After completing the SIBO Mastery Course, experiencing my own SIBO diagnosis and treatment journey and of course, ongoing research, I decided to compile a list of the main reasons why SIBO treatment fails.
We know that SIBO is a condition with a high rate of relapse, so it's imperative to have a comprehensive treatment plan from the get go.
Knowing the reasons why treatment can fail informs a successful treatment plan. Here are the top 10 reasons why SIBO treatment fails.
- 1. Not treating the underlying cause/s
- 2. Not treating for long enough
- 3. Not using prokinetics (esp. if the MMC is damaged)
- 4. Not rotating herbal medicines
- 5. Not using essential supplements to work with rifaxamin
- 6. Not addressing stress
- 7. Not addressing the dysbiosis aspect of SIBO
- 8. If you have methane SIBO, not treating the underlying hydrogen gas
- 9. If you have methane SIBO, not adequately treating the constipation itself
- 10. Not spacing meals appropriately
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1. Not treating the underlying cause/s
I've written an entire blog post on the wide range of underlying causes of SIBO. SIBO is a symptom of a larger problem. Unfortunately for many people, this isn't a consideration when treating SIBO for various reasons. Working with a good healthcare practitioner trained in SIBO means that the diagnostic process involves investigating what is happening behind the scenes to cause the overgrowth. It informs the treatment plan and also the maintenance plan, which is designed to prevent relapse.
2. Not treating for long enough
This is mostly applicable to herbal antimicrobials but can also be applicable to the Elemental Diet and rifaxamin. Many people need more than the usual 8 weeks of herbal antimicrobials, up to 16 weeks.
When it comes to the Elemental Diet, the efficacy improves from 80% to 85% by adding on a third week of the diet. Even though it's only a 5% increase, I think it's worthwhile.
With rifaxamin, some people do end up needing a second round of it. This can be minimised by adding strategic supplements alongside it which are known to increase it's efficacy.
3. Not using prokinetics (esp. if the MMC is damaged)
Prokinetics are either pharmaceutical drugs or herbal medicines which enhance gastrointestinal motility - they basically keep everything moving in the right direction within the ideal timeframe. They're also used outside of SIBO, for conditions such as gastroparesis and can offer symptomatic relief of nausea, reflux, bloating and constipation. They aren't the same as laxatives, which help to produce a bowel movement. A prokinetic may help in that regard but that's not its primary purpose.
The MMC is the Migrating Motor Complex and this can be impaired in many people with SIBO, especially those that relapse. The MMC governs the co-ordination of a "cleansing wave" which helps to sweep excess bacteria out of the stomach and small intestine. It can become damaged due to food poisoning/traveller's diarrhoea because the microbes involved can trigger autoimmune damage to the nerves that control the MMC.
Prokinetics can be used during antimicrobial treatment and also afterwards to prevent relapse - they are especially important for people with MMC impairment.
4. Not rotating herbal medicines
Bacteria have their own sophisticated defense mechanisms, which means they can adapt quite skilfully to any attempt to eradicate them. In my practice, I always rotate herbal medicines - eg. 2 weeks of one mixture and then 2 weeks of another, repeating until the treatment period finishes. All herbal medicines have complex chemistry and we know there is quite a variety of microbial species involved in SIBO so it makes sense to keep them guessing! Also, many people have SIFO (Small Intestinal Fungal Overgrowth) alongside SIBO, which means it's good to choose herbals that have both antimicrobial and antifungal activity. ALWAYS work with someone who has an actual herbal medicine qualification for this reason - there are many practitioners treating SIBO with herbs who do not have appropriate qualifications.
5. Not using essential supplements to work with rifaxamin
Rifaxamin has been found to be more effective when taken with PHGG (Partially Hydrolyzed Guar Gum), a prebiotic. It sounds counterintuitive to add in something that feeds bacteria, but it actually works. In a 2010 study, i was found that the addition of 5g of PHGG a day during treatment with rifaxamin, increased the eradication rate from 62% in the rifaxamin-only group to 85% in the rifaxamin-PHGG group.
It also plays other roles in SIBO treatment too, so is an essential part of all forms of SIBO treatment.
Rifaxamin is also bile soluble, so specific herbs or supplements are a good idea in that regard too. We also know that bile is antimicrobial, so that's yet another reason to address this.
6. Not addressing stress
Stress impairs digestion due to is dampening effect on the parasympathetic nervous system (aka the "rest and digest" system). It can also have a negative effect on sleep, which then has a knock-on effect of increasing appetite which make it hard to space meals appropriately - which interferes with MMC function.
7. Not addressing the dysbiosis aspect of SIBO
The latest science tells us that SIBO is a condition of dysbiosis, not just an overgrowth of bacteria in the wrong location.
8. If you have methane SIBO, not treating the underlying hydrogen gas
Methane SIBO requires hydrogen production to be occurring in the background. One methane molecule is made from four hydrogen molecules, so if you have methane SIBO there is a decent amount of fermentation occurring in the small intestine. If no hydrogen appears on your breath test, it simply means that the methanogens have become very efficient at converting the hydrogen over to methane.
9. If you have methane SIBO, not adequately treating the constipation itself
Methane SIBO and constipation are a vicious cycle because excessive methane levels can be both a cause and consequence of constipation. Breaking the chain is important, so that means addressing the methane levels and also the constipation concurrently.
10. Not spacing meals appropriately
This point is relevant to everyone, regardless of whether your MMC nerve function has autoimmune damage or not. The MMC is important to everyone's digestive function and is interrupted if an individual snacks between meals. Ideally, a full 5 hours between meals is a good target. There are exceptions to this of course, such as those with gastroparesis, breastfeeding mothers and also people with chronic fatigue syndrome may need to eat more often.
Work with me
Struggling with chronic digestive symptoms? Have a tough case of SIBO? Relapsed after treatment? I'm here to help you. Find out more about how I treat SIBO as a Naturopath and Nutritionist.
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