# Prescription Options

## Prescription Prokinetics for GP Discussion

If natural prokinetics + herbal treatment doesn't resolve SIBO, these are worth discussing with your GP.

### Low-Dose Erythromycin (50mg at bedtime)

- **What it does:** Motilin receptor agonist — motilin is the hormone that directly triggers the MMC. At 50mg, this is purely a motility agent, NOT functioning as an antibiotic (antibiotic dose is 250-500mg).
- **Dose:** 50mg at bedtime. May need compounding pharmacy to reach this dose — standard tablets are typically 250mg+.
- **Duration:** Long-term maintenance, taken ongoing after active SIBO treatment.
- **Effectiveness:** One of the most potent prokinetics available. Commonly prescribed by SIBO specialists (Dr. Pimentel at Cedars-Sinai, Dr. Siebecker).
- **Availability:** Your GP should be able to prescribe it. Raise the sub-antibiotic prokinetic use specifically — many GPs won't think of erythromycin as a prokinetic unless you mention it.

### Prucalopride (Resolor)

- **What it does:** 5-HT4 receptor agonist — stimulates serotonin receptors in the gut that drive intestinal contractions.
- **Dose:** 0.5-1mg at bedtime. Standard Resolor tablets come in 1mg and 2mg in AU.
- **Duration:** Ongoing maintenance after active SIBO treatment.
- **Effectiveness:** Strong evidence for promoting intestinal contractions. Particularly useful if constipation is part of the picture.
- **Availability:** PBS-listed in Australia. Originally approved for chronic constipation, used off-label for SIBO prevention.

### Low Dose Naltrexone (LDN) — Already Taking

- 2.5mg at bedtime (diarrhoea types) or 5mg (constipation types)
- Briefly blocks opioid receptors → endorphin upregulation → anti-inflammatory + motility effects
- Can be combined with other prokinetics (different mechanism)

Both prescription prokinetics are long-term maintenance medications — they don't cure SIBO, they prevent recurrence by keeping the MMC running properly.

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## Elemental Diet (Reserve Option)

A liquid-only formula of pre-digested nutrients consumed for 2-3 weeks. Nutrients absorb in the upper small intestine before bacteria can feed on them, starving the overgrowth.

### Evidence

- 80% breath test normalisation rate in one 14-day course (vs ~50-65% for antibiotics)
- Lowers gas levels by ~70 ppm per round on average
- Effective for all SIBO types (hydrogen, methane, hydrogen sulfide)
- One round of elemental diet can eliminate or greatly reduce the need for multiple rounds of antibiotics

### Practical Considerations

- Cannot combine with antibiotics or herbal antimicrobials (diet starves bacteria into dormancy; antimicrobials need active replicating bacteria)
- Must be followed by prokinetics and gradual food reintroduction
- Mentally challenging — no solid food for 2-3 weeks
- Costly (commercial formulas)
- Dr. Siebecker has a homemade recipe, though commercial formulas are more reliable

### Side Effects

- Die-off symptoms (same as any SIBO treatment)
- Reduced motility (no food stimulating natural contractions)
- Potential fungal overgrowth (prophylactic anti-fungals sometimes prescribed alongside)

### When to Consider

- After herbal antimicrobials have been tried and haven't fully cleared SIBO
- If breath test remains elevated despite completing Phase 1-3
- If symptoms are severe enough to justify the difficulty
- As a first-line treatment for very high breath test results (some practitioners prefer it over antibiotics for severe cases)

### Available in Australia

Commercial elemental diet formulas can be sourced through integrative practitioners. Some brands available online. Discuss with your treating practitioner for specific product recommendations and supervision.