I just started on prucalopride today and the amount of stomach pain and diarrhea is incredible! I did not expect this reaction- do you know if this is normal? It’s nice to hear about the options available to treat SIBO. I’ve just completed my antibiotic treatment and have been left with a very upset stomach from the treatment so i was hoping that everything would get better.
    Thanks for the info!

  • r says

    I have mostly diarrhoea sometimes. LD erythromycin 50mg is great for my gut at bedtime- at least 3hrs after eating

  • Lynn Platt says

    Can you take iberogast if you have a duedenal ulcer?

  • Abhi says

    Hi Angie,

    Thx for putting this altogether. Sibo is a frustrating disease and my entire youth has been consumed by SIBO C.

    Am about to start a Rifaximin n Matranidazole treatment with iberogast as the prokinetic that follows. If Iberogast doesn’t work I would try Prucalopride.

    What I would love to know is how long to continue with prokinetics after antibiotics and in case one round of antibiotics don’t work (in obstinate cases) was there any talk at the symposium that another round has any benefit?

    Thx again.

    • Angie Alt says

      Hi Abhi-
      I can’t tell you how long to continue the prokinetics, that is really a question for your doctor. Some folks only need it short-term, others need it indefinitely. As far as multiple rounds of antibiotics, again this is something for your doctor to determine, but it is not uncommon w/ SIBO.

  • […] (15). SIBO tedavisine ek olarak kullanılan prokinetik ajanlara şunlar örnek verilebilir (16, […]

  • Vanessa says

    Hi, I’ve been looking at Iberagast before I found this article. It’s not AIP compliant because it contains alcohol, and I don’t know about some of the other ingredients as they are not on any AIP food list that I can find. Can anyone confirm, and what’s your view on using this product as a prokinetic whilst doing AIP? I think poor motility is half my problem, due to Hashimoto’s mainly. I also have coaliac disease and leaky gut, and suspect SIBO. I use ginger but to no real effect. Thanks.

    • Angie Alt says

      Vanessa, I think when it comes to SIBO treatment, the relatively small risks of using a “not perfectly AIP compliant” supplement, like Iberogast, are worth it. If you think it could be useful in helping w/ motility, I’d give it a shot, even if you are also doing AIP at the same time.

  • Tony Antoniou says

    In my experience Iberogast is waste of time and money and did nothing for my constipation at all.

  • I am a young 83 year old with a history of Crohn s in the large intestine, for 50 years. I started with a colostomy which was changed to an ileostomy 10 years ago and the colon was removed except for the rectal stub. The ileostomy is difficult to manage (liquid diarrhoea) for which I take Codeine phosphate 30mg and immodium both 3 times day half an hour before meals to slow the small intestine down, (to improve the diarrhoea)
    Do you think that this “slowing down” may have caused the Sibo which has been diagnosed with a recent hydrogen test. I have had 2 courses of Flagyl and 2 of Amoxycillin Co 500mg, which only worked for a few weeks, when the sibo reappeared. I am about to go on a Fodmat course. Can you recommend any of the drugs mentioned in your article please? …..Thank you, Joan Barnett

    • Angie Alt says

      Hi Joan-
      We’re not a medical doctors, so we can’t recommend medications. What I can tell you is that once there are anatomical changes (for instance w/ surgery) it can become more difficult to successfully treat SIBO & eradicate it long-term. Be sure to read the whole SIBO series here on the blog for lots more details that you could speak to your doctors about, I’m sure the low-FODMAP diet will help w/ symptom management at the very least. Best of luck!

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