Dec. 15, 2025
SIBO Part III: Treatment
Dr. Navin Kumar, gastroenterologist and RTL co-founder, joins guest-host Ally Scheve to discuss how to treat Small Intestinal Bacterial Overgrowth (SIBO). In this final episode of the three part series, they discuss the approach to antibiotic therapy for SIBO, the importance of understanding the subtype of SIBO when determining a treatment plan, and conclude with non-antibiotic approaches to treatment.
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WEBVTT
00:01.111 --> 00:02.573
[SPEAKER_00]: Welcome back to Run the List.
00:02.593 --> 00:08.062
[SPEAKER_00]: I am Ali Shibi, a current third year medical student at Harvard and a recent number of the RTL team.
00:08.503 --> 00:18.219
[SPEAKER_00]: I am back with Dr. Kumar, a gastroenterologist at Brighamun Women's Hospital, and one of the co-founders of RTL, for our third and final episode of our series on Cibo.
00:18.739 --> 00:20.863
[SPEAKER_00]: Today, we will discuss how to treat Cibo.
00:21.524 --> 00:22.766
[SPEAKER_01]: Thank you so much, Ali.
00:23.006 --> 00:26.612
[SPEAKER_01]: Let's wrap up our Cibo series today and run the list.
00:27.132 --> 00:32.761
[SPEAKER_00]: So now that we are all on the same page, let me quickly summarize the past two episodes.
00:33.542 --> 00:42.677
[SPEAKER_00]: Cibo is due to a pathological increase in bacteria in the small bowel with associated diarrhea and abdominal bloating worse after meals.
00:42.657 --> 00:51.631
[SPEAKER_00]: Diagnosis is most commonly established via lactolose breath testing, which measures methane and hydrogen produced by bacteria over time.
00:52.252 --> 01:04.210
[SPEAKER_00]: If hydrogen rises by greater than or equal to 20 ppm, or methane levels reach 10 ppm or higher, at any point during the test, the diagnosis of CBO is made.
01:04.190 --> 01:06.555
[SPEAKER_00]: So let's return to our case for one final time.
01:07.216 --> 01:18.359
[SPEAKER_00]: Ms. R is a 45-year-old female with a history of obesity, status post-rune, why gastric bypass, who presents to primary care clinic with two months of worsening, bloating, flatulence, and diarrhea.
01:18.901 --> 01:25.354
[SPEAKER_00]: She's found to have sebo on breath testing, and now that we have established her diagnosis, how do we treat her?
01:25.537 --> 01:26.318
[SPEAKER_01]: Thank you, Ali.
01:26.338 --> 01:31.606
[SPEAKER_01]: So, the first step is to identify the subtype of CBO that Ms. R has.
01:31.646 --> 01:33.549
[SPEAKER_01]: And there's basically two different types.
01:33.609 --> 01:37.955
[SPEAKER_01]: You can either have hydrogen predominant CBO or methane predominant CBO.
01:38.376 --> 01:52.877
[SPEAKER_01]: You'll recall in our last episode on Dinosys, we talked about the importance of the breath test measuring for both of those gas levels, hydrogen and methane because the treatment is dictated by the type of pattern we see between those two gas levels.
01:52.857 --> 01:56.101
[SPEAKER_01]: So let's assume that she has hydrogen predominant seabull.
01:56.741 --> 02:07.354
[SPEAKER_01]: In that case, the best antibiotic approach is to use anobotic called refaximin, or zifaxin, which is dose at 550 milligrams three times a day for 14 days.
02:07.774 --> 02:14.502
[SPEAKER_01]: You may recall this antibiotic as a use for hepatic and cephalopathy in patients with cirrhosis.
02:14.722 --> 02:22.611
[SPEAKER_01]: It is the same antibiotic, but it's a different dosage, and again it's just for a two-week
02:22.591 --> 02:26.575
[SPEAKER_01]: will take it indefinitely for their hepatic and cephalopathy.
02:27.135 --> 02:28.877
[SPEAKER_01]: So, what is refaxement?
02:28.897 --> 02:34.562
[SPEAKER_01]: What's a non-absorble antibiotic that has gram-positive, gram-negative, and anaerobic coverage?
02:35.002 --> 02:40.007
[SPEAKER_01]: And it effectively decreases the bacterial population of the small bowel.
02:40.027 --> 02:45.652
[SPEAKER_01]: As a non-absorble antibiotic, refaxement's primary effect is within the intestinal tract.
02:46.052 --> 02:50.556
[SPEAKER_01]: And what's nice about that is that you have less side effects from systemic
02:50.536 --> 03:05.601
[SPEAKER_01]: So in my experience, the most common side effects that patients may have on refaxment are GI upset in diarrhea because again, the main area of action is within the intestinal tract, but some patients also can develop some white headiness.
03:05.621 --> 03:10.249
[SPEAKER_01]: So it's nice to caution them about these potential side effects before they start.
03:10.229 --> 03:17.578
[SPEAKER_01]: To be honest, the main issue with refaxment is the cost of the antibiotic as it's very expensive if it's not covered by insurance.
03:18.019 --> 03:27.490
[SPEAKER_01]: So I always tell my patients, let me see if I can get this antibiotic covered for you, but do not fill it if it's not covered by insurance because the cost is very, very high.
03:28.171 --> 03:39.645
[SPEAKER_01]: So when that happens, when refaxment is not covered, there are many other alternative antibiotics that can also be used and have been studied for Sebo, and they all work generally about
03:39.625 --> 03:55.170
[SPEAKER_01]: Refactsment again is our preferred antibiotic, but if it's not available or not covered, you can use these alternative antibiotics such as augmenting, which is often my primary choice due to the safety profile of this antibiotic, as well as metroninousol, ciperfoxicin, or bacterium.
03:55.437 --> 03:55.878
[SPEAKER_00]: Awesome.
03:56.158 --> 03:57.361
[SPEAKER_00]: That was a great explanation.
03:57.421 --> 04:00.907
[SPEAKER_00]: Sounds like there's a lot of options for antibiotic treatment.
04:01.308 --> 04:04.955
[SPEAKER_00]: And ideally, we would be able to prescribe Ms. R. Roy Phaxaman.
04:05.576 --> 04:10.746
[SPEAKER_00]: Now, what would you recommend her if the SIBO breath testing was positive for pathogens?
04:11.080 --> 04:19.792
[SPEAKER_01]: So if she had befanogens, and especially if it's methane predominant seabull, the optimal antibiotic approach is actually to use two antibiotic.
04:19.852 --> 04:27.322
[SPEAKER_01]: So again, we use refaximin, which is used at that same dosage, which is 550 milligrams three times a day for 14 days.
04:27.822 --> 04:31.367
[SPEAKER_01]: But then the recommendation is to add a second antibiotic.
04:31.347 --> 04:42.869
[SPEAKER_01]: known as Neo-Mison that's dosed at 500 milligrams twice a day for 14 days, and those two antibiotics are taken together, so it's a lot of antibiotics within a short time period of two weeks.
04:43.550 --> 04:53.068
[SPEAKER_01]: Neo-Mison has a more concerning side effect profile as an amino glycoside, and so it can cause auto toxicity, kidney injury, and nerve damage,
04:53.048 --> 05:01.886
[SPEAKER_01]: And the one I've actually seen occur is the ototoxicity which manifests with a permanent tinnitus or ear ringing of the ear.
05:02.487 --> 05:13.048
[SPEAKER_01]: So it's really important to counsel your patients about the potential side effects of neomycin because they are serious and as I mentioned they can be permanent.
05:13.028 --> 05:29.064
[SPEAKER_01]: So, one thing I always check with my patients before prescribing Neomison is to see if they have any baseline issues with hearing or kidney injury or nerve issues because if they do, I'm really hesitant to use that medication that Neomison in those patients.
05:29.505 --> 05:42.698
[SPEAKER_01]: Just to know, Neomison also has a higher rate of GI distress, and so I often tell patients if it seems like they'll be okay taking it, they should take it with food because that'll help minimize some of the GI side effects, including nausea.
05:42.678 --> 05:51.477
[SPEAKER_01]: Now, given all the potential side effects that I mentioned with the neomison, many patients and providers to, for good reason, prefer to avoid the risk of neomison.
05:52.018 --> 05:59.995
[SPEAKER_01]: And so, in some cases, even if it's methane predominant CO, they will treat with just refaxment alone to see if that will be enough.
05:59.975 --> 06:16.077
[SPEAKER_01]: to take care of the pathogens in those patients, small intestinal tract, and sometimes it does work, sometimes it does, but it's always a risk benefit, a discussion with the addition of neomycin because of those potentially permanent and damaging side effects.
06:16.715 --> 06:17.276
[SPEAKER_00]: excellent.
06:17.557 --> 06:28.180
[SPEAKER_00]: I'm sure you get a lot of patients who may not be keen to start antibiotics and given all that you've discussed in terms of some of the side effects that can be pretty severe.
06:28.220 --> 06:32.209
[SPEAKER_00]: Are there any alternative modes of treatment for SIBO?
06:32.442 --> 06:41.854
[SPEAKER_01]: Yes, you are certainly right that many patients do not want to expose themselves to these antibiotics, especially the neomycin piece, as we discussed, because of the potential side effects.
06:42.594 --> 06:49.002
[SPEAKER_01]: And so there are other options that can be pursued to address the symptoms that arise from CBO.
06:49.263 --> 06:53.708
[SPEAKER_01]: The main non antibiotic approach is truly to modify the diet.
06:53.688 --> 06:57.753
[SPEAKER_01]: So dietary changes can be another option for seabull management.
06:58.393 --> 07:09.846
[SPEAKER_01]: And what the idea is here is for patients to focus on eating foods that have low amounts of fermentation products, which those small intestinal bacteria like to break down.
07:10.247 --> 07:14.872
[SPEAKER_01]: So the way to do this, it's most reliably achieved by following a low-fod map diet.
07:15.412 --> 07:23.121
[SPEAKER_01]: That is an acronym that stands for fermentable, oligo, dye, and mono-saccharides, and polyoles.
07:23.101 --> 07:28.212
[SPEAKER_01]: So it will be hard to actually memorize what foods fall into each category.
07:28.232 --> 07:31.179
[SPEAKER_01]: There are some great resources online to look at.
07:31.219 --> 07:35.629
[SPEAKER_01]: The one that I love to use is www.katescarlata.com.
07:35.669 --> 07:38.595
[SPEAKER_01]: She's a nutritionist who has a lot of experience in this area.
07:38.575 --> 07:52.419
[SPEAKER_01]: And so it's very helpful to go to that website, share it with your patients so that they can start looking at what a low fawn map diet may be, and what I love about that website, it shows options of foods that they can have, and then foods that they should try to avoid.
07:52.780 --> 07:58.069
[SPEAKER_01]: The challenge is that many of these food items that they're trying to avoid, like broccoli.
07:58.049 --> 08:07.859
[SPEAKER_01]: cauliflower are otherwise part of a very healthy diet and so patients have to strike this balance between controlling their seaboe symptoms and optimizing their nutritional intake.
08:07.959 --> 08:14.146
[SPEAKER_01]: And for this reason, it makes a lot of sense if it's available to your patients, to refer them to nutrition.
08:14.466 --> 08:27.600
[SPEAKER_01]: The dietitians can be very helpful in helping to guide patients in terms of balancing the avoidance of high-fod map foods, but still getting appropriate and well-balanced meals into their GI systems.
08:27.935 --> 08:32.021
[SPEAKER_01]: So another treatment mechanism that might be brought up by patients is probiotics.
08:32.362 --> 08:38.791
[SPEAKER_01]: So probiotics, despite their growing popularity in recent years, are generally not considered an effective treatment for seabull.
08:39.372 --> 08:43.197
[SPEAKER_01]: There is some limited evidence that probiotics can improve gut motility.
08:43.838 --> 08:48.766
[SPEAKER_01]: And as we talked in episode 1 about how seabull is often attributed to impaired motility.
08:49.226 --> 08:53.773
[SPEAKER_01]: This theoretical benefit has not actually translated to meaningful clinical results.
08:53.753 --> 09:03.204
[SPEAKER_01]: In fact, our current national guidelines suggest to not use probiotics because the evidence is so limited for benefit to patients.
09:03.224 --> 09:07.969
[SPEAKER_01]: So as a result, we are not recommending probiotics as a mainstay of therapy for SIBO.
09:08.370 --> 09:14.116
[SPEAKER_01]: Now, lastly, there are some other symptomatic treatments that we can offer to our patients like peppermint oil and semethicone.
09:14.136 --> 09:17.500
[SPEAKER_01]: They can help with the symptoms of SIBO, particularly gas and bloating.
09:17.480 --> 09:26.144
[SPEAKER_01]: So I often tell patients about these two other supplements that they can try just to help them manage their gas symptoms from the underlying condition.
09:26.705 --> 09:27.748
[SPEAKER_00]: That is very helpful.
09:28.290 --> 09:33.143
[SPEAKER_00]: For most patients, antibiotics, ideally refaxmen remain the cornerstone of treatment.
09:33.680 --> 09:49.747
[SPEAKER_00]: but dietary modifications can be a reasonable alternative for those who prefer to avoid antibiotics due to the side effects or other reasons, and should be pursued for patients who take an antibiotic course as well to try to minimize recurrence of symptoms.
09:50.609 --> 09:53.634
[SPEAKER_00]: Thank you for an overview of Cibo Management, Dr. Kumar.
09:53.794 --> 09:55.637
[SPEAKER_00]: Any final pearls you'd like to leave us with?
09:56.090 --> 10:00.960
[SPEAKER_01]: So, Leali, let's as always do our three key takeaways from our RTL episode.
10:00.980 --> 10:14.790
[SPEAKER_01]: So, number one, remember to look at the specific type of seabull that your patients have as the gas pattern, whether it's hydrogen versus methane predominant, is going to influence the antibiotic choice that you make for them.
10:14.905 --> 10:20.114
[SPEAKER_01]: Number two is refaxment is the best studied and safest antibiotic for treating CBO.
10:20.615 --> 10:36.643
[SPEAKER_01]: It has less efficacy and methane predominance CBO, and in those cases when you're dealing with patients who have methane predominance CBO, consider the risk benefit profile of adding the amycin to the antibiotic regimen as it does have a higher rate of efficacy, but you again have to consider the potential side effects.
10:36.623 --> 10:50.811
[SPEAKER_01]: And then number three, given the benefit of adhering to a low-fod map diet for all patients, and particularly those who prefer to avoid antibiotics, think about referring your patients to nutrition to help modify their diets in a safe and healthy manner.
10:51.272 --> 10:56.843
[SPEAKER_01]: The low-fod map diet can be extremely helpful in patients with seabull and with IVS symptoms.
10:56.823 --> 11:00.128
[SPEAKER_01]: and so it's something to always encourage your patients to try to pursue.
11:00.148 --> 11:10.585
[SPEAKER_01]: It can be difficult to adhere to it long-term, and so that's why it's very helpful to have your patients work with a nutritionist as well as a goal for it along this journey.
11:11.206 --> 11:14.512
[SPEAKER_00]: Thank you, Dr. Kumar, for joining me to discuss the treatment of CBO.
11:14.912 --> 11:17.216
[SPEAKER_00]: We made it through our last episode on CBO.
11:17.577 --> 11:22.645
[SPEAKER_00]: I learned a lot over these past three episodes, and hopefully we'll be back to run the list soon.
11:23.165 --> 11:26.193
[SPEAKER_01]: Thank you so much, Ali, you are such a wonderful guest host.
11:26.213 --> 11:27.115
[SPEAKER_01]: You did an amazing job.
11:27.136 --> 11:34.776
[SPEAKER_01]: When these three episodes together, we covered a topic that I know is very interesting for both patients and providers and comes up a lot.
11:34.796 --> 11:42.456
[SPEAKER_01]: I'm glad we were able to dive in and talk about the three key parts of Sebo all the way from presentation to diagnosis and out treatment.
00:01.111 --> 00:02.573
[SPEAKER_00]: Welcome back to Run the List.
00:02.593 --> 00:08.062
[SPEAKER_00]: I am Ali Shibi, a current third year medical student at Harvard and a recent number of the RTL team.
00:08.503 --> 00:18.219
[SPEAKER_00]: I am back with Dr. Kumar, a gastroenterologist at Brighamun Women's Hospital, and one of the co-founders of RTL, for our third and final episode of our series on Cibo.
00:18.739 --> 00:20.863
[SPEAKER_00]: Today, we will discuss how to treat Cibo.
00:21.524 --> 00:22.766
[SPEAKER_01]: Thank you so much, Ali.
00:23.006 --> 00:26.612
[SPEAKER_01]: Let's wrap up our Cibo series today and run the list.
00:27.132 --> 00:32.761
[SPEAKER_00]: So now that we are all on the same page, let me quickly summarize the past two episodes.
00:33.542 --> 00:42.677
[SPEAKER_00]: Cibo is due to a pathological increase in bacteria in the small bowel with associated diarrhea and abdominal bloating worse after meals.
00:42.657 --> 00:51.631
[SPEAKER_00]: Diagnosis is most commonly established via lactolose breath testing, which measures methane and hydrogen produced by bacteria over time.
00:52.252 --> 01:04.210
[SPEAKER_00]: If hydrogen rises by greater than or equal to 20 ppm, or methane levels reach 10 ppm or higher, at any point during the test, the diagnosis of CBO is made.
01:04.190 --> 01:06.555
[SPEAKER_00]: So let's return to our case for one final time.
01:07.216 --> 01:18.359
[SPEAKER_00]: Ms. R is a 45-year-old female with a history of obesity, status post-rune, why gastric bypass, who presents to primary care clinic with two months of worsening, bloating, flatulence, and diarrhea.
01:18.901 --> 01:25.354
[SPEAKER_00]: She's found to have sebo on breath testing, and now that we have established her diagnosis, how do we treat her?
01:25.537 --> 01:26.318
[SPEAKER_01]: Thank you, Ali.
01:26.338 --> 01:31.606
[SPEAKER_01]: So, the first step is to identify the subtype of CBO that Ms. R has.
01:31.646 --> 01:33.549
[SPEAKER_01]: And there's basically two different types.
01:33.609 --> 01:37.955
[SPEAKER_01]: You can either have hydrogen predominant CBO or methane predominant CBO.
01:38.376 --> 01:52.877
[SPEAKER_01]: You'll recall in our last episode on Dinosys, we talked about the importance of the breath test measuring for both of those gas levels, hydrogen and methane because the treatment is dictated by the type of pattern we see between those two gas levels.
01:52.857 --> 01:56.101
[SPEAKER_01]: So let's assume that she has hydrogen predominant seabull.
01:56.741 --> 02:07.354
[SPEAKER_01]: In that case, the best antibiotic approach is to use anobotic called refaximin, or zifaxin, which is dose at 550 milligrams three times a day for 14 days.
02:07.774 --> 02:14.502
[SPEAKER_01]: You may recall this antibiotic as a use for hepatic and cephalopathy in patients with cirrhosis.
02:14.722 --> 02:22.611
[SPEAKER_01]: It is the same antibiotic, but it's a different dosage, and again it's just for a two-week
02:22.591 --> 02:26.575
[SPEAKER_01]: will take it indefinitely for their hepatic and cephalopathy.
02:27.135 --> 02:28.877
[SPEAKER_01]: So, what is refaxement?
02:28.897 --> 02:34.562
[SPEAKER_01]: What's a non-absorble antibiotic that has gram-positive, gram-negative, and anaerobic coverage?
02:35.002 --> 02:40.007
[SPEAKER_01]: And it effectively decreases the bacterial population of the small bowel.
02:40.027 --> 02:45.652
[SPEAKER_01]: As a non-absorble antibiotic, refaxement's primary effect is within the intestinal tract.
02:46.052 --> 02:50.556
[SPEAKER_01]: And what's nice about that is that you have less side effects from systemic
02:50.536 --> 03:05.601
[SPEAKER_01]: So in my experience, the most common side effects that patients may have on refaxment are GI upset in diarrhea because again, the main area of action is within the intestinal tract, but some patients also can develop some white headiness.
03:05.621 --> 03:10.249
[SPEAKER_01]: So it's nice to caution them about these potential side effects before they start.
03:10.229 --> 03:17.578
[SPEAKER_01]: To be honest, the main issue with refaxment is the cost of the antibiotic as it's very expensive if it's not covered by insurance.
03:18.019 --> 03:27.490
[SPEAKER_01]: So I always tell my patients, let me see if I can get this antibiotic covered for you, but do not fill it if it's not covered by insurance because the cost is very, very high.
03:28.171 --> 03:39.645
[SPEAKER_01]: So when that happens, when refaxment is not covered, there are many other alternative antibiotics that can also be used and have been studied for Sebo, and they all work generally about
03:39.625 --> 03:55.170
[SPEAKER_01]: Refactsment again is our preferred antibiotic, but if it's not available or not covered, you can use these alternative antibiotics such as augmenting, which is often my primary choice due to the safety profile of this antibiotic, as well as metroninousol, ciperfoxicin, or bacterium.
03:55.437 --> 03:55.878
[SPEAKER_00]: Awesome.
03:56.158 --> 03:57.361
[SPEAKER_00]: That was a great explanation.
03:57.421 --> 04:00.907
[SPEAKER_00]: Sounds like there's a lot of options for antibiotic treatment.
04:01.308 --> 04:04.955
[SPEAKER_00]: And ideally, we would be able to prescribe Ms. R. Roy Phaxaman.
04:05.576 --> 04:10.746
[SPEAKER_00]: Now, what would you recommend her if the SIBO breath testing was positive for pathogens?
04:11.080 --> 04:19.792
[SPEAKER_01]: So if she had befanogens, and especially if it's methane predominant seabull, the optimal antibiotic approach is actually to use two antibiotic.
04:19.852 --> 04:27.322
[SPEAKER_01]: So again, we use refaximin, which is used at that same dosage, which is 550 milligrams three times a day for 14 days.
04:27.822 --> 04:31.367
[SPEAKER_01]: But then the recommendation is to add a second antibiotic.
04:31.347 --> 04:42.869
[SPEAKER_01]: known as Neo-Mison that's dosed at 500 milligrams twice a day for 14 days, and those two antibiotics are taken together, so it's a lot of antibiotics within a short time period of two weeks.
04:43.550 --> 04:53.068
[SPEAKER_01]: Neo-Mison has a more concerning side effect profile as an amino glycoside, and so it can cause auto toxicity, kidney injury, and nerve damage,
04:53.048 --> 05:01.886
[SPEAKER_01]: And the one I've actually seen occur is the ototoxicity which manifests with a permanent tinnitus or ear ringing of the ear.
05:02.487 --> 05:13.048
[SPEAKER_01]: So it's really important to counsel your patients about the potential side effects of neomycin because they are serious and as I mentioned they can be permanent.
05:13.028 --> 05:29.064
[SPEAKER_01]: So, one thing I always check with my patients before prescribing Neomison is to see if they have any baseline issues with hearing or kidney injury or nerve issues because if they do, I'm really hesitant to use that medication that Neomison in those patients.
05:29.505 --> 05:42.698
[SPEAKER_01]: Just to know, Neomison also has a higher rate of GI distress, and so I often tell patients if it seems like they'll be okay taking it, they should take it with food because that'll help minimize some of the GI side effects, including nausea.
05:42.678 --> 05:51.477
[SPEAKER_01]: Now, given all the potential side effects that I mentioned with the neomison, many patients and providers to, for good reason, prefer to avoid the risk of neomison.
05:52.018 --> 05:59.995
[SPEAKER_01]: And so, in some cases, even if it's methane predominant CO, they will treat with just refaxment alone to see if that will be enough.
05:59.975 --> 06:16.077
[SPEAKER_01]: to take care of the pathogens in those patients, small intestinal tract, and sometimes it does work, sometimes it does, but it's always a risk benefit, a discussion with the addition of neomycin because of those potentially permanent and damaging side effects.
06:16.715 --> 06:17.276
[SPEAKER_00]: excellent.
06:17.557 --> 06:28.180
[SPEAKER_00]: I'm sure you get a lot of patients who may not be keen to start antibiotics and given all that you've discussed in terms of some of the side effects that can be pretty severe.
06:28.220 --> 06:32.209
[SPEAKER_00]: Are there any alternative modes of treatment for SIBO?
06:32.442 --> 06:41.854
[SPEAKER_01]: Yes, you are certainly right that many patients do not want to expose themselves to these antibiotics, especially the neomycin piece, as we discussed, because of the potential side effects.
06:42.594 --> 06:49.002
[SPEAKER_01]: And so there are other options that can be pursued to address the symptoms that arise from CBO.
06:49.263 --> 06:53.708
[SPEAKER_01]: The main non antibiotic approach is truly to modify the diet.
06:53.688 --> 06:57.753
[SPEAKER_01]: So dietary changes can be another option for seabull management.
06:58.393 --> 07:09.846
[SPEAKER_01]: And what the idea is here is for patients to focus on eating foods that have low amounts of fermentation products, which those small intestinal bacteria like to break down.
07:10.247 --> 07:14.872
[SPEAKER_01]: So the way to do this, it's most reliably achieved by following a low-fod map diet.
07:15.412 --> 07:23.121
[SPEAKER_01]: That is an acronym that stands for fermentable, oligo, dye, and mono-saccharides, and polyoles.
07:23.101 --> 07:28.212
[SPEAKER_01]: So it will be hard to actually memorize what foods fall into each category.
07:28.232 --> 07:31.179
[SPEAKER_01]: There are some great resources online to look at.
07:31.219 --> 07:35.629
[SPEAKER_01]: The one that I love to use is www.katescarlata.com.
07:35.669 --> 07:38.595
[SPEAKER_01]: She's a nutritionist who has a lot of experience in this area.
07:38.575 --> 07:52.419
[SPEAKER_01]: And so it's very helpful to go to that website, share it with your patients so that they can start looking at what a low fawn map diet may be, and what I love about that website, it shows options of foods that they can have, and then foods that they should try to avoid.
07:52.780 --> 07:58.069
[SPEAKER_01]: The challenge is that many of these food items that they're trying to avoid, like broccoli.
07:58.049 --> 08:07.859
[SPEAKER_01]: cauliflower are otherwise part of a very healthy diet and so patients have to strike this balance between controlling their seaboe symptoms and optimizing their nutritional intake.
08:07.959 --> 08:14.146
[SPEAKER_01]: And for this reason, it makes a lot of sense if it's available to your patients, to refer them to nutrition.
08:14.466 --> 08:27.600
[SPEAKER_01]: The dietitians can be very helpful in helping to guide patients in terms of balancing the avoidance of high-fod map foods, but still getting appropriate and well-balanced meals into their GI systems.
08:27.935 --> 08:32.021
[SPEAKER_01]: So another treatment mechanism that might be brought up by patients is probiotics.
08:32.362 --> 08:38.791
[SPEAKER_01]: So probiotics, despite their growing popularity in recent years, are generally not considered an effective treatment for seabull.
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[SPEAKER_01]: There is some limited evidence that probiotics can improve gut motility.
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[SPEAKER_01]: And as we talked in episode 1 about how seabull is often attributed to impaired motility.
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[SPEAKER_01]: This theoretical benefit has not actually translated to meaningful clinical results.
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[SPEAKER_01]: In fact, our current national guidelines suggest to not use probiotics because the evidence is so limited for benefit to patients.
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[SPEAKER_01]: So as a result, we are not recommending probiotics as a mainstay of therapy for SIBO.
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[SPEAKER_01]: Now, lastly, there are some other symptomatic treatments that we can offer to our patients like peppermint oil and semethicone.
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[SPEAKER_01]: They can help with the symptoms of SIBO, particularly gas and bloating.
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[SPEAKER_01]: So I often tell patients about these two other supplements that they can try just to help them manage their gas symptoms from the underlying condition.
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[SPEAKER_00]: That is very helpful.
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[SPEAKER_00]: For most patients, antibiotics, ideally refaxmen remain the cornerstone of treatment.
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[SPEAKER_00]: but dietary modifications can be a reasonable alternative for those who prefer to avoid antibiotics due to the side effects or other reasons, and should be pursued for patients who take an antibiotic course as well to try to minimize recurrence of symptoms.
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[SPEAKER_00]: Thank you for an overview of Cibo Management, Dr. Kumar.
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[SPEAKER_00]: Any final pearls you'd like to leave us with?
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[SPEAKER_01]: So, Leali, let's as always do our three key takeaways from our RTL episode.
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[SPEAKER_01]: So, number one, remember to look at the specific type of seabull that your patients have as the gas pattern, whether it's hydrogen versus methane predominant, is going to influence the antibiotic choice that you make for them.
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[SPEAKER_01]: Number two is refaxment is the best studied and safest antibiotic for treating CBO.
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[SPEAKER_01]: It has less efficacy and methane predominance CBO, and in those cases when you're dealing with patients who have methane predominance CBO, consider the risk benefit profile of adding the amycin to the antibiotic regimen as it does have a higher rate of efficacy, but you again have to consider the potential side effects.
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[SPEAKER_01]: And then number three, given the benefit of adhering to a low-fod map diet for all patients, and particularly those who prefer to avoid antibiotics, think about referring your patients to nutrition to help modify their diets in a safe and healthy manner.
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[SPEAKER_01]: The low-fod map diet can be extremely helpful in patients with seabull and with IVS symptoms.
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[SPEAKER_01]: and so it's something to always encourage your patients to try to pursue.
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[SPEAKER_01]: It can be difficult to adhere to it long-term, and so that's why it's very helpful to have your patients work with a nutritionist as well as a goal for it along this journey.
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[SPEAKER_00]: Thank you, Dr. Kumar, for joining me to discuss the treatment of CBO.
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[SPEAKER_00]: We made it through our last episode on CBO.
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[SPEAKER_00]: I learned a lot over these past three episodes, and hopefully we'll be back to run the list soon.
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[SPEAKER_01]: Thank you so much, Ali, you are such a wonderful guest host.
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[SPEAKER_01]: You did an amazing job.
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[SPEAKER_01]: When these three episodes together, we covered a topic that I know is very interesting for both patients and providers and comes up a lot.
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[SPEAKER_01]: I'm glad we were able to dive in and talk about the three key parts of Sebo all the way from presentation to diagnosis and out treatment.