FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, which are the four classes of fermentable sugars and sugar alcohols. The Low FODMAP diet is one of three commonly prescribed diets when treating SIBO and is also prescribed to prevent SIBO recurrence. The low FODMAP diet eliminates the foods that contain the most fermentable carbohydrates within the intestines. The low FODMAP diet, however, does not restrict polysaccharide and disaccharide sources of carbohydrates that are poorly absorbed, so for some patients with SIBO, this diet can worsen the problem. If a patient doesn’t improve on the low FODMAP, the Specific Carbohydrate Diet (SCD) may be a viable alternative. SCD was first developed to treat celiac. It is also very effective for those patients during SIBO treatment who aren’t responding as well to the Low FODMAP. SCD limits complex carbs (disaccharides and polysaccharides), lactose and sucrose. These ingredients are harmful to the digestive system and lead to yeast overgrowth, bacteria overgrowth, and inflammation. According to data from surveys, SCD has a 75% to 84% success rate.

SIBO Treatment Options

Dietary changes are not normally enough to treat SIBO, but dietary changes are crucial as part of an herbal or pharmaceutical treatment regimen. The pharmaceutical used to treat SIBO is normally Xifaxan 500 mg twice a day for 14 days with two more refills used in succession for a total of six weeks. If methanogenic bacteria are also present, Xifaxan is paired with neomycin for the first two weeks of treatment. Both Xifaxan and neomycin are intraintestinal antibiotics and are effective in treating SIBO with minimal side effects.

Herbal treatments are also effective. The most researched product for treatment of SIBO is Metagenics Candibactin-AR and Candibactin-BR. In a clinical study, combined use of Candibactin-AR and Candibactin-BR was as effective as Xifaxin in treating SIBO when administered daily over four weeks. Both Candibactin AR and BR are taken together for one month. Probiotics and fermentable foods are contraindicated when either herbal or pharmaceutical treatments are employed.

While the treatment is usually three rounds of Xifaxan or a month of Candibactin-AR/-BR, it is imperative to consider and assess clinical symptoms to determine when to cease treatment.  For example, treatment too long with Xifaxan can result in drier stool and constipation, so it is important to weigh symptom improvement throughout treatment.  Lactulose or glucose breath test post-treatment can be used to determine if asymptomatic residual disease remains.  It is always a good idea to ask your patients to provide an update of their symptoms every two weeks.