Overuse of Herbal Antimicrobials & Probiotics

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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.

Overview of Case Studies

DrMichaelRuscio:

Hi everyone. Welcome back to another episode of Dr. Ruscio radio. This is Dr. Ruscio, and today we are going to be jumping in with another kind of potpourri of topics. One is a case study regarding how the over use of herbal antimicrobials can be a problem. I’ll clarify my position here because in Healthy Gut, Healthy You, I advocate for considering low dose cyclical antimicrobial therapy. Alternatively, just using in a somewhat ongoing fashion, a low and minimally effective dose of herbal antimicrobials, which should be distinguished from blindingly using antimicrobials to treat lab tests alone. I’ve harped on this numerous times in the past, that treating lab tests in isolation can be a problem. So we’ll discuss a case study where other functional medicine providers were heavy handed with antimicrobials, and this ostensibly led to a patient contracting or developing the imbalance of C. diff. We will also discuss a recent paper from a recent convention of the American College of Gastroenterology looking at Rifaximin versus probiotics for IBS, and also, perhaps most excitingly a head to head trial, looking at a soil-based probiotic versus Rifaximin for small intestinal bacterial overgrowth. I think you may be surprised by the findings. We’ll go into more detail on all these in a moment. First, I want to, again, showcase to you that these are all excerpts from the Future of Functional Medicine Review, our monthly paid access newsletter. This is predominantly written for clinicians, although you don’t have to be a clinician to subscribe. We cover one case study per month and three to five research study summaries. The case studies are so important because this is how you see a culmination of all the concepts in functional medicine and also, how you see portrayals of where errors in the philosophy in functional medicine lead to as in this case, a fairly serious microbiota imbalance due to over-reliance on antimicrobial therapy. One of these studies helps to substantiate that probiotics seem to have, spoiler alert, equal effectiveness for SIBO as does Rifaximin. Who could have thought?

DrMR:

If you’ve been following the podcast, you know I’ve been discussing this for quite some time. Sharing with you what the evidence says and removing the bias that seems to permeate the SIBO community, that probiotics should be avoided with SIBO. I can’t fully understand this as there is clear data supporting their use in SIBO. So the Future of Functional Medicine Review provides you relevant research and also research that is integrated into a clinical model. So you see the culmination of the research and actually this particular issue that we’re pulling from for these various summaries really ties together quite nicely, that the case study seemed to fall victim to the erroneous thinking that you should treat SIBO labs in isolation leading to overtreatment with herbals that then led to presumably C. diff. Much of this problem was rectified by probiotics, which the American College of Gastroenterology meeting concluded had a similar efficacy for SIBO as does Rifaximin. So I really feel that this newsletter is quite meaningful and something that I hope you will give a look. If you sign up in the month of September, your first month of full access is only $1. I want to make it as easy as possible for you to look around and see if it would suit you. But if you feel like it does, I really hope that you will take the 30 minutes to an hour once a month to arm yourself with the knowledge that can have a substantial impact on your understanding of functional medicine as well as how to operate as most effectively as a clinician, and also how not to get pulled into so much of the dogma that that permeates the field.

DrMR:

Again, I don’t want to be handing out these criticisms as if we’re the only operation in town that has this right, but is disheartening to see what happens in the field. A lot of that I think is because people are not taking the time to question beliefs and update their model. If you assume guilty until proven innocent or ineffective or non-validated until proven effective or validated. That’s how you can weed out a lot of the landmines that you can step on that will afford a patient’s attempt to become healthier.

Recovery from Herbal Microbials

DrMR:

In the July 2020 newsletter we published a case study, entitled “Recovery from Herbal Antimicrobials after Misguided Functional Medicine gives a Patient C. difficile”. I should mention that this is a case study from one of the doctors in our clinic. If you haven’t heard the update yet, I’ve recently moved from from California to Austin. My clinic has been expanded and I’ve hired a few doctors. The nice thing about case studies from people other than myself, is that it exemplifies that if someone is trained in the model, they can execute the model and really help avoid some of the pitfalls that are fairly endemic in the field. So in this case, a 34 year old male was challenged by multiple symptoms since 2016, predominantly affecting his eyes, genito urinary tract and his gut. His chief complaints were burning and inflamed eyes and eyelids, and also GI discomfort and stool irregularity. He had a number of previous diagnoses, IBS, prostititus, blepharitis, occular rosacea (Basically inflammatory conditions of the eye) and the tear ducts potentially. Acute respiratory failure, achilles tendon rupture, , recurrent SIBO – 2017, 2018, 2019 (crucial), pleurisy and C. diff in 2019. The initial impression Chris was recently diagnosed with acute C. diff colitis in the setting of longterm antimicrobial use. He appears in a tenuous state needing significant support. It appears that aggressive and perhaps misguided functional medicine therapies have led to his current worsening state. The initial recommendations for this patient, included first an autoimmune paleo diet template which I believe was because he came in with a history of using paleo. Also part of the initial recommendations: Saccharomyces boulardii probiotic combined with a soil based probiotic combined with a lactobacillus and bifidobacterium blend probiotic, L glutamine powder, digestive enzyme with HCL, and an immunoglobulin cod liver oil. He was encouraged to discontinue other products recommended by his previous functional medicine provider. I want to underscore that. One of the things that we do in the clinic kind of on day one is wean people down to only the most needed supplements from their previous supplement protocol.

DrMR:

I’ve discussed in the past this concept I’ve defined loosely as supplement creep, where people read blogs about XYZ supplement and they add XYZ supplement. Then they see a doctor for a few months and they add a few more supplements and there’s this constant aggregation without ever determining what is really needed and what may not be needed. That supplement holiday, so to speak, is an important part of this functional medicine reset, where we’re going to really try to come at the functional medicine model again, via a different model, a more conservative circumspect evidence based model. Part of that involves not thinking that more supplements equals better results. It also means that more testing doesn’t equal better results. And so that’s an important thing to mention here. We have published case studies in the past where arguably the largest change leading to improvement in one of these case studies was the supplement holiday where the patient got off the 15 some odd supplements she was on previously that she didn’t need not realizing that some of those supplements were causing negative reactions. She kept taking more stuff, thinking more supplements equaled better results.

DrMR:

So that’s definitely something important that we have really incorporated into the model. The rationale here is we are avoiding the use of antimicrobial products and instead are choosing to focus on broad spectrum probiotics, as well as digestive support. We have recommended a hypoallergenic protein meal replacement that may be easier to consume and digest, which can also aid additional L-glutamine powder and repair of the gut lining. We also suspect that the temporary removal of a few paleo compliant foods, vis-a-vis the AIP or autoimmune paleo diet, may help in the short term. Remember that paleo is elimination diet level one, you could call it. If you want to be a bit more restrictive and weed out some additional foods that may be problematic for a smaller subset of the population, this is where the graduation to the autoimmune paleo diet can be helpful. Also important to remember that these changes should be looked at in a temporary context, not permanent. I think something else that we do really well at the clinic is not lead people. Again, this kind of reoccurring concept that we shouldn’t be fanatical. More dietary restrictions doesn’t necessarily mean better results. There may be a term to be a bit more heavy with supplements and a bit more assertive with diet, but not in the longer term. This was a temporary restriction, but we will broaden that soon as you’ll see.

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DrMR:

Then at the next followup visit we had a set of labs to look over and we also wanted to follow up on what was the subjective or symptomatic impact of those recommendations. Importantly here, bowel movements have been more formed, less gassy and less mucus like. Chris also reported that he is not having big fluctuations of diarrhea and constipation. So normalization of consistency. He has also been able to take supplements from his plan without reactions and follow the AIP (autoimmune paleo diet) pattern. Looking at his labs, there was confirmation of C difficile toxin, A and B, and some opportunistic dysbiotic organisms were found. Morganella, Proteus, and Citrobacter most notably. You can see the labs in the case study write up. I’ll try to include these in the email newsletter if there’s enough room. The impression here after looking at all of this, after looking at his GI map results, he showed an expected dysbiosis of the stool. There was also some autoimmune testing run for the CDTB antibodies, which was negative. One of the reasons why I I’ve questioned the utility of this is in many cases you’ll see negativity, although there is some documentation showing that marker tracks, but then again, how to treat that is still questionable. So anyway, without getting on a tangent. Autoimmunity for damage, the motility apparatus was negative. Again, quick backstory. There are some cases of recurrent SIBO may be due to this underlying auto-immunity. Continuing with the impression. We must be quite cautious with our use of antimicrobials to prevent relapse while simultaneously addressing the dysbiotic Flora. So the recommendation here was a higher dose probiotic and a very mild, low dose anti-microbial. In following up six weeks later, Chris felt like his stool patterns had improved since starting treatment. He only noticed some perianal irritation and pain while sitting for long periods of time. So that was another symptom that had also improved. The recommendation is here is stop the antimicrobial herbs. Start a multi ingredient gut repairative formula, including glutamine. Continue the digestive support, continue the probiotics, but now bring the probiotic dose down to normal and broaden his diet to more of a general paleo like template.

DrMR:

After following up a number of weeks later and looking at the retesting that was ordered. The patient in this case wanted to retest. Our doctor didn’t feel quite the need, but the patient wanted to. So we’re happy to assist in that. So at his follow up there was no major changes. He was maintaining his improvements. There was no presence of C diff toxin, A or B. There was no presence of Morganella, or Citrobacter. There was normalization of clostridium species and normalization of candida species. So the labs, while they didn’t look perfect, they looked much improved. This led to the final impression. There are marked changes in the stool tests, nearly all positive. Despite all the changes on the stool test, however, it would be a stretch to say his GI symptoms were completely eliminated, but they have greatly improved as has his stool consistency. Given the large positive clinical and laboratory changes we will scale back some of the supplements even further and continue to monitor him.

Results of Symptom Based Treatment

DrMR:

So essentially here what this sums to, and I’m going to draw a little bit of an inference, but I’m assuming that the past office was treating the SIBO breath test results. Remember there was 2017, 2018 and 2019 SIBO positive. This is”recurring SIBO” while not looking at the patient’s symptoms. So likely what happened was there was this narrative that you will see that SIBO is a chronic condition and it tends to remit and relapse and you can never get rid of it. Part of this actually comes from conversations between Dr. Allison Siebecker and I or just Allison’s narrative on this and also mine that I think has been taken out of context. The narrative is that IBS and/or SIBO can be relapsing and remitting, but a large facet of that observation, in my opinion, comes from the fact that the research is a derivative of regular populations who may be engaging in monotherapeutic treatment. So they just do Rifaximin. They don’t tend to address sleep, smoking, exercise, diet, probiotics. There’s a decent probability if none of those inputs that can either discourage or encourage a healthy microbiota are addressed, you will see a chronic relapsing over time. Also keep in mind, an analogy that we’ve discussed in the podcast before. Say you had a hamstring injury in college. Every once in a while, if you’re sitting too much, if your exercise routine is out of balance, you may notice some hamstring pain or perhaps resultant knee pain because things have drifted back into imbalance. It wouldn’t be a big deal to say I have to go back to my stability exercises, my stretches, my foam rolling, whatever it was that helped to remedy the resultant imbalance there.You wouldn’t think of that as a big deal or as this esoteric, underlying, issue that needs to be dealt with that’s chronic.

SIBO as a Chronic Condition

DrMR:

A few things there are important to be kept in mind because if you look at SIBO as this chronic condition and you combine that with looking at the labs monochromatically what can end up happening is, and again, I’m drawing an inference and making a presumption, but this patient was given antimicrobial therapy. There was probably a minimal response, if any response at all symptomatically, but the clinicians kept treating the labs, treating the labs, treating the labs, trying to get the labs normal, not realizing it’s more important to initially focus on the symptoms. Sure the labs may help you navigate the menu of therapeutics, but the more important barometer is the patient’s symptoms. So in this case, this “scientific approach” to functional medicine that looks scientific, but it’s actually much less scientific because serial SIBO testing is not something that’s really been sanctioned by major bodies, nor is there good evidence showing that that’s any better than empiric treatment. All of these things kind of aggregate together. The expectation that SIBO is going to be chronic and this big deal as some people will say, “when I see a patient who is diagnosed with SIBO I tell them it’s going to be at least a six month process”. I personally think that’s really the wrong way to handle this. That combined with a predominance on favoring labs, rather than looking at that as one fourth of the data and looking at a patient’s symptomatic response to the therapies as more important than a lab finding. This all congeals together and results in the thought process of we think you’re going to need more antimicrobials than you will, and we’re going to treat your labs at the expense of your symptoms, and because we think that antimicrobial therapy is the best therapy for SIBO (because of another assumption that’s discordant with what the data shows, which is that antimicrobial therapy is better than probiotic therapy), we’re gonna use routine antimicrobial therapy. So all these things are a problem. And they’re a very sharp contrast with what I recommend in Healthy Gut, Healthy You, which is making sure you’ve built a case for a symptomatic improvement on anti-microbials. If you notice this improvement and then once you end the anti-microbials, the symptomatic regression that may tell us that your microbiome needs more of a nudge in order to be able to maintain balance on the other side of the nudge. Very different than what I’m assuming happened here, which is, again, a combination of a number of assumptions, or just a number of misreads of what the scientific literature shows.

DrMR:

Rifaximin versus Probiotics in the Treatment of IBS

DrMR:

This is actually evidenced by the other two pieces I wanted to showcase from our Future of Functional Medicine newsletter. One of these comes from the January 2020 report. This is the symposium report I alluded to earlier, the full title “An evidence based approach to IBS and CIC (chronic idiopathic constipation) Applying New Advances to Daily Practice, a review of an adjunct clinical symposium of the American College of G”astroenterology meeting”. The main thing I want to kind of draw your attention to here is a similar effectiveness was displayed for Rifaximin in the treatment of IBS as probiotics and the treatment of IBS. The relative risk reduction for Rifaximin was 0.84 and actually slightly better for probiotics, 0.79. So one would mean there’s no difference between placebo and treatment or the comparitor or treatment. So one essentially means neutrality. Above one means that there’s an essentially negative effect in the therapeutic. Below one means it reduces your risk of the intervention. So a relative risk reduction of 0.2 could be stated another way as a 20% improvement over placebo from the treatment. So said a little more simply, if you’re looking at relative risk, if you see a 0.2% reduction, you can assume that there’s a 20% chance that whatever treatment you’re giving is better than placebo. So in this case, Rifaximin led to a 0.84. So about a .16 reduction and the probiotics are 0.79. So that is a .19 percent reduction. So the probiotics were actually slightly better. Whether the difference between those two is considered significant, I’m not sure. But the point I’m making is they are pretty darn similar, perhaps even identical. Where does this relative risk reduction showing similarity between Rifaximin and probiotics with a slight edge, potentially, for the probiotics come from. 23 clinical trials covering 2,575 patients for the probiotics. For Rifaximin, 6 studies with 2,879 patients. This is part of where I think some who have yet to get behind probiotics derive their opinion because the trials for the probiotics are smaller. So there’s 23 trials with 2,500 patients. Whereas with Rifaximin, there are six trials with 2,800 patients. So this leads to the quality of the evidence for the observation, with the probiotics being low and the quality of the evidence for the Rifaximin being high.

DrMR:

It is important to acknowledge that. I think that is where part of the argument for those who have not yet gotten on board with probiotics comes from. It also depends on your relative gauge. In my mind, 23 clinical trials, albeit smaller finding a less expensive and arguably less invasive therapy, probiotics, seems to make that a more favorable starting point than the more expensive and potentially more invasive therapy Rifaximin. Even though the safety data for Rifaximin are good and the incidents of adverse events between the two is similar.

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Bacillus Species Spores as Treatment for IBS

DrMR:

So this ties in to another study, which kind of further reinforces my posit. It was a head to head trial, entitled “Bacillus Species Spores: A Promising Treatment Option for Patients with Irritable Bowel Syndrome”. So in short, this trial looked at a soil-based probiotic versus Rifaximin for the treatment of irritable bowel syndrome. It found that probiotics had a similar effect as Rifaximin. 10 days of Rifaximin was compared to 30 days on the probiotic. At the 30 day mark, there was a slightly better effect for the probiotic, at 60 days out, the treatment effect was equivalent. So this is another point that I think should make those who are resistant to probiotics, be a bit more open minded. This was a small study. There was no placebo control. That’s important to mention. What we are showing though, at a 60 day reevaluation point, if we’re going to be the most fair in how we phrase this, because if I was going to be misleading, I would only tell you about the 30 day followup. I’d say, “look, probiotics are better than Rifaximin”. This is true, but that’s also right when the probiotic treatment ended, whereas the Rifaximin treatment had ended 20 days prior, right? So it’s day one in one group, they start 10 days of Rifaximin. The other group, they start 30 days of probiotics. There’s a followup at 30 days. So that’s right at the end of the probiotic, but it’s 20 days after the 10 days on the Rifaximin. So if you’re going to be a little bit misleading, you’d only cite the 30 day outcome. But if you go out to 60 days, there seems be a similarity in the effect. Let’s just be honest and how we report this, but look at what we’re seeing. We’re seeing a similar outcome. I don’t have anything against Rifaximin, but the thing that I’m trying to draw your attention to here is for some reason, there still exists. this dogma, that antimicrobial therapy, whether it be herbal or antibiotic should be preferred for SIBO and IBS. There have been a number of data points, a meta analysis of 18 clinical trials for SIBO, there was one trial that looked at probiotics versus Rifaximin for SIBO finding equivalent outcomes. In fact, in those who had SIBO plus IBS, the probiotics worked better. There is this trial looking at IBS, comparing Rifaximin versus probiotics and finding equivalent effectiveness. So I really think if you have a bias of Rifaximin, you can find data points reinforcing that Rifaximin or antibiotics are better than probiotics. If you have a neutral perspective on this, then it seems more tenable to say, let’s start with the probiotics, which are less expensive, have easier accessibility and they probably have a better side benefit profile. This means other secondary benefits. There are likely more of them reported for probiotics than for Rifaximin.

DrMR:

We should also acknowledge that there are some studies for which, at least the preliminary data, finds better secondary benefits for Rifaximin as compared to probiotics. One example, I was just looking into some studies on hepatic encephalopathy, essentially where the liver isn’t adequately filtering certain toxins out of the blood. They get into the brain and they cause this neurological sequela secondary to what’s going on with the liver. It’s been found that Rifaximin can reduce that. There is some evidence showing that probiotics may reduce that, but the finding seems to be better for this kind of gut-liver induced brain fog for Rifaximin than it is for probiotics. But the general point, exception aside, seems to at least hint that if you’re looking for the primary treatment effect to be SIBO or IBS, but you’re also looking at what has the most secondary benefits that probiotics actually may have more secondary benefits. Potential improvements in joint inflammation, brain fog, skin, sleep, we’ve talked about a number of these. One study finding that there is a marginal improvement in thyroid hormone medication absorption, although that is a preliminary finding. Another study we’ve talked about in the past where Saccharomyces boulardii helps to lower homocysteine. So when you look at all this stuff together, this is where my concern is that there may be some evidence limited thinking where sure, if we’re doing this only based upon the number of patients in the trials and the power of the trials, we would give Rifaximin the edge fine. But I think we’ve got to look a little bit more broadly and not be evidence limited. In this case, I think it’s hard to make the argument that antimicrobial therapy, Rifaximin or potentially herbals should be across the board favored before probiotics. And if we go back to the case study from a moment ago, the longterm herbal antimicrobial therapy actually led to a deleterious outcome in that individual. Again, I’m presuming that in part.

The Future of Functional Medicine Review Newsletter

DrMR:

In any case, hopefully this is all kind of tying together. Meaning the case study exemplifies how, if we’re following the dogma of “antimicrobial therapy is best for SIBO” and “SIBO testing must be done in a serial fashion:, we can look scientific on the surface, but actually be operating in a way that is quite discordant with the science shows. This leads to suboptimal outcomes for the patients. So these are the concepts that we try to inculcate and articulate in the Future of Functional Medicine Review clinical newsletter. This is how we are handling these cases in the clinic where, as this information imbues itself into a philosophy, you really start seeing the fruits of that philosophy, being able to help these patients who otherwise may have had a really tough road.

DrMR:

That’s why I’m so happy to be offering the Future of Functional Medicine Review newsletter. Also having other doctors now inside my clinic, so we can help more of you who are in need of responsible, evidence-based, but not evidenced limited, practical, cost, effective functional medicine care. So just a reminder that if you do want to sign up for the newsletter, if you sign up in September, it only costs $1 for your first month of access. If you go to DrRuscio.com/review, you can plug in and learn more about that. I really hope that you will give that a look because there’s a lot there that I think we can learn from. I hope you will follow the case studies and the research study reviews. I try to make everything they’re concise so you can learn a lot quickly.

DrMR:

I know we’re all busy, but I’m also very eager to share these pearls that we’ve learned with everyone from health coaches, all the way up through conventional medical doctors. So we can all carry the same torch of logical, rational, cost-effective, evidence-based, functional medicine. So I hope you will head over to drruscio.com/Review and sign up, or if you’re a patient who needs help, look up our clinic. Hope this has been helpful and gives you kind of a light through some of the contention and the area of SIBO/IBS probiotics, antibiotics, and anti-microbials. We will talk to you guys next time.

Outro:

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