Today I want to talk to you about an alternative SIBO protocol I have been using with clients since last year - and that’s probiotics.

I know, controversial, so let’s get started and you’ll learn why I have begun using them.

Most doctors do not consider probiotics as an official, gold standard treatment option, as the studies tend to be lacking in quality or are quite small.(1)

In my training, we are taught the three main treatments are the elemental diet, antibiotics and antimicrobials, so as a result, I have always leant on these three, and with good reason. They have solid research behind them and a lot of clinical success.

However, I came up against repeated challenges:

MCAS clients couldn’t tolerate many of these options, especially herbs, and many of them didn’t have the strength and resilience to take on the elemental diet.
Because clients often had multiple root causes that made getting into remission a challenge, clients would be on repeated treatment rounds for a long time, often a year. This was expensive, but also physically very taxing, especially in those with other health issues. Many would be symptomatic due to die off (an inflammatory reaction when SIBO dies) for the duration or frequently, especially in those with MCAS or POTS (which reacts to stress).
hEDS/HSD and POTS clients would find it hard to get in remission at all. Often there was a yo-yo pattern, we’d be about to get into negative, and it would jump back up again due to the structural and functional problems we see in this demographic, such as dysmotility and gastroparesis. Or these clients would get into remission, only to relapse quickly, even with lots of support in place to prevent relapse.

These challenges aren’t unusual and are unfortunately an issue due to the way these conditions deeply affect the function of the GI tract. As I saw more and more clients with endo, SIBO and the trifecta of MCAS, POTS and hEDS/HSD, I began looking for a more sustainable way of treating SIBO, or keeping it at bay (for those who can’t get into remission) whilst significantly reducing symptoms.

I had historically avoided using probiotics because:

Some probiotics are high histamine or histamine liberators, so can worsen MCAS.
For some, probiotics make the SIBO worse (think of the small intestine like a bucket and you’re just chucking more ‘stuff’ into it).
My understanding from previous discussions was that probiotics would only work for low numbers, and would take a long time (maybe a year or two) to eradicate SIBO.

However, I stumbled across Dr Ruscio’s approach for treating SIBO with probiotics. He pointed out that a recent meta-analysis concluded that probiotics were effective for:

Treating SIBO, especially lowering hydrogen levels
Improving bowel symptoms (esp. abdominal pain)

The meta-analysis looked at 18 studies, and found an overall eradication rate of 62.8%.(2)

He takes the approach of using a combination of probiotics because research has shown that multi species probiotics tend to be more effective for IBS - of which, SIBO is a huge root cause (3) - for improving symptoms.

He uses a combination of:

Spore based probiotics (bacillus coagulans and bacillus claussii)
Lacto-bifido blends
Saccharomyces boulardii

He recommends starting one by one, to test tolerance, before adding the next one in.

He uses these for three months, in conjunction with a dietary protocol like the low FODMAP diet, before trying any other SIBO treatments. He adds diet to improve symptoms but also because one study showed better outcomes for SIBO levels with a combination of both probiotics and a low fermentable diet. (4)

If these are not effective after three months (providing patients tolerate treatment and don’t need to stop early), he then moves on to other treatment options.(5)

Okay so let’s look at why this approach may work better for complex endo and SIBO cases:

May bring symptom relief sooner (1-3 months) which means overall clients can improve at a quicker rate. Many of the studies on SIBO showed significant reductions in symptoms in 2 weeks to a few months, even if the SIBO is still present and in the process of being treated.
Because probiotics are not actively killing in the same way as herbs or antibiotics (they tend to outcompete instead and rebalance microbiome), die off may be less, so could be better for more sensitive clients.
High histamine/histamine liberator probiotics can be avoided by carefully selecting strains.
In my experience so far, probiotics can significantly reduce levels just as effectively, if not more, than the other forms, with less effort, cost and reactivity.
Much cheaper than most of the other options.
More sustainable - clients feel good on probiotics but not always on other treatments. Taking probiotics feels normal because a lot of the general public take them, it’s not another ‘abnormal’ thing they have to do for their health.
If it gets SIBO to manageable levels and symptom reduction in those with hEDS/HSD or POTS who can’t get into remission, this is a win because they can sustainably keep probiotics in their lives, keep SIBO damage minimal (probiotics have been shown to improve leaky gut and intestinal inflammation) and improve symptoms and quality of life.
Probiotics have also been shown to improve pain in endometriosis patients and reduce lesion size and growth rate in animal models.(6)

Let’s look at the data of the probiotics I typically work with:

L. reuteri DSM 17938

In a study of 20 IMO patients, four weeks of L. reuteri DSM 17938, twice a day significantly reduced methane levels, and led to complete eradication in 11 (55%) of patients.(7)

In numerous other studies, it has also been shown to effectively treat constipation(8), abdominal pain(9) and diarrhoea(10).

The study on methane levels used 100 million CFU (Colony-Forming Units) twice a day, 30 minutes after meals.

Saccharomyces Boulardii

Okay, now let’s look at saccharomyces boulardii.

In a blinded, randomized, placebo-controlled study, 33 patients with SIBO were either treated with saccharomyces boulardii or a placebo. The SB group received 250mg capsules of SB twice a day, for three months.(11)

After treatment, 80% of those treated with S.B were negative for SIBO, in contrast to 23% in the placebo group.

The SB group also showed a reduction in LPS translocation and C-Reactive Protein levels, so inflammation had gone down, which is great for endo patients, but also, LPS (a toxin that comes off certain bacteria) in the blood had also reduced, and as we have discussed many times on this show, LPS contributes to endo development, so a reduction is a huge win.(12)

In another randomised controlled trial, 54 SIBO patients received either dietary advice alone, or dietary advice plus saccharomyces boulardii. The SB group received a 250mg capsule, AM and PM for 15 days.(13)

The results after the treatment was:

SB and dietary advice: 41% eradication
DA: 29% eradication

IBS symptom severity score:

SB and dietary advice: -134
DA: -93

Percentage of patients with diarrhea:

SB and dietary advice: 25.9%
DA: 47.6%

So again, we can see that even though not all patients achieved SIBO eradication, there were significant improvements in symptoms.

A clinical trial also looked at saccharomyces boulardii and the antibiotic metronidazole. They compared S.B alone, metronidazole alone and then both combined for two months.(14)

SIBO eradication rates across the groups were:

Metronidazole and S.B: 55%
SB: 33%
Metronidazole: 25%

Additionally, symptoms improved in the SB treatments, with a reduction in diarrhoea, gas, bloating and abdominal pain, so even though some didn’t achieve eradication, their symptoms still improved.

Two of the studies used the same 250mg capsule, but it was an in lab formula with no information about the CFU (Colony-Forming Units). Additionally, the study with the S.B and metronidazole did not give any information other than the 200mg twice a day.

Bacillus strains

Now let’s look at bacillus strains.

In a randomised control trial, 30 SIBO patients were assigned to receive either antibiotics alone, or antibiotics followed by bacillus coagulans and prebiotics (FOS). There is no indication of the CFU patients received of B.coagulans. (15)

The hydrogen results were:

SB group: 93.3% were negative
Antibiotic alone group: 66.7% negative

The SB group also had 100% resolution of abdominal pain in contrast to 46.7% in the antibiotic group. The SB group also had significant improvements in bloating, burping and diarrhoea.

In another study, 60 SIBO patients were randomly assigned to either bacillus clausii three times a day for one month or metronidazole for one week.(16) There is a typo in the study so it’s not clear what CFU patients received.

SIBO eradication rates -

SB group: 56.6%
M group: 40%

Gastrointestinal side effects were also much lower in the SB group.

Lacto-bifido blends

Finally let’s look at lacto-bifido blends.

There are several studies that look at the effects of either lactobacillus strains, bifidobacterium or a combination of both.

The 2017 meta-analysis(2) looked at these studies, as well as the ones we have explored above (and a few others) and found that probiotics were an effective treatment for SIBO.

However, historically, I have always been cautious with probiotic blends and SIBO because there is a higher chance of reactivity with more strains and I won’t know what my client is reacting to exactly as there are a number of bacterial strains in the formula. And of course, because there’s more bacterial strains, there’s also a higher chance of SIBO worsening if they are a client who finds probiotics worsens SIBO, not improves it, which is always a possibility.

But, Dr Ruscio advises to include a lacto-bifido blend in his protocol based on the research, so I originally included this in my approach.

However, I started noticing in some clients who I used lacto-bifido blends with, hydrogen would go down, but methane would go up. We had l.reuteri already in tow, so we couldn’t add anything extra to deal with this rising methane levels unless we also added herbs or antibiotics, which I was trying to avoid.

I did some digging and found some research showing that methane levels increased with probiotics, whereas hydrogen levels fell:

For example, one study using bifidobacterium infantis 35624 for two weeks resulted in significant increases in methane, with patients who had been negative for IMO becoming positive after treatment. (17)

Another more recent study found that one month of probiotic use was associated with significantly higher levels of positive IMO. Unfortunately, I was unable to find which strains they used. (18)

However, l.retueri, bacillus coagulans/classii and s.boulardii are all transient strains, meaning they do not colonise in the gut, instead, they remain for a short period of time and then pass through the bowel. As a result, it is thought by practitioners that these may be safer for SIBO patients as they are less likely to colonise in the small intestine.

So, given that these three were “safer” and we have evidence that bifidobacterium strains may worsen intestinal methanogen overgrowth, I pulled the lacto-bifido blends in some of these clients, and methane levels fell again. For example, one clients methane levels had reached 65ppm, but once we pulled the lacto-bifido blend and continued with the rest, levels fell to below 10ppm.

The question remains however, in clients with IMO, are probiotics the right route? My current verdict is I don’t know, I think it’s highly individual and right now, the best approach is to test probiotics out and see how you responds.

My approach

I now give all my clients the option to try probiotics first, before trying the more ‘aggressive’ form of treatments.

I warn them that probiotics are not yet gold standard, may not be as effective for some, and can worsen SIBO in others, but also point out that eradication can happen with less effort and money on their part, and that I’ve seen extremely high levels drop by half in three months, and others dropping significantly in 6 weeks. For example, one client’s hydrogen levels dropped from 171ppm to 56ppm after three months.

Because this is such a new area (at least for me), I am tweaking and tailoring all the time, but I am really excited to see how these protocols progress and I have started to formulate my own approach for each gas type, based on what I’m seeing to be working well.

Like with any SIBO protocol, it’s important to not just chuck treatments at the problem, but also look at why the SIBO developed in the first place and how we can either resolve those root causes or improve those root causes and keep SIBO either in remission or as low as possible moving forward.

If you’d like to learn more about that, I have several episodes about SIBO treatments and SIBO replace prevention that I have put in the show notes.

References:

SIBO Episodes (there are more, this is just a selection)

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