If a person has both SIBO and B12 deficiency, are their mannitol levels and trifolamin low enough for it not to cause digestive issues, or is this a situation in which we may have to be guided by whether digestive issues occur or not?

I rarely have seen digestive issues with trifolamin. I think it’s actually more common for people to have over-stimulating effects from the B12. Some people, especially if they’re B12 deficient, you have to work them in to the trifolamin, so you might start with a hydroxy B12 product alone at a lower dose and then gradually ramp that up and then eventually switch them over to a trifolamin sublingual tablet. The symptoms usually would be almost like hyperthyroid symptoms just really revved up, overstimulated, and not so much the heat but just like insomnia—can’t fall asleep, can’t stay asleep, etc. I think that’s more common with the trifolamin than a digestive response to the mannitol, but I have seen it all now in 10 years in practice and the reactions to just about everything that you can imagine. If there is an increase in uptake in digestive symptoms and that’s the only change you made, I wouldn’t rule that out either.