Dr. Amy Nett: Great question, and next week we’re going to be talking more about SIBO, but quickly I’ll mention I think this is a really interesting situation that we see with some frequency. First of all, I would recommend listening to the podcast that Chris did last year with Dr. Pimentel. They talked about this exactly, where you have high methane and then you treat and then you see high hydrogen. When you see high levels of methane, we’re talking about overgrowth of Archaea. We think that Archaea can actually essentially utilize some of the hydrogen gas. What this means is if you have an overgrowth of Archaea, it can essentially be hiding the overgrowth of microorganisms that produce hydrogen because they are essentially sort of utilizing that hydrogen gas so you’re not detecting it on the breath test. Hopefully that makes sense. When you have an overgrowth of Archaea, it might be masking or hiding overgrowth of hydrogen-producing bacteria. So if you used neomycin along with the CandiBactin-AR and CandiBactin-BR and you lowered the levels of Archaea, you might be unmasking the overgrowth of hydrogen-producing microorganisms. So I don’t that it’s necessarily a lab error. Again, if you’re saying she’s feeling great and doesn’t have any symptoms, then maybe, but then we just say no test is perfect, of course, but I think you can make the argument that it is possible that you just killed off the Archaea and you’ve unmasked the overgrowth of hydrogen-producing organisms.
So it depends. If she doesn’t have any symptoms and you know you just want to do prebiotics, probiotics, and sort of build up the gut from this point, that’s a very reasonable approach. If there’s a question as to whether or not there’s SIBO, maybe she does still have some lingering symptoms, then I would consider maybe another 30 days of an herbal antimicrobial protocol. We’ll talk about the different options that we use. You wouldn’t do neomycin in this case. Neomycin can be used for methane overgrowth, but it’s not one that I use a lot. I’m not as comfortable with the side effect profile for neomycin, so I still treat with rifaximin initially even for methane overproduction. Some people do do rifaximin and neomycin, so that’s certainly a reasonable option, but you could do just rifaximin if it’s hydrogen overproduction. Those are a couple of different options, and like you said, if she’s feeling great, it’s an option to not treat again. I’m not a big fan of treating based on labs alone, so the other question is, how high are the hydrogen levels? I think that’s something else to consider. How high are the hydrogen levels? What do her symptoms look like? Then decide if you want to go on with additional treatment. You have a few options for herbs or rifaximin. If you do rifaximin, depending on how high the hydrogen is, maybe a 10- to 14-day course, something like 400 milligrams t.i.d. for 10 to 14 days.