Dr. Amy Nett: Again, we’re probably going to be talking in much more detail about SIBO, small intestinal bacterial overgrowth. There’s a lot of discussion in terms of using prokinetics, the idea being that one of the theories behind what causes small intestinal bacterial overgrowth is potentially some degree of nerve damage that can happen during an episode of acute gastroenteritis and that there’s some thought that there may be a decrease in function of the migrating motor complex, so some people suggest that we do need to consider using prokinetics to successfully treat small intestinal bacterial overgrowth. We generally start our treatment of small intestinal bacterial overgrowth, of SIBO, by using an herbal antimicrobial protocol. We tend to start with a slightly more minimalist approach because we find that the majority of patients are actually able to recover without specifically using a prokinetic agent.
If people are still having a lot of problem with GI motility, there are a couple of approaches. One proposed idea in terms of improving that migrating motor complex is actually to decrease meal frequency. The migrating motor complex, which is that sweeping wave that goes through the small intestine, generally occurs between meals. There are certainly times when patients should be eating every two to three hours. Most often in the case of HPA axis dysregulation, we’re certainly thinking about increasing meal frequency, but if patients are able to decrease meal frequency, that may be one approach to improving the migrating motor complex. Where we tend to start in terms of improving GI motility, we use an herbal formula called Iberogast, and that’s an herbal formula that’s thought to be … essentially you can think of it as a GI adaptogen. In our patients who tend towards constipation, it tends to help move things along, but it also works for some of our patients with diarrhea and helps to slow things down, so it brings balance to the GI tract. So that would be something that if we feel like someone is having trouble with motility, we’re probably going to start with Iberogast.
We sometimes also use a product called MotilPro. MotilPro is through Pure Encapsulations. MotilPro is primarily a combination of ginger and 5-HTP, and that we use for patients who are really struggling with constipation. Again, when you’re looking at decreased motility and constipation in the setting of SIBO, it’s more often in the setting of the high-methane type of SIBO, which we’ll talk about, but when you see high levels of methane gas. Most often we start with Iberogast and 5-HTP.
I’ve experimented a little bit with using low-dose naltrexone as a prokinetic agent. I know that’s been discussed as a prokinetic. We haven’t had a lot of success. We use LDN more for autoimmune conditions, but I have seen it discussed in the setting of SIBO as a prokinetic. I think people, in general, are moving away from that.
Then low-dose erythromycin is the other prokinetic agent, and I don’t think I’ve actually needed to use that at this point. When you think about GI motility, you want to look at other causes because, again, we don’t want to have to use a prokinetic. We want to try to figure out what’s causing that decreased motility. Sometimes metals can affect motility, chronic inflammatory response syndrome, so sometimes it’s more digging a little bit deeper.