Does your gut need a reset?

Yes, I'm Ready

Do you want to start feeling better?

Yes, Where Do I Start?

Do you want to start feeling better?

Yes, Where Do I Start?

Can Prokinetic Agents Help SIBO and Gut Symptoms?

Your Complete Guide to the Pros and Cons of Prokinetics

Key Takeaways
  • Pharmaceutical and natural prokinetic agents are designed to improve gut motility (get a sluggish gut moving).
  • There’s been a tendency for these to be considered a “silver bullet” in the treatment of SIBO patients.
  • In fact, motility problems may often go away of their own accord if underlying gut dysbiosis and inflammation are treated.
  • Prokinetic agents can help with motility, but only if still needed when the fundamentals of diet and probiotic therapy are in place.

Within the world of functional medicine, the use of pharmaceutical or natural prokinetic agents in patients with SIBO (small intestine bacterial overgrowth), IBS (irritable bowel syndrome), and other gastrointestinal disorders is hotly debated. 

Prokinetics are a complex topic, and there are some gaps in the research. It’s easy to get bogged down in the details. But if you’re struggling with unpleasant gut-related symptoms, you’ll mainly just want to know if prokinetics will work for you or not.

In this article, we’ll walk you through the evidence and help you to come to a considered decision about using them.

Prokinetic agents: man with a stomachache holding his stomach

What Are Prokinetic Agents?

Prokinetics agents are pharmaceutical and natural substances that support gut motility — the healthy downward movement of food through your digestive tract.

Prokinetic agents are popularly used for treating reflux diseases like heartburn (where food and acid move upwards from the stomach into the esophagus). But as well as treating gastroesophageal reflux, it’s also become more common to use them for conditions like SIBO or IBS. This is based on the idea that slow movement through the gastrointestinal tract may be an underlying cause of these conditions.

Examples of prokinetic drugs include tegaserod, prucalopride, macrolide and mosapride. However natural prokinetic agents have also been identified. For example, probiotics, curcumin, melatonin, peppermint oil, ginger, and some ayurvedic medicines may all aid gastric motility. 

Natural Prokinetic Agents

Prokinetic agents: ginger root, candy and powder
Probiotics Live bacteria Shown to improve constipation, stool frequency, intestinal transit time, and IBS symptoms, both alone and when combined with mosapride [1, 2, 3, 4, 5, 6].
Chinese herbal medicineSpecific Chinese herbs including modified Runchang-Tang, modified Chaihu Shugan, and modified Xiaoyao San More effective than prokinetic drugs at improving constipation and indigestion [7, 8, 9, 10, 11].
Iberogast ®An herbal blend — ingredients include bitter candytuft, angelica root and chamomile. Equivalent efficacy in treating functional dyspepsia to the now defunct prokinetic drug Cisapride (withdrawn in the USA due to side effects) [12, 13, 14]. 
Peppermint oilEssential oilMay help improve motility, reduce inflammation, and improve gut microbiota [15, 16, 17, 18].
CurcuminBioactive substance found in turmeric May improve digestive symptoms of IBS, ulcerative colitis, and peptic ulcer disease [19, 20].
Japanese herbal medicine Specific Japanese herbs including rikkunshito (RKT), dai-kenchu-to (DKT), and hange koboku to (HKT)Shown to improve constipation, motility, gastric emptying, reflux, and digestive symptoms [21, 22, 23, 24, 25].
MelatoninHormone available as a supplement Shown to reduce abdominal pain and other digestive symptoms, potentially in part by improving motility [26, 27, 28].
GingerCulinary spice Soothes nausea [29]; mixed evidence that it speeds stomach emptying [30, 31].
TriphalaAyurvedic laxative medicineImproved the frequency and consistency of bowel movements in one clinical trial [32].
Prodigest ®Standardized combination of artichoke and ginger extracts Found to be 24% better than placebo at improving motility after a meal, suggesting efficacy as a prokinetic agent [33].

Pharmaceuticals With Prokinetic Effects

Name ClassificationEffects
Prucalopride (Motegrity, Resolor), Mosapride, Tegaserod* Serotonin receptor agonistsStimulate peristalsis and normalise motility.
*Tegaserod is older generation and has adverse effects that include cardiac arrhythmia [34]
Low-dose ErythromycinMacrolide antibioticA low dose stimulates the secretion of motilin hormone, which in turn activates the cyclic, recurring motility pattern (the migrating motor complex, or MMC) that occurs in the stomach and small bowel during fasting [35]
Metoclopramide, Domperidone*Benzamide-derivative dopamine receptor antagonistsAccelerate gastric emptying in diabetic gastroparesis (incomplete stomach emptying most commonly affecting people with diabetes); acts as an antiemetic (inhibitor of vomiting) [36]
*Domperidone is no longer routinely available in the USA 
Low Dose NaltrexoneOpioid receptor antagonistInconclusive evidence that in low doses it regulates gut motility, and can ease chronic constipation and Crohn’s disease symptoms [37, 38]
BethanecholCholinergic agent (mimics the central nervous system neurotransmitter acetylcholine) Used for reflux and gastroparesis in the past, but largely replaced by newer agents [35, 39]

Gut Motility and Dysmotility

Can Prokinetic Agents Help SIBO and Gut Symptoms? - Gut Motility %26 Peristalsis Landscape L

To understand why you might need prokinetics, it’s important to understand what good gut motility means.

In a normal healthy gut, peristalsis is the distinctive pattern of propulsive smooth muscle contractions. This propels foodstuffs down the esophagus into the stomach via the lower esophageal sphincter into the small intestine and then via the ileocecal valve into the large intestine (colonic region).

If those peristaltic movements aren’t working properly and become sluggish, things can get out of whack in the GI tract — this is known as dysmotility.

For an analogy, think of flowing water in a river or stream, and then compare it with a stagnant pond. Good motility helps keep your gastrointestinal ecosystem, or microbiota, in balance. But just as standing water can foster bacterial growth, when food is moving too slowly, it can cause bacteria and fungi to overgrow. 

Poor Gut Motility Might Not Be a Main Cause of SIBO 

The idea that poor gastrointestinal motility can be a factor in SIBO and/or IBS isn’t in dispute. However, it’s important not to run away with the idea that these conditions are exclusively, or even primarily, a motility disorder.

My contention is that poor motility is actually far less common in IBS and SIBO that those within the SIBO community suggest.

For example, other documented causes of/risk factors associated with SIBO that aren’t to do with impaired with motility documented include [40]:

  • Low stomach acid affecting the stomach’s ability to digest or degrade harmful intestinal bacteria
  • Low levels of digestive enzymes
  • Chronic pancreatic insufficiency
  • Autoimmune disorders.

Factors other than poor gut motility that can contribute to IBS include:

  • Gut dysbiosis (as a result of poor diet, stress, antibiotic use and other lifestyle factors [41, 42]
  • A bout of food poisoning (estimated to trigger between 5% and 32% of IBS cases) [43]
  • A leaky gut [44, 45]
  • Immune disruptions [46, 47]
  • Altered serotonin levels (serotonin is a chemical messenger and one of the body’s most important signaling chemicals for digestion) [48]

Given all these possible contributing factors to IBS and SIBO, by only honing in on gut motility as the issue (and by implication, prokinetics being the answer), we may miss important pieces of the puzzle. 

Dysbiosis, Inflammation and Gut Motility

Prokinetic agents: illustration of stomachache

A more holistic approach is to consider the overall dysbiosis and inflammation that underlies most cases of SIBO and IBS, which are themselves highly interrelated [49].

One interpretation of the data on motility and SIBO is that reduced gut motility precedes gut symptoms and predisposes people towards developing SIBO [50]. However, it’s more likely that the existing inflammation and gut bacteria imbalance associated with SIBO and IBS actually cause reduced gut motility [51].

For example, one observational study found inflammation to be a major driver of motility problems in Crohn’s disease patients [52].

Excess blood sugar can also contribute to inflammation, and, in turn, motility issues [53, 54].

One theory is that inflammation interferes with the ability of intestinal cells called interstitial cells of Cajal (ICC) — involved in healthy gut motility — to repair themselves.

If you are in the early stages of SIBO treatment, you will likely have low motility as a result of gut dysbiosis and inflammation that disrupt the gut motility apparatus — but that doesn’t necessarily mean you have a functional motility problem that requires prokinetic therapy. 

What I have consistently found in clinical practice is that by remedying the underlying gut dysbiosis and damping down inflammation, we can resolve the motility issues and improve symptoms of SIBO and IBS without needing much other intervention. 

Effective Gut Healing Strategies

One small observational study in patients whose IBS/SIBO was successfully treated with antibiotics did find that a popular prokinetic medication (low dose erythromycin) staved off a relapse longer than patients who did nothing (five months versus two months) [55].

However, we need to weigh the risk-to-benefit ratio when using prokinetic medications. No studies have been done to show how long non-pharmaceutical alternatives stave off SIBO recurrence, and this approach could be more effective.

I’ve found that a more well-rounded and multifaceted approach to gut healing is the best way to go before leaping to prokinetic agents. For nearly all my patients, motility issues can be resolved with this approach, without using prokinetics.

When approaching gut health more holistically, a step-by-step approach beginning with diet and probiotics generally works best.


Prokinetic agents: FODMAP Food List infographic by Dr. Ruscio

Any diet that cuts down on sugary and highly processed foods and focuses instead on whole foods, such as leafy greens and lean proteins, can help to calm inflammation and begin getting your gut in better shape. 

However, for IBS and SIBO in particular, you might want to go straight to the low FODMAP diet. It has been shown to be particularly helpful in these conditions [56, 57, 58, 59].

Low FODMAP diets cut out or minimize certain types of fermentable, bacteria-feeding carbs (FODMAPs) that can flare SIBO and IBS symptoms. High FODMAP foods include common foods like dairy, honey, onions, and wheat. You may not have to cut them out forever, but doing so while you’re experiencing the worst IBS/SIBO symptoms may help you to feel better.

An observational study involving 13 IBS patients and 13 healthy controls found that a low FODMAP diet also increased the densities of endocrine cells that secrete serotonin. This in turn stimulates motility and speeds up transit time in both small and large intestines [60]. We can’t read too much into this small study, but it does seem to suggest that a gut healing diet might in itself act like a prokinetic agent.

Probiotic Therapy

How Probiotics Work infographic by Dr. Ruscio

Your second vital strand in easing gut symptoms and re-establishing gut health is taking a probiotic supplement. There’s a wealth of research showing just how beneficial probiotics can be:

  • One recent clinical trial (330 patients) found that probiotics significantly reduced abdominal pain and bloating in IBS patients. Subjects also experienced a significant normalization in stool consistency and quality of life [61].
  • Many other high-quality studies agree that probiotics improve IBS symptoms, including gas, diarrhea, and constipation, bloating, abdominal pain [4, 62, 63, 64, 65, 66, 67].
  • With reference to intestinal motility, various human trials and a systematic review and meta-analysis of randomized, controlled trials found that specific probiotic species and strains could decrease gut transit time by 12 hours (i.e. improve motility) [1].
  • A meta-analysis summarizing 18 clinical trials also showed that probiotics are an effective treatment for SIBO, reducing bacterial overgrowth and hydrogen concentrations, and improving symptoms [68, 69, 70, 71].

Follow-up Therapies

If you don’t have complete symptom relief after sorting your bases of diet and probiotics, another couple of approaches that may work include antimicrobials and an elemental diet.

These approaches both help to correct gut bacteria imbalance and remove lingering bad bacteria.


Rifaximin is an antibiotic medicine that can help clear SIBO infections [72, 73]. More natural but often as effective are plant-based antimicrobials [74] such as oregano oil (active ingredient carvacrol) [75], berberine [76], and caprylic acid [77].

Elemental Diet

Elemental Diet Benefits infographic by Dr. Ruscio

An elemental diet provides all the nutrients in a predigested form, thereby giving your system a rest and allowing it to heal. An elemental formula can be used to replace all your meals over a block of several days, or just to replace one or two meals on a regular basis. 

Research has shown that elemental diets even used 50% of the time can significantly gut symptoms and flares [78].

How and When to Try Prokinetic Agents

You should by all means consider taking a prokinetic if, after trying all the steps above, you still have issues with gut issues or SIBO. You may be a candidate if you have constipation-dominant IBS [79, 80]. IBS-C tends to be more associated with bacteria that produce methane, which slows down motility and could play a role in constipation [81].

If you could benefit from a pharmaceutical prokinetic — which can have a stronger action — you’ll need to discuss this with a doctor and get a prescription.

However you may prefer a plant-based prokinetic such as Iberogast or peppermint oil (peppermint conveniently also doubles up as an antimicrobial) [82]. These may be less effective in certain cases, but may still help to achieve the effect of gently improving the motility of your gut.

Pharmaceutical drugs also tend to have more frequent and severe side effects than natural treatments. Mosapride, lubiprostone, cisapride, and other prokinetic drugs have been linked to side effects including headaches, dizziness, insomnia, and increased digestive side effects including nausea, heartburn, diarrhea, and constipation (in other words, many of the symptoms you’re trying to get rid of!). In some cases, prokinetic drugs can also lead to more serious side effects.

Tying It All Together

Prokinetic agents do have their place, but there’s been a tendency to jump to them too fast for SIBO treatment. Most cases of SIBO and IBS aren’t caused by poor gut motility. More likely, the poor motility is a result of the inflammation and dysbiosis that are part and parcel of these conditions.

By tackling the underlying issues with a comprehensive gut healing regimen, you’re likely to get better results in the long runYou find a lot more detail on healing your gut in my book, “Healthy Gut Healthy You.” Or, you might consider a personal consultation for more in-depth help with gut-related health issues.

➕ References
  1. Miller LE, Ouwehand AC, Ibarra A. Effects of probiotic-containing products on stool frequency and intestinal transit in constipated adults: systematic review and meta-analysis of randomized controlled trials. Ann Gastroenterol. 2017 Sep 21;30(6):629–39. DOI: 10.20524/aog.2017.0192. PMID: 29118557. PMCID: PMC5670282.
  2. Shi Q, Tan L, Liu C, Wang H, Zhang J, Wang H, Zhai J. Comparative efficacy of pharmacological and nonpharmacological treatments for chronic idiopathic constipation in China: a Bayesian network meta-analysis. BMC Complement Altern Med. 2019 Nov 14;19(1):311. doi: 10.1186/s12906-019-2741-z. PMID: 31727037; PMCID: PMC6857160.
  3. Wen Y, Li J, Long Q, Yue CC, He B, Tang XG. The efficacy and safety of probiotics for patients with constipation-predominant irritable bowel syndrome: A systematic review and meta-analysis based on seventeen randomized controlled trials. Int J Surg. 2020 Jul;79:111-119. doi: 10.1016/j.ijsu.2020.04.063. Epub 2020 May 6. PMID: 32387213.
  4. McFarland LV, Dublin S. Meta-analysis of probiotics for the treatment of irritable bowel syndrome. World J Gastroenterol. 2008 May 7;14(17):2650–61. DOI: 10.3748/wjg.14.2650. PMID: 18461650. PMCID: PMC2709042.
  5. Alexandre V, Bertin C, Boubaya M, Airinei G, Bouchoucha M, Benamouzig R. Randomized clinical trial: efficacy of a food supplement, TRANSITECH, on healthy individuals with mild intermittent constipation. Eur J Gastroenterol Hepatol. 2016 Sep;28(9):1087-93. doi: 10.1097/MEG.0000000000000672. PMID: 27347788.
  6. Lim YJ, Jamaluddin R, Hazizi AS, Chieng JY. Effects of Synbiotics among Constipated Adults in Serdang, Selangor, Malaysia-A Randomised, Double-Blind, Placebo-Controlled Trial. Nutrients. 2018 Jun 26;10(7):824. doi: 10.3390/nu10070824. PMID: 29949873; PMCID: PMC6073678.
  7. Zhao X, Fang Y, Ye J, Qin F, Lu W, Gong H. A meta-analysis of randomized controlled trials of a traditional Chinese medicine prescription, modified RunChang-Tang, in treating functional constipation. Medicine (Baltimore). 2021 May 21;100(20):e25760. doi: 10.1097/MD.0000000000025760. PMID: 34011036; PMCID: PMC8137032.
  8. Yang N, Jiang X, Qiu X, Hu Z, Wang L, Song M. Modified chaihu shugan powder for functional dyspepsia: meta-analysis for randomized controlled trial. Evid Based Complement Alternat Med. 2013;2013:791724. doi: 10.1155/2013/791724. Epub 2013 May 13. PMID: 23762161; PMCID: PMC3666434.
  9. Qin F, Liu JY, Yuan JH. Chaihu-Shugan-San, an oriental herbal preparation, for the treatment of chronic gastritis: a meta-analysis of randomized controlled trials. J Ethnopharmacol. 2013 Mar 27;146(2):433-9. doi: 10.1016/j.jep.2013.01.029. Epub 2013 Jan 29. PMID: 23376045.
  10. Qin F, Huang X, Ren P. Chinese herbal medicine modified xiaoyao san for functional dyspepsia: meta-analysis of randomized controlled trials. J Gastroenterol Hepatol. 2009 Aug;24(8):1320-5. doi: 10.1111/j.1440-1746.2009.05934.x. PMID: 19702899.
  11. Wang C, Zhu M, Xia W, Jiang W, Li Y. Meta-analysis of traditional Chinese medicine in treating functional dyspepsia of liver-stomach disharmony syndrome. J Tradit Chin Med. 2012 Dec;32(4):515-22. doi: 10.1016/s0254-6272(13)60063-1. PMID: 23427381.
  12. Madisch A, Vinson BR, Abdel-Aziz H, Kelber O, Nieber K, Kraft K, et al. Modulation of gastrointestinal motility beyond metoclopramide and domperidone : Pharmacological and clinical evidence for phytotherapy in functional gastrointestinal disorders. Wien Med Wochenschr. 2017 May;167(7–8):160–8. DOI: 10.1007/s10354-017-0557-3. PMID: 28424994. PMCID: PMC5409921.
  13. Gundermann KJ, Godehardt E, Ulbrich M. [The efficacy of a combination herbal medicine in the treatment of functional dyspepsia. Meta-analysis of randomized double-blind studies on the basis of a valid gastrointestinal symptom profile]. MMW Fortschr Med. 2004 Aug 5;146 Suppl 2:71–6. PMID: 16739362.
  14. Gundermann K-J, Godehardt E, Ulbrich M. Efficacy of a herbal preparation in patients with functional dyspepsia: a meta-analysis of double-blind, randomized, clinical trials. Adv Ther. 2003 Feb;20(1):43–9. DOI: 10.1007/BF02850118. PMID: 12772817.
  15. Hawrelak JA, Wohlmuth H, Pattinson M, Myers SP, Goldenberg JZ, Harnett J, et al. Western herbal medicines in the treatment of irritable bowel syndrome: A systematic review and meta-analysis. Complement Ther Med. 2020 Jan;48:102233. DOI: 10.1016/j.ctim.2019.102233. PMID: 31987249.
  16. Tan N, Gwee KA, Tack J, Zhang M, Li Y, Chen M, et al. Herbal medicine in the treatment of functional gastrointestinal disorders: A systematic review with meta-analysis. J Gastroenterol Hepatol. 2020 Apr;35(4):544–56. DOI: 10.1111/jgh.14905. PMID: 31674057.
  17. Black CJ, Yuan Y, Selinger CP, Camilleri M, Quigley EMM, Moayyedi P, et al. Efficacy of soluble fibre, antispasmodic drugs, and gut-brain neuromodulators in irritable bowel syndrome: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol. 2020;5(2):117–31. DOI: 10.1016/S2468-1253(19)30324-3. PMID: 31859183.
  18. Mosaffa-Jahromi M, Lankarani KB, Pasalar M, Afsharypuor S, Tamaddon A-M. Efficacy and safety of enteric coated capsules of anise oil to treat irritable bowel syndrome. J Ethnopharmacol. 2016 Dec 24;194:937–46. DOI: 10.1016/j.jep.2016.10.083. PMID: 27815079.
  19. Atefi M, Darand M, Entezari MH, Jamialahmadi T, Bagherniya M, Sahebkar A. A Systematic Review of the Clinical Use of Curcumin for the Management of Gastrointestinal Diseases. Adv Exp Med Biol. 2021;1291:295-326. doi: 10.1007/978-3-030-56153-6_18. PMID: 34331698.
  20. Lopresti AL, Smith SJ, Rea A, Michel S. Efficacy of a curcumin extract (Curcugen™) on gastrointestinal symptoms and intestinal microbiota in adults with self-reported digestive complaints: a randomised, double-blind, placebo-controlled study. BMC Complement Med Ther. 2021 Jan 21;21(1):40. doi: 10.1186/s12906-021-03220-6. PMID: 33478482; PMCID: PMC7818735.
  21. Huestis MJ, Keefe KR, Kahn CI, Tracy LF, Levi JR. Alternatives to Acid Suppression Treatment for Laryngopharyngeal Reflux. Ann Otol Rhinol Laryngol. 2020 Oct;129(10):1030-1039. doi: 10.1177/0003489420922870. Epub 2020 May 25. PMID: 32449369.
  22. Otake K, Uchida K, Mori K, Ide S, Koike Y, Takamura M, Inoue M, Kusunoki M. Efficacy of the Japanese herbal medicine rikkunshito in infants with gastroesophageal reflux disease. Pediatr Int. 2015 Aug;57(4):673-6. doi: 10.1111/ped.12582. Epub 2015 Mar 25. PMID: 25559780.
  23. Nagano T, Itoh H, Takeyama M. Effect of Dai-kenchu-to on levels of 3 brain-gut peptides (motilin, gastrin and somatostatin) in human plasma. Biol Pharm Bull. 1999 Oct;22(10):1131-3. doi: 10.1248/bpb.22.1131. PMID: 10549871.
  24. Nagano T, Itoh H, Takeyama M. Effects of Dai-kenchu-to on levels of 5-hydroxytryptamine (serotonin) and vasoactive intestinal peptides in human plasma. Biol Pharm Bull. 2000 Mar;23(3):352-3. doi: 10.1248/bpb.23.352. PMID: 10726893.
  25. Oikawa T, Ito G, Koyama H, Hanawa T. Prokinetic effect of a Kampo medicine, Hange-koboku-to (Banxia-houpo-tang), on patients with functional dyspepsia. Phytomedicine. 2005 Nov;12(10):730-4. doi: 10.1016/j.phymed.2005.03.001. PMID: 16323291.
  26. Mozaffari S, Rahimi R, Abdollahi M. Implications of melatonin therapy in irritable bowel syndrome: a systematic review. Curr Pharm Des. 2010;16(33):3646-55. doi: 10.2174/138161210794079254. PMID: 21128901.
  27. Song GH, Leng PH, Gwee KA, Moochhala SM, Ho KY. Melatonin improves abdominal pain in irritable bowel syndrome patients who have sleep disturbances: a randomised, double blind, placebo controlled study. Gut. 2005 Oct;54(10):1402-7. doi: 10.1136/gut.2004.062034. Epub 2005 May 24. PMID: 15914575; PMCID: PMC1774717.
  28. Lu WZ, Song GH, Gwee KA, Ho KY. The effects of melatonin on colonic transit time in normal controls and IBS patients. Dig Dis Sci. 2009 May;54(5):1087-93. doi: 10.1007/s10620-008-0463-z. Epub 2008 Aug 23. PMID: 18720001.
  29. Lete I, Allué J. The Effectiveness of Ginger in the Prevention of Nausea and Vomiting during Pregnancy and Chemotherapy. Integr Med Insights. 2016 Mar 31;11:11–7. DOI: 10.4137/IMI.S36273. PMID: 27053918. PMCID: PMC4818021.
  30. Wu K-L, Rayner CK, Chuah S-K, Changchien C-S, Lu S-N, Chiu Y-C, et al. Effects of ginger on gastric emptying and motility in healthy humans. Eur J Gastroenterol Hepatol. 2008 May;20(5):436–40. DOI: 10.1097/MEG.0b013e3282f4b224. PMID: 18403946.
  31. Phillips S, Hutchinson S, Ruggier R. Zingiber officinale does not affect gastric emptying rate. A randomised, placebo-controlled, crossover trial. Anaesthesia. 1993 May;48(5):393–5. DOI: 10.1111/j.1365-2044.1993.tb07011.x. PMID: 8317647.
  32. Mukherjee P, Rai S, Bhattacharyya S, et al. Clinical Study of “Triphala” – A Well Known Phytomedicine from India. Iranian Journal of Pharmacology and Therapeutics. 2006.
  33. Lazzini S, Polinelli W, Riva A, Morazzoni P, Bombardelli E. The effect of ginger (Zingiber officinalis) and artichoke (Cynara cardunculus) extract supplementation on gastric motility: a pilot randomized study in healthy volunteers. Eur Rev Med Pharmacol Sci. 2016;20(1):146–9. PMID: 26813467.
  34. Which medications in the drug class Prokinetic Agents are used in the treatment of Constipation? [Internet]. [cited 2021 Aug 6]. Available from:
  35. Quigley EMM. Prokinetics in the management of functional gastrointestinal disorders. J Neurogastroenterol Motil. 2015 Jul 30;21(3):330–6. DOI: 10.5056/jnm15094. PMID: 26130629. PMCID: PMC4496896.
  36. Vijayvargiya P, Camilleri M, Chedid V, Mandawat A, Erwin PJ, Murad MH. Effects of Promotility Agents on Gastric Emptying and Symptoms: A Systematic Review and Meta-analysis. Gastroenterology. 2019 May;156(6):1650–60. DOI: 10.1053/j.gastro.2019.01.249. PMID: 30711628.
  37. Ploesser J, Weinstock LB, Thomas E. Low dose naltrexone: side effects and efficacy in gastrointestinal disorders. Int J Pharm Compd. 2010 Apr;14(2):171–3. PMID: 23965429.
  38. Patten DK, Schultz BG, Berlau DJ. The Safety and Efficacy of Low-Dose Naltrexone in the Management of Chronic Pain and Inflammation in Multiple Sclerosis, Fibromyalgia, Crohn’s Disease, and Other Chronic Pain Disorders. Pharmacotherapy. 2018 Mar;38(3):382–9. DOI: 10.1002/phar.2086. PMID: 29377216.
  39. National Center for Biotechnology Information. PubChem Compound Summary for CID 2370, Bethanechol.
  40. Sorathia SJ, Rivas JM. Small intestinal bacterial overgrowth. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. PMID: 31536241.
  41. Menees S, Chey W. The gut microbiome and irritable bowel syndrome. [version 1; peer review: 3 approved]. F1000Res. 2018 Jul 9;7. DOI: 10.12688/f1000research.14592.1. PMID: 30026921. PMCID: PMC6039952.
  42. Hawrelak JA, Myers SP. The causes of intestinal dysbiosis: a review. Altern Med Rev. 2004 Jun;9(2):180–97. PMID: 15253677.
  43. Thabane M, Marshall JK. Post-infectious irritable bowel syndrome. World J Gastroenterol. 2009 Aug 7;15(29):3591–6. DOI: 10.3748/wjg.15.3591. PMID: 19653335. PMCID: PMC2721231.
  44. Camilleri M, Gorman H. Intestinal permeability and irritable bowel syndrome. Neurogastroenterol Motil. 2007 Jul;19(7):545–52. DOI: 10.1111/j.1365-2982.2007.00925.x. PMID: 17593135.
  45. Barbara G. Mucosal barrier defects in irritable bowel syndrome. Who left the door open? Am J Gastroenterol. 2006 Jun;101(6):1295–8. DOI: 10.1111/j.1572-0241.2006.00667.x. PMID: 16771952.
  46. Barbara G, Cremon C, Carini G, Bellacosa L, Zecchi L, De Giorgio R, et al. The immune system in irritable bowel syndrome. J Neurogastroenterol Motil. 2011 Oct 31;17(4):349–59. DOI: 10.5056/jnm.2011.17.4.349. PMID: 22148103. PMCID: PMC3228974.
  47. Barbara G, Zecchi L, Barbaro R, Cremon C, Bellacosa L, Marcellini M, et al. Mucosal permeability and immune activation as potential therapeutic targets of probiotics in irritable bowel syndrome. J Clin Gastroenterol. 2012 Oct;46 Suppl:S52-5. DOI: 10.1097/MCG.0b013e318264e918. PMID: 22955358.
  48. Jin D-C, Cao H-L, Xu M-Q, Wang S-N, Wang Y-M, Yan F, et al. Regulation of the serotonin transporter in the pathogenesis of irritable bowel syndrome. World J Gastroenterol. 2016 Sep 28;22(36):8137–48. DOI: 10.3748/wjg.v22.i36.8137. PMID: 27688655. PMCID: PMC5037082.
  49. Chen B, Kim JJ-W, Zhang Y, Du L, Dai N. Prevalence and predictors of small intestinal bacterial overgrowth in irritable bowel syndrome: a systematic review and meta-analysis. J Gastroenterol. 2018 Jul;53(7):807–18. DOI: 10.1007/s00535-018-1476-9. PMID: 29761234.
  50. Roland BC, Ciarleglio MM, Clarke JO, Semler JR, Tomakin E, Mullin GE, et al. Small intestinal transit time is delayed in small intestinal bacterial overgrowth. J Clin Gastroenterol. 2015 Aug;49(7):571–6. DOI: 10.1097/MCG.0000000000000257. PMID: 25319735.
  51. Singh R, Zogg H, Wei L, Bartlett A, Ghoshal UC, Rajender S, et al. Gut microbial dysbiosis in the pathogenesis of gastrointestinal dysmotility and metabolic disorders. J Neurogastroenterol Motil. 2021 Jan 30;27(1):19–34. DOI: 10.5056/jnm20149. PMID: 33166939. PMCID: PMC7786094.
  52. Menys A, Makanyanga J, Plumb A, Bhatnagar G, Atkinson D, Emmanuel A, et al. Aberrant motility in unaffected small bowel is linked to inflammatory burden and patient symptoms in crohn’s disease. Inflamm Bowel Dis. 2016 Feb;22(2):424–32. DOI: 10.1097/MIB.0000000000000601. PMID: 26509756.
  53. Forrester SJ, Kikuchi DS, Hernandes MS, Xu Q, Griendling KK. Reactive Oxygen Species in Metabolic and Inflammatory Signaling. Circ Res. 2018 Mar 16;122(6):877-902. doi: 10.1161/CIRCRESAHA.117.311401. PMID: 29700084; PMCID: PMC5926825.
  54. Wellen KE, Hotamisligil GS. Inflammation, stress, and diabetes. J Clin Invest. 2005 May;115(5):1111-9. doi: 10.1172/JCI25102. PMID: 15864338; PMCID: PMC1087185.
  55. Pimentel M, Morales W, Lezcano S, Sun-Chuan D, Low K, Yang J. Low-dose nocturnal tegaserod or erythromycin delays symptom recurrence after treatment of irritable bowel syndrome based on presumed bacterial overgrowth. Gastroenterol Hepatol (N Y). 2009 Jun;5(6):435–42. PMID: 20574504. PMCID: PMC2886395.
  56. Staudacher HM, Whelan K. The low FODMAP diet: recent advances in understanding its mechanisms and efficacy in IBS. Gut. 2017 Aug;66(8):1517–27. DOI: 10.1136/gutjnl-2017-313750. PMID: 28592442.
  57. Marsh A, Eslick EM, Eslick GD. Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. Eur J Nutr. 2016 Apr;55(3):897–906. DOI: 10.1007/s00394-015-0922-1. PMID: 25982757.
  58. Schumann D, Klose P, Lauche R, Dobos G, Langhorst J, Cramer H. Low fermentable, oligo-, di-, mono-saccharides and polyol diet in the treatment of irritable bowel syndrome: A systematic review and meta-analysis. Nutrition. 2018 Jan;45:24–31. DOI: 10.1016/j.nut.2017.07.004. PMID: 29129233.
  59. Altobelli E, Del Negro V, Angeletti PM, Latella G. Low-FODMAP Diet Improves Irritable Bowel Syndrome Symptoms: A Meta-Analysis. Nutrients. 2017 Aug 26;9(9). DOI: 10.3390/nu9090940. PMID: 28846594. PMCID: PMC5622700.
  60. Mazzawi T, Hausken T, Gundersen D, El-Salhy M. Dietary guidance normalizes large intestinal endocrine cell densities in patients with irritable bowel syndrome. Eur J Clin Nutr. 2016 Feb;70(2):175–81. DOI: 10.1038/ejcn.2015.191. PMID: 26603880. PMCID: PMC4744244.
  61. Martoni CJ, Srivastava S, Leyer GJ. Lactobacillus acidophilus DDS-1 and Bifidobacterium lactis UABla-12 Improve Abdominal Pain Severity and Symptomology in Irritable Bowel Syndrome: Randomized Controlled Trial. Nutrients. 2020 Jan 30;12(2). DOI: 10.3390/nu12020363. PMID: 32019158. PMCID: PMC7071206.
  62. Yuan F, Ni H, Asche CV, Kim M, Walayat S, Ren J. Efficacy of Bifidobacterium infantis 35624 in patients with irritable bowel syndrome: a meta-analysis. Curr Med Res Opin. 2017 Jul;33(7):1191–7. DOI: 10.1080/03007995.2017.1292230. PMID: 28166427.
  63. Tiequn B, Guanqun C, Shuo Z. Therapeutic effects of Lactobacillus in treating irritable bowel syndrome: a meta-analysis. Intern Med. 2015;54(3):243–9. DOI: 10.2169/internalmedicine.54.2710. PMID: 25748731.
  64. Whelan K. Probiotics and prebiotics in the management of irritable bowel syndrome:  a review of recent clinical trials and systematic reviews. Curr Opin Clin Nutr Metab Care. 2011 Nov;14(6):581–7. DOI: 10.1097/MCO.0b013e32834b8082. PMID: 21892075.
  65. Ford AC, Quigley EMM, Lacy BE, Lembo AJ, Saito YA, Schiller LR, et al. Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis. Am J Gastroenterol. 2014 Oct;109(10):1547–61; quiz 1546, 1562. DOI: 10.1038/ajg.2014.202. PMID: 25070051.
  66. Zhang C, Jiang J, Tian F, Zhao J, Zhang H, Zhai Q, et al. Meta-analysis of randomized controlled trials of the effects of probiotics on functional constipation in adults. Clin Nutr. 2020 Oct;39(10):2960–9. DOI: 10.1016/j.clnu.2020.01.005. PMID: 32005532.
  67. Ishaque SM, Khosruzzaman SM, Ahmed DS, Sah MP. A randomized placebo-controlled clinical trial of a multi-strain probiotic formulation (Bio-Kult®) in the management of diarrhea-predominant irritable bowel syndrome. BMC Gastroenterol. 2018 May 25;18(1):71. DOI: 10.1186/s12876-018-0788-9. PMID: 29801486. PMCID: PMC5970461.
  68. Zhong C, Qu C, Wang B, Liang S, Zeng B. Probiotics for Preventing and Treating Small Intestinal Bacterial Overgrowth: A Meta-Analysis and Systematic Review of Current Evidence. J Clin Gastroenterol. 2017 Apr;51(4):300–11. DOI: 10.1097/MCG.0000000000000814. PMID: 28267052.
  69. Krammer, HJ., von Seggern, H., Schaumburg, J. et al. Effect of Lactobacillus casei Shirota on colonic transit time in patients with chronic constipation. coloproctology 33, 109–113 (2011).
  70. Agrawal A, Houghton LA, Morris J, Reilly B, Guyonnet D, Goupil Feuillerat N, Schlumberger A, Jakob S, Whorwell PJ. Clinical trial: the effects of a fermented milk product containing Bifidobacterium lactis DN-173 010 on abdominal distension and gastrointestinal transit in irritable bowel syndrome with constipation. Aliment Pharmacol Ther. 2009 Jan;29(1):104-14. doi: 10.1111/j.1365-2036.2008.03853.x. Epub 2008 Sep 17. PMID: 18801055.
  71. Waller PA, Gopal PK, Leyer GJ, Ouwehand AC, Reifer C, Stewart ME, Miller LE. Dose-response effect of Bifidobacterium lactis HN019 on whole gut transit time and functional gastrointestinal symptoms in adults. Scand J Gastroenterol. 2011 Sep;46(9):1057-64. doi: 10.3109/00365521.2011.584895. Epub 2011 Jun 13. PMID: 21663486; PMCID: PMC3171707.
  72. Scarpellini E, Giorgio V, Gabrielli M, Filoni S, Vitale G, Tortora A, et al. Rifaximin treatment for small intestinal bacterial overgrowth in children with irritable bowel syndrome. Eur Rev Med Pharmacol Sci. 2013 May;17(10):1314–20. PMID: 23740443.
  73. Shah SC, Day LW, Somsouk M, Sewell JL. Meta-analysis: antibiotic therapy for small intestinal bacterial overgrowth. Aliment Pharmacol Ther. 2013 Oct;38(8):925–34. DOI: 10.1111/apt.12479. PMID: 24004101. PMCID: PMC3819138.
  74. Chedid V, Dhalla S, Clarke JO, Roland BC, Dunbar KB, Koh J, et al. Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Glob Adv Health Med. 2014 May;3(3):16–24. DOI: 10.7453/gahmj.2014.019. PMID: 24891990. PMCID: PMC4030608.
  75. Sharifi-Rad M, Varoni EM, Iriti M, Martorell M, Setzer WN, Del Mar Contreras M, et al. Carvacrol and human health: A comprehensive review. Phytother Res. 2018 Sep;32(9):1675–87. DOI: 10.1002/ptr.6103. PMID: 29744941.
  76. Yu H-H, Kim K-J, Cha J-D, Kim H-K, Lee Y-E, Choi N-Y, et al. Antimicrobial activity of berberine alone and in combination with ampicillin or oxacillin against methicillin-resistant Staphylococcus aureus. J Med Food. 2005;8(4):454–61. DOI: 10.1089/jmf.2005.8.454. PMID: 16379555.
  77. Omura Y, O’Young B, Jones M, Pallos A, Duvvi H, Shimotsuura Y. Caprylic acid in the effective treatment of intractable medical problems of frequent urination, incontinence, chronic upper respiratory infection, root canalled tooth infection, ALS, etc., caused by asbestos & mixed infections of Candida albicans, Helicobacter pylori & cytomegalovirus with or without other microorganisms & mercury. Acupunct Electrother Res. 2011;36(1–2):19–64. PMID: 21830350.
  78. Takagi S, Utsunomiya K, Kuriyama S, Yokoyama H, Takahashi S, Iwabuchi M, et al. Effectiveness of an “half elemental diet” as maintenance therapy for Crohn’s disease: A randomized-controlled trial. Aliment Pharmacol Ther. 2006 Nov 1;24(9):1333–40. DOI: 10.1111/j.1365-2036.2006.03120.x. PMID: 17059514.
  79. Passos M do CF, Takemoto MLS, Corradino GC, Guedes LS. Systematic review with meta-analysis: lubiprostone efficacy on the treatment of patients with constipation. Arq Gastroenterol. 2020 Dec;57(4):498–506. DOI: 10.1590/S0004-2803.202000000-83. PMID: 33331483.
  80. Mozaffari S, Nikfar S, Abdollahi M. Metabolic and toxicological considerations for the latest drugs used to treat irritable bowel syndrome. Expert Opin Drug Metab Toxicol. 2013 Apr;9(4):403–21. DOI: 10.1517/17425255.2013.759558. PMID: 23330973.
  81. Pimentel M, Lembo A. Microbiome and its role in irritable bowel syndrome. Dig Dis Sci. 2020 Mar;65(3):829–39. DOI: 10.1007/s10620-020-06109-5. PMID: 32026278.
  82. Singh R, Shushni MAM, Belkheir A. Antibacterial and antioxidant activities of Mentha piperita L. Arabian Journal of Chemistry. 2015 May;8(3):322–8. DOI: 10.1016/j.arabjc.2011.01.019.
➕ Links & Resources

More on Prokinetics:

Recommended Products

Need help or would like to learn more?
View Dr. Ruscio’s, DC additional resources

Get Help


I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!