SIBO, Motility & Prokinetics


prokinetics

I’m gearing up to move into the “repair” and “maintain” phase of SIBO destruction. Once you’ve killed most of the bad gut critters, you need to get to the root of the problem. In other words, poor gut motility. According to Angela Pifer, the SIBO Guru, SIBO is usually a secondary symptom to another problem, the root cause. Allison Siebecker ND and Mark Pimental MD, both would confer. They believe the root is the MMC. Others believe the root to stem from a malabsorption or poor breakdown of fermentable carbohydrates.  As with most conditions,  there is no magic pill for SIBO.  Instead, you will need a  holistic or whole body approach.

WHAT IS MOTILITY AND MMC?

Motility simply means how well things are moving along in your gut. If you have slow motility, your food is sitting in your digestive tract fermenting and feeding bacteria and methanogens. Motility cannot to be improved by taking a laxative either. It is much more complex than that.

The migrating motor complex (MMC) is the wave-like muscle contractions that clears your gut of food residue. This sweeping action takes place twice during the digestive process. First muscle contraction starts in your stomach and travels through your small intestine. The second muscle contraction starts in your duodenum (latter part of small intestine) and travels up to the ileocecal valve in your small intestine. Without food residue to feast on, bad gut critters cannot be fed.

Research generally demonstrates that the MMC contractions start about 1 1/2 to 2 hours after NOT eating. That’s right, I said “not” eating. If you’re a grazer, like eating multiple small meals throughout the day, then you could be impairing your MMC from doing its job of keeping your gut “house” clean. Sylvie McCracken, author of The SIBO Solution and fellow SIBO sojourner, refers to the four phases of the MMC from an article posted by Colorado State University. [2]

  • A calm period lasting about 45 to 60 minutes
  • A period of peristaltic contractions which increase in frequency and last for about 30 minutes
  • A period of rapid, evenly-spaced peristaltic contractions lasting about 5 to 15 minutes
  • A short transition period until phase one starts again

WHAT’S MY NEXT STEP ON MY SIBO JOURNEY?

Currently, I am finishing up a round of pharmaceutical antibiotics. Pifer suggests that these drugs simply knock the organisms down so you feel like you have recovered for a very short time. Subsequently, I will need to look at repairing and healing my gut.

Furthermore, Pifer explains that “SIBO is a secondary condition; a symptom that something is not right with your system. It is an extreme imbalance in your body that is best addressed from a functional medicine approach: identifying the ROOT CAUSE, and coupling dietary and herbal therapies together to knock down SIBO to the degree that you can address digestive and immune insufficiencies, heal the gut, and rebalance your gut flora.” [1]

Tweetable: Confused about how to keep SIBO away? Tweet!

So this week I’ll summarize some of the SIBO prokinetic supplements offered in Canada and the USA — each country has one available that the other doesn’t.

PROKINETIC AGENTS
What are prokinetics? And why do you need them?

Prokinetics are used to stimulate the MMC (migrating motor complex), which is usually compromised due to gut nerve damage according to Dr Mark Pimental. [3] Thus prokinectics are used to encourage the wave-like contractions to sweep your gut clear of bacteria and food residue. However, many individuals with SIBO or IBS have very slow motility, which allows the food residue to ferment and feed the bacteria.

When do you take prokinetics?

After you finish SIBO treatment, whether traditional antibiotics or herbal antibiotics, you should immediately start taking a prokinetic agent to stimulate the MMC. Usually, prokinetic agents are taken at bedtime because your body is repairing and detoxifying without food to complicate things.

Prokinetic Agents – some over-the-counter and others by prescription

Iberogast — is an adaptogenic supplement that helps with IBS, SIBO-D (diarrehea/hydrogen gas) or SIBO-C (constipation/methane gas). The nine herbs combined generally have few side effects and is safe for long-term use. However, as a prevention of SIBO relapse, the jury is still out. Dr Siebecker suggests using Resolor (Canada) or Erythromycin (USA), if you want to be avoid SIBO relapse. [4] I found Iberogast is a mainstream pharmacy in Calgary. It was less expensive to purchase it there than online. Dosage: 20 drops at bedtime or with meals

Resolor/Prucalopride — it is a 5HT4 agonist and works specifically on the stomach, small intestine and the colon. However, this prokinetic agent requires a prescription. This drug is available in Canada and Europe, but isn’t approved for the US market. Dosage is very small to get the needed effect. Check with your healthcare provider for this one — he/she will need to look into IBS Care in Alberta Health. Additionally, this is the suggested protocol for SIBO relapse prevention. [5]

MotilPro by Pure Encapsulation — this product is available on Amazon.com, but cannot be shipped to Canada. For more information, check out the link HERE 

Ginger (Zingiber officinale) —Interestingly, many propriatorey blends include ginger. Ginger promotes gastric emptying rate and motility. Dr. Siebecker uses a dose of 1,000 mg/day. [6] The caution is that ginger is not appropriate for patients on blood thinners. One study in the International Journal of Clinical Pharmacology revealed that ginger significantly increased the MMC function. [7] As for me, I’ll continue to include homemade ginger-turmeric tea to my daily routine. I did find ZingiQOL by Thorne Research at iHerb Canada, which Tom Malterre from Whole Life Nutrition and author of The Elimination Diet suggested. 

It’s important to say here that most prokinetics are given at bed time, since this is the longest fast in a 24-hour period that many individuals have. Subsequenlty, this long period without food provides the most opportunity for the MMC to do its work. Dr Nirala Jacobi, naturopath and SIBOtest.com, suggests prokinetic agents should be continued for at least 6 months, even if your symptoms have resolved. [8]

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RESOURCES

[1] Angela Pifer, “Welcome to SIBO Guru,” http://siboguru.com
[2] Bowen, R. “The Migrating Motor Complex.” Colorado State. (22 Oct. 1995) http://arbl.cvmbs.colostate.edu/hbooks/pathphys/digestion/stomach/mmcomplex.html.
[3] Mark Pimental, MD, Director of the GI Motility Program at Cedars-Sinai Medical Centre, “Prokinectic Prevention of SIBO,” SIBO Symposium 2015, https://cemoodle.ncnm.edu/course/search.php?search=SIBOSymposium+2015
[4] Allison Siebecker, ND, “Natural Prokinetic: Iberogast,” SIBO Symposium 2015.
[5] Allison Siebecker, ND, “Prevention,” http://www.siboinfo.com/prevention.html
[6] Ibid
[7] GH Micklefield MD et al, “Effects of ginger on gastroduodenal motility,”
https://www.ncbi.nlm.nih.gov/pubmed/10442508
[8] Dr Nirala Jacobi ND, CMO, SIBOTest, SIBO Webinar 2015 – “Advances in the Treatment and Management of SIBO,” http://www.slideshare.net/SIBOTest/sibo-webinar-2015


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