Listener Questions on FMT for C. diff, Coughing After Eating

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Intro:

Welcome to Dr. Ruscio Radio discussing the cutting edge in health, nutrition, and functional medicine. To make sure you’re up to date on this and other important topics, visit drruscio.com and sign up to receive weekly updates. That’s DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Welcome back to another episode of Dr. Ruscio Radio. This is Dr. Ruscio. Today I’m with Erin Ryan, and we will be jumping into another episode of listener questions. So Erin, here we go.

Are Probiotics Pathogenic in Vulnerable People?

ErinRyan:

All right, let’s go. Our first question is from Debbie. She asks “Are you familiar with spore-based probiotics that also produce endospores? How would you treat a SIBO condition caused by them? I have methane SIBO that occurred right after taking these probiotics because I didn’t know they can be pathogenic in vulnerable people. They have not, and apparently can not be killed by Rifaximin plus neomycin because they are spores. Please help.”

DrMR:

Good question. This is a good example of a question that is built upon many assumptions and inferences. The challenge of a question like this that we have to be careful with how much we take away from speculation or inference or theory because oftentimes, sadly, people come away with the conclusion that thwarts them from thinking through the problem because they’re only thinking within the confines of whatever the posit is. Also, and more problematic, people often think that the condition or issue is worse than it actually is. Now, if there’s some kind of credible piece of evidence here, I’m happy to look at it. However, I’ve read a bunch of the papers on soil- based or spore-forming probiotics, and even did a foray into a pocket of research in Asia that doesn’t really get discussed much in the US so I’ve definitely dug fairly deeply in this arena. This is not something that you really see come up in a substantial way. There’s some kind of tangential commentary that some type of soil-based probiotics, not formulas, but some of the bacillus strains or other spore-forming or soil-based strains using these labels kind of loosely may be pathogenic. However, in terms of, has that been robustly documented where someone taking a quality soil-based or spore-forming product ends up with some type of pathogenic colonization? I don’t know that there’s been any case of that actually documented. Now again, I will remain open because I care about what the data says. However, because I am familiar with the data I know that sometimes these kind of tangental commentary remarks will be placed at the end of a paper that say something like “Oh, by the way, some soil-based probiotics may be pathogenic”. These can get conflated and turn into a runaway narrative, the type that we see probably leading to this question.

DrMR:

It’s a good question. This is not a dig on the person asking the question. It’s a highlighting of how we have to be a bit more circumspect with how quickly we integrate certain theories into our model or how we’re analyzing. In this case it sounds like someone who took a probiotic had a bad reaction and now this narrative is kind of being projected onto that situation. It is definitely possible that someone can have a negative reaction to a probiotic. Any type of probiotic. It is also possible that there could be a coincidence where someone went into a flare or even a prolonged flare or regression that coincided with the initiation of the probiotic. It’s very, very, very unlikely that taking a reputable or even non-reputable soil-based probiotic would cause this kind of a problem. Case in point, when Prescript-Assist reformulated and even actually in their original formulation, most of those species were not studied in humans. In the current formula, which I remain open to, it’s just until we have safety documentation, I’d rather not use something. Only four of the 28 species in that formula have actually been studied in humans. But even with that, there are droves of people taking that who don’t seem to report any negative effect and probably a fair amount who notice a positive impact from it. So when we look at all these things again, while I remain open on this, it’s very unlikely that the probiotic caused some type of irrevocable harm, nor that it is totally non-amenable to treatment with Rifaximin or neomycin. Again, that’s probably one miscontextualized piece combined with another miscontextualized piece resulting in a runaway narrative. So this is more likely a probiotic flare. I would throw out completely the thinking that there’s some type of irrevocable colonization by a probiotic and I would go back to the IBS and/or SIBO algorithm and just work the problem. This is the travesty. When people get pigeonholed into this kind of hypothesis, they start thinking narrowly within the confines of that hypothesis. In this case it’s probably mostly fallacious and it stops them from thinking about whether this is, more simply stated, someone who’s having IBS regression.

DrMR:

It stops us from evaluating how we can go to the algorithm, looking at their onset, their symptoms, their history, their response to prior treatment and use that to correctly navigate through the algorithm. In the vast majority of cases, this gets you to the other side where you’re feeling quite a bit better. So it’s a good question. Again, this is not a dig on the person asking the question, but I think this reflects how we really build a house of cards in natural medicine. I would strongly question if there’s any substantial data that affirms any of those claims. One person tells another and then people start talking about it and no one takes the time to fact check. Sadly, this leads to thinking in a in a narrow confine. So, I would quite simply go back to the IBS or SIBO algorithm, work the problem. This is almost for sure how you will help this person get over the symptoms that seem to be kind of plaguing them.

ER:

Okay. Yeah, that open-mindedness is so important. I’d say we get a question like this once a week. Someone zeroing in on one thing that could be the issue, but if you keep a more open mind, you can definitely get to a better solution.

DrMR:

It’s incredibly common. This is something that I see in the clinic all the time. I spend probably at least 30% of my time, maybe up to 50% of the time talking people out of a test they think they need, or a problem that they think they have. Again, based upon these interesting little snippets that tend to just guide people. Things that are new or novel or different are so enticing to people and before you know, it, there’s this thing that people are assuming it’s true.

ER:

I feel like by the time some people get to you, they’ve been to probably a handful of other different types of doctors and said, forget it, I’m going to do my own research. And then they’ve done what they think is their due diligence and end up with something they found on the internet.

Treat the Patient, Not the Test Results

DrMR:

Here’s a good example of this, not to take away from the questions, but I just saw a case of this yesterday in the clinic. This was a former patient of mine, haven’t seen her in a few years. She has been doing generally well, although over the past few months she was kind of regressing. So she went to her local MD who was kind of integrative. They did a stool test. The stool test was generally unremarked other than some low healthy species, a few different low species of lactobacillus and also low scores in diversity and low scores in various short chain, fatty acids like butyrate. Now, if you treat the test, you would take this patient and put them on typically a higher prebiotic diet, perhaps a prebiotic supplement and perhaps fiber, especially when this gal’s chief complaint was constipation. I’ve been saying this for years and I always kind of tell the story of back at the gut health panel, maybe five years ago at Paleo f(x), I felt like I was a crazy person because everyone was talking about how important it is that we feed our gut bacteria. And I’m saying, don’t you see all the patients with IBS who get really flared from doing this. It’s not to say you can never do it, but this is something that is probably gonna hurt more people than it’s going to help. The tide has been thankfully shifting where people understand this, but coming back to this gal’s family practice/ integrative MD looking at the GI Effects test. She had a prior response to a low FODMAP diet. So indicator one that prebiotics would flare her. So treating the low short chain, fatty acids, meaning, you know, feeding the bacteria with prebiotics and fiber so as to increase the short chain, fatty acids, would almost for certain flare this person, even though her labs indicated that. She also commented that fiber supplementation tends to make her more bloated and more constipated, even though there’s some evidence showing that just based upon symptoms, fiber can help with constipation. It would be a fool’s errand to look at this lab and say, well, the labsshow that we should be feeding our gut with fiber and with prebiotics. We can easily suss out with like three questions if her history suggests that that will be a bad maneuver for her gut. We don’t need all this fancy smancy data from labs, which, by the way, is often inaccurate and just really inferential. This is another example of that same type of thinking where everyone’s talking about short chain, fatty acids, how important those are. There’s a clear contradiction to what you see on these labs, and again, those labs are still not very accurate in large part, and how do you actually want to use these tools to help improve someone’s gut health. So, yeah, it’s kind of a reoccurring theme of the podcast. Yes testing can be helpful, but I’m becoming more and more confident in my position that testing probably does more harm than it does good because of all the markers practitioners run that are not helpful or not valid leading them to treat the tests rather than treat the patient. This burns money and it makes it harder and takes longer to get the person healthy. You’re so preoccupied treating these erroneous lab markers, rather than just looking at a good clinical algorithm and navigating the person through the algorithm based upon their history, their symptoms, or presentation, their prior response to treatment and maybe a couple of lab markers speckled in. Unfortnately, that kind of takes a back seat to all the other context.

ER:

Yeah. This is one reason why I will probably never eat sauerkraut again, because I saw a naturopath who sent me on my way saying, look, here’s what you need to do. Daily, have some kombucha, have sauerkraut, have goat Keifer and you should start feeling better in no time. So I did that for weeks on end and felt so much worse. I was like, I’m not getting over the hump. Do I need more? Yeah, yeah, yeah, try more. I was so, so sick. So yeah, I don’t think I’m ever going to touch that again. I’m just someone who just can’t really eat prebiotic type foods and I’m fine without them.

DrMR:

Yeah. It’s worth a trial, but it sounds like they were doubling down on that rather than saying, Oh, okay, we hit an inflection point in the algorithm, now we move in a different direction. That was more of a linear, you know, if more doesn’t work then pour even more on to the fire. This is where we can do a lot better in the field.

ER:

I just shudder at the thought of sauerkraut. Okay. So our next question is an audio question from Hector.

FMT capsules for C. diff

Hector:

Hi, Dr. Ruscio. I enjoy your podcasts a lot. I was on the OpenBiome website and noticed that they now have fecal microbiota treatment capsules on their website and it appears they’re enrolling people in clinical trials for the use of these capsules for C. diff. Just wondering if you had any more information on where those trials are right now, and also when these capsules will be available to the general public through providers for the treatment of other gut-related issues and what your feelings are on the viability of these capsules. Thank you.

DrMR:

So great question. I haven’t actually been following too closely what’s going on with OpenBiome and FMT capsules, although that’s very exciting. It sounds like these are being able to be mailed to people and that, thankfully, would make FMT much more accessible. I don’t know what the current status there is. I do know that the more research that pours in for C.diff. It’s really incontrovertable at this point, FMT can be very helpful for those patients, especially if they’re resistant to antibiotic treatment. IBD, as I’ve said before, probably the second thing that will get approval for this. IBS, the data are a little bit more mixed, but certainly maybe a viable end of the line therapeutic option. I emphasize end of the line. What’s nice about the capsules, obviously, is that we really circumvent the fact that a lot of people probably don’t want to do a nasal gastric tube. I’ve never done it, but I’m assuming it’s pretty unpleasant. Then enemas, also I’m assuming that’s something that most people don’t want to do. I mean, sure, if you’re in dire straights, you can do it and you probably would do it, but the “crapsules” as a woman called them a long time ago, I think are a really attractive option. Some have theorized that the capsules may work better to help shift the microbiota in the small intestine. I believe there’s been a couple of studies that may have shown that ilial Crohn’s or inflammatory bowel disease is affected more. So the small intestine and/or SIBO may do better with the capsules. Although I may be miss recalling that detail and there may not be a solid trend there in the data. But the theory kid of makes sense. In accordance with the philosophy of note from before, I am not going to pile onto that theory until there’s adequate data. So that’s why I kind of couch my narrative here. It could be that the capsules are better for stuff, imbalances in the small intestine, but we should be careful not to pile on to that theory until there’s been adequate data to substantiate that.

DrMR:

So right now it’s a theory. Maybe it will be proven, maybe it won’t be. To your question, I don’t know what the status is. However I’m encouraged in hearing that. My thinking is it’s only gonna be a matter of time until someone can do this, perhaps even fully remotely, where they can do a telehealth visit, the doctor can go over their history and essentially write them a prescription for FMT capsules. I’m hoping at some point that will be viable for inflammatory bowel disease also, especially when looking at some of the strong biologic drugs and what the negative longterm side effects of those can be when weighed against the safety profile for FMT. So that’s great to hear, thank you for sharing that and I’m sorry that I don’t have more to offer there, but I think in some we’re definitely moving in a good direction with FMT in terms of the data to support it, and also the ease of accessibility. In this case, there’s a capsule rather than having to do something like a nasal gastric tube or an enema.

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Persistent Cough after Eating

ER:

Okay, Angela’s question is “I always cough after I eat. Pretty much after every meal and no matter what it is I’m eating. It doesn’t matter whether or not I take digestive enzymes. It is not an I can’t catch my breath cough, but more like an aggressive throat clearing cough, any ideas?

DrMR:

Yeah. So there are a few things that could be, that could be reflux. There’s silent reflux, there is LPR, there is bile reflux. So there are a couple of different kinds of subsets underneath the umbrella term of reflux. It could also be what’s known as EOE or eosinophilic esophagitis. It’s more likely to be the EOE if the cough is accompanied by feeling like something is stuck in your throat, or there’s a little bit of irritation in your throat. Eosinophils are just immune cells. So it’s eosinophilic (the immune cells) causing esophogitis (inflammation in the throat). In these cases, when people think there’s something stuck in their throat, it’s actually not any thing, but rather itfeels like something because of the inflammation that is happening due to the immune cells, attacking some of the tissue in your throat. So if you’re feeling that that kind of stuck feeling, or kind of coughing to try to clear that out of your throat, it’s more likely the EOE. If you don’t feel any sensation, but you’re coughing more reflexively, meaning you don’t feel like there’s any problem, but you’re just coughing, that could be reflux. Now the nice thing about the gut is how we address this tends to have a lot of commonalities. Your diet is the foundational aspect to look at. In addition you want to look at your sleep and exercise. So if you’re sleeping four hours a night and you’re incredibly stressed and you’re not getting any time in the sun, all these things are going to exacerbate any kind of weak link in your chain, so to speak. So make sure you have those things out of the way. Second to that would be diet.

DrMR:

This is where an elimination diet comes in. If you haven’t gone on a paleo like elimination diet, or just any kind of elimination diet this is worth trying. An elimination diet is where you get rid of potential inflammatory foods, gluten and grains for some people, processed foods, soy, spicy foods, chocolate, caffeine. All of these can be a problem. You can go a little further if you want, and this is something I talk about in Healthy Gut, Healthy You. You can remove potential irritating or inflammatory food and then go all the way to an autoimmune paleo-like protocol. This is all in an attempt to figure out what irritates you and only avoid those irritants and not have to avoid everything recommended by the diet in the longterm. The elimination helps you identify the triggers and then you move to the broadest possible application of that diet in the longterm. So that’s kind of path one, dietarily speaking.

Speaker 2:

It could also be an issue with FODMAPs. So if you haven’t gone lower FODMAP, then that’s something to consider. This does seem to lower the inflammation in the gut and inflammation, in a roundabout way, may actually stimulate stomach acid. So this may be hyperacidity secondary to food choices and those food choices could be antigens or irritants, or they could be fermentable substrates. Hence the low FODMAP. It is also possible that it could be histamine and you may want to just do a one week trial on the low histamine diet and see if this gets better. So those are various kind of dietary permutations you can try. None of them would take very long to see if you can figure out if a food trigger is what’s driving this. Now, it’s also possible that it could be a problem with stomach acid being too low. Usually, at least as best I’ve been able to piece this together, those various food triggers will lead you to have a hyper acidic response, if it is a acidic issue. It could also be the eosinophils if it’s just an inflammatory trigger. But on the other side, it’s also possible that reflux could be due to having inadequate hydrochloric acid release in your stomach. Now your age has a big impact on this. We published a video case study on a patient named Mason a number of months ago. He was, I believe, either late sixties or early seventies. So being in that age category, it is more likely that your stomach isn’t secreting enough acid. With age, many things kind of slow down, stomach acid being one of those. So for him, vegetarian low-FODMAP was a huge bump. Then another huge bump from hydrochloric acid. So depending on your age, hydrochloric acid may be more or less indicated. Also, if you have any kind of autoimmune condition or a history of anemia, that increases the probability up to maybe 50% that you may benefit from hydrochloric acid. Important side note, don’t assume that you need hydrochloric acid, run the experiment, run it for about a week. If you notice clearly that that clearing of your throat gets better then that tells you that you needed HCL. If you have a flare or you notice nothing at all, then you don’t. So that’s kind of layer two. Along with layer two there’s another permeation you can consider. That would be dysbiosis. There, I believe, is evidence associating small intestinal bacterial overgrowth to GERD and reflux. I’m fairly confident that’s been published. Also evidence showing that a low FODMAP diet can help with reflux, and that probiotics can help with reflux.

DrMR:

The probiotics help with a number of things. They help with inflammation and they help with dysbiosis. Sounds kind of familiar, right? It’s the exact kind of algorithm that I lay out in Healthy Gut, Health You. So the good news is many of these various disorders come down to figuring out how to heal one’s gut and that’s more algorithm dependent or just personalized in the therapies of the individual. We like to think that we have these unique symptoms that require a unique therapy. The uniqueness of the individual is addressed in how you navigate the algorithm. It’s not necessarily addressed in the nuances of your symptoms, at least for the most part. So here we could have two different people with two different symptoms, but they may both notice that low FODMAP and using hydrochloric acid got rid of, let’s say in the one case it was reflux and in the other case it was bloating. So the personalization occurs in how you navigate the algorithm. Another example, you could have two people with the same symptoms of throat clearing. One person may notice that low FODMAP made them constipated while the other person noticed the low FODMAP improved their reflux. Then those same two people may try hydrochloric acid and have totally opposite responses. So it’s important to keep that in mind, because you don’t want to not go through the Healthy Gut, Healthy You algorithm, because you think that your symptoms are unique and somehow are not addressed underneath that umbrella. I mean, there’s certainly exceptions for that. It’s not a panacea. But the point I’m trying to articulate is that various symptomatic presentations tend to all be addressed by the algorithm because the algorithm is not static. It’s a step by step process that you personalize to you, and that’s where you figure out what your unique underlying needs are to address the surface level issue of a symptom. So hopefully that helps you navigate that throat clearing.

ER:

For EOE, I’m just curious, is that something that like an ENT would diagnose or is that back to sort of a gut specialist?

DrMR:

Either one. It’s something that an EGD can diagnose. What you may also be confronted with is some doctors may not even want to diagnose that initially, they may want to just try a various treatment. You know, the more invasive the diagnosis is, the more likely a provider is to try the treatment before the test. This is actually something I think conventional medicine does quite well. They don’t just hand out testing willy nilly. They think this test has a certain expense, a certain invasiveness and if this test was positive, it would lead us to try X treatment. So why not just try X treatment and if we see results in the symptoms, then that tells us that most likely that diagnosis was present. There are holes in that philosophy, but I think it ends up being a net good for the patient. But yes, an ENT or a GI should be able to diagnose that.

Red Light Therapy

ER:

Okay. Alright. So we’re going to go to Bill’s audio question about red light therapy.

Bill:

In relation to the red light therapy I would like information concerning the minimum effective dose using the red light therapy for issues such as fatigue and low testosterone, especially the minimum size and cost to attain those effects. For example, if you’re looking to lower fatigue, can you get one of the smaller units and just increase your exposure? I imagine you would have to distribute that over your body, or does it make more sense to just go with a larger one in order to attain that effect? I’m also hearing other people criticize these devices because of flicker fatigue and they’re looking for sources in incandescent bulbs that could produce in the same spectrum. Thank you.

DrMR:

Okay. Great question. I’m not really the guy to answer this. I am not a expert in the application of red light therapy. I would refer you to Ari Whitten as one of the best sources. He has been on the podcast two times. Now he wrote a book on this and he lays out guidelines. I do think that your note about flicker fatigue or just those who are sensitive to light therapy is legitimate. In fact, I’ve noticed personally a threshold where my sleep will get quite poor if I overexpose to red light therapy. So this is definitely something to be cognizant of and is something that we’ve talked about on the podcasts with Ari. How some people are hyper responders. I believe the data for low testosterone are very sparse. I think the only study there was with ram testicle. So I don’t know, that’s probably something that if you wanted to do one or two baseline blood draws and then start doing some red light therapy and see if you notice an appreciable change, you could do that. If you’re looking to increase your testosterone probably the best way to do that is with HCG. Then regarding fatigue, again, Ari has laid out guidelines in our previous episodes regarding fatigue. It depends on the output of the device, how far away you are from it. But the nuances there are not ones that I’m familiar with. Also regarding the minimal effective dose. From what I’ve seen or gathered from the conversations with Whitten, I think that’s a bit individual, but I would refer you to the past podcasts that we’ve done with him. Also to his book to kind of get some of those questions answered. They’re great questions. It’s just this, isn’t something that I’m reading all the studies on, nor am I kind of using this in the clinic as a therapy I’m recommending and giving detailed prescriptions for, and then monitoring how people do. So I don’t think I’m the best person to answer that question, but Ari would definitely be. He’s very conservative and evidence-based, and he’s not just someone who jumps on the bandwagon. So I think he’ll be an excellent resource for you.

ER:

Yeah. And bill, if you’re listening, we have an infographic in the notes on one of those podcast episodes, I believe it’s still there. He gives a breakdown of different ways to use it, like three to six inches away for three to 10 minutes, or something like that. I didn’t see fatigue listed in that one, so he may talk about fatigue and one of the other episodes, but he breaks it down very easily. If I recall, I think he said you don’t even necessarily need the big, huge light. One of the smaller panels will do, you just have to move it around. Anyway, it’s really fascinating episode. So check that out.

Could Low Level Postive ANA be due to Gluten Antibodies?

ER:

So our next question is from Rachel, she says, I have a positive 180 speckled ANA. I’ve been tested for everything. It has all come back negative, even blood serum, celiac tests. I also did a GI-MAP, which did have high antigliadin IGA 0 to 157 is the range, I was 942. Is it possible that my consistently positive ANA at the low level might be because of those antibodies for gluten?

DrMR:

Good question. I don’t know. I suppose it’s possible. A challenge with ANA is that it is nonspecific, so you need something else to confirm it. I don’t know if I would read too much into the ANA alone.

ER:

What is ANA?

DrMR:

It is antinuclear antibodies. So you may see an elevated TG antibody in a patient who’s suspicious of thyroid and the data there have shown that you may see that as a normal finding in a sizable subset of the population, and there may be no correlation between thyroglobulin antibodies and thyroid health. Some data does suggest that, but there’s certainly been a number of studies, actually, one of themwe just wrote up in the Future of Functional Medicine Review clinical newsletter, where there was no predictive association with thyroglobulin antibodies. Also with the stool IGA gliadin antibody testing, there’s less data for that. Serum is really what’s been used the most. Even with serum or blood, I believe, the accuracy there was only 60%. So the stool is going to be even less. So there could be something there, but there could also be nothing there. This is again why I find myself continually in the position of arguing the other side, even though I am not against lab testing, it probably comes off that way. However, this is a good case where I don’t know all the details here, but you could be led down this road of needing to find a thing where there really may be nothing. The gliadin antibodies may be an anomalous finding. They could mean something and you can figure that out just by doing a gluten removal and re-introduction objectively, don’t nocebo yourself. The ANA could also be inconsequential. What I would do there is try to get a better read on if gluten is a problem for you. You have to try to get yourself into a neutral mental framework because it is remarkable how much we can work ourselves into a tizzy. I just went through this. I thought the residence I was in in Austin had mold and really what ended up happening was it was kind of a rough move in terms of sleep disruption and other things. So my body just wasn’t as healthy. Then I was in a new environment and was associating my not feeling well to the new environment. And it kind of freaked me out for a few days. So, you know, the reason why I share my own personal story in context with yours is to hopefully prevent you from getting led down this road where there may not really be anything there or any cause for alarm.

Speaker 2:

Again, this is something that, because I don’t know all the context you want to take with a grain of salt, but ANA in and of itself is not diagnostic. If you’ve gone through a bunch of other workups and found nothing, then I wouldn’t be worried about it. It could just be like thyroglobulin antibodies being high. That in and of itself may not be indicative of any problem. With the gliadin antibodies, that could mean something. If the blood, which is the most accurate, has a 60% accuracy, then this is going to be less than that. So we may be able to say that that may have a 50ish percent probability of actually being a viable or an accurate marker. I know that doesn’t give you a lot of assistance with improving your health, but I’m not sure if there are any symptoms there. So I would look more to the symptoms that you have and work with the clinician who may be able to help you improve your health, and perhaps be less concerned with these markers. Again, there’s a lot here, obviously that I don’t know. So take that with a grain of salt, discuss with your local doctor, but hopefully that helps you navigate some of this.

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Rifaximin Dosing

ER:

So I have two other audio questions, but I think we only have time for one. We can either go as a practitioner question or a quick Rifaximin question.

DrMR:

Let’s table the practitioner one and go with the Rifaximin.

ER:

This is an easy one.

Listener Question:

All right, Dr. Ruscio, what would be a typical dosage of the prescription Rifaximin for SIBO. If we wanted to have our holistic doctor prescribe this antibiotic what would be the typical prescription dosage that could tell him based on your book? Thank you.

DrMR:

To give you a few kind of different options, Rifaximin dosing is pretty standardized at this point. So with Rifaximin there should be fairly wide agreement when using this. 550 milligrams, three times per day for 14 days. Now that is sometimes paired with neomycin at 500 milligrams a day, two times per day for 14 days, or potentially Metronidazole at 250 milligrams, three times per day for 14 days. Of course, all of these things check with your local doctor. Get their ok. But these are kind of the standard protocols that are used. If he’s suspecting small intestinal fungal overgrowth, he will use, and we shared this on the podcast a few years back, Rifaximin with that same dosing with Fluconazol of a 100 milligrams once per day for three weeks. Start on the Rifaximin for one week and then at the start of the second week of Rifaxamin, they will start to Fluconazol. So they’re going to overlap and then finishing with a tail of Fluconazol. So there’s a few of the dosages. Again, those are fairly widely available. So there shouldn’t be a challenge kind of pinning that down with your local doctor in helping you. Also remember, and I feel like this isn’t discussed often enough in some kind of SIBO centric circles, remember that Rifaximin is available as a prescription, not requiring a positive SIBO breath test. It’s available just for those with the symptoms of IBS. Again, the reason why I share that is because I think we’ve really drifted into a territory where we’re using testing way too much. Just consider this, if you treat the test results and you don’t get any better, what do you do then? Well, welcome to anywhere from 50 to 75% of patients, right? Where you treat the labs and they don’t get any better, or they may even get worse. You know, this is the perspective I bring to this conversation time and time and time again. We have to do more than treat the lab tests in order to keep the individual healthy. So I just want to slip that philosophical note into the mix here, along with those dosing guidelines for a few different pharmaceuticals that can be used for SIBO and/or for presumed SIFO, most people are not going to have a legitimate duodenal aspirate diagnosis for SIFO, but rather it’ll be more of a presumption based upon presentation. That gives you some dosing protocols.

DrMR:

These are always fun conversations. I hope people are benefiting from how I’m answering some of these questions at a deeper level. In some aspects of trying to address thinking, philosophy, framing. If we can get a better understanding at that deeper level then a lot of these questions resolve themselves. Often times the questions are a symptom of errors in the deeper kind of epistemological framework that we use to analyze all these claims that are percolating on the surface level. So hopefully this is helping people. I would welcome any feedback one way or the other on this, because I’m always trying to stay in tune with you guys. Hopefully it’s providing some benefit.

ER:

Okay, well that’s all the time we have to speak.

DrMR:

Awesome. Well, thank you guys. Thank you, Erin. And we will talk to you next time.

Outro:

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