# Prokinetics

## What Are Prokinetics?

Prokinetics stimulate the Migrating Motor Complex (MMC) — the small intestine's natural cleansing wave that sweeps bacteria out between meals. They are NOT laxatives. Laxatives work on the colon and do not stimulate the MMC. Prokinetics primarily work on the oesophagus, stomach, and small intestine.

Prokinetics are arguably the most important part of any SIBO protocol. Without them, even successful bacterial eradication results in relapse because the underlying motility dysfunction that allowed SIBO to develop hasn't been addressed.

Prokinetics can be combined — they have different mechanisms of action. Example stacks: LDN + Iberogast + ginger.

## Natural Prokinetics (No Prescription)

| Product | Mechanism | Dose | When |
| --- | --- | --- | --- |
| Iberogast | 9-herb blend. Stimulates motility + anti-spasmodic + anti-inflammatory. | 20 drops 3x daily (before meals + bedtime). 40-60 drops at bedtime for stronger MMC support. | 15-30 min before meals, and at bedtime |
| Ginger root extract | Modulates serotonergic 5-HT4 and 5-HT3 receptors in the gut wall. Supports gastric emptying and intestinal transit. ~90% of body's serotonin is in the gut. | 1000mg (or Nutricost 550mg 4:1 extract = 2200mg equivalent, 1 capsule) | Bedtime — most valuable during overnight fast when MMC runs longest |
| Artichoke leaf extract | Anti-spasmodic + choleretic (stimulates bile). Synergy with ginger — artichoke provides complementary actions alongside ginger's serotonergic activity. | 600mg | After meals |
| MotilPro (Pure Encapsulations) | 5-HTP + ginger (1000mg) + acetyl-L-carnitine + B6. Supports serotonin-driven gut motility. | 3-6 capsules daily in divided doses | Between meals or bedtime. **May worsen reflux. Contraindicated with SSRIs due to 5-HTP content.** |

## Prescription Prokinetics (Discuss with GP)

| Drug | Mechanism | Dose | Notes |
| --- | --- | --- | --- |
| Low-dose erythromycin | Motilin receptor agonist — directly stimulates the MMC. At 50mg this is NOT functioning as an antibiotic. Motilin is the hormone that triggers the MMC. | 50mg at bedtime. May need compounding pharmacy. | One of the most potent prokinetics available. Long-term maintenance. Commonly prescribed by SIBO specialists (Dr. Pimentel, Dr. Siebecker). |
| Prucalopride (Resolor) | 5-HT4 receptor agonist — stimulates serotonin receptors in the gut that drive intestinal contractions. | 0.5-1mg at bedtime. Standard tablets come in 1mg and 2mg in AU. | PBS-listed in AU. Originally approved for chronic constipation, used off-label for SIBO prevention. Particularly useful if constipation is part of the picture. |
| Low Dose Naltrexone (LDN) | At 2.5-5mg, briefly blocks opioid receptors → body upregulates endorphin production → anti-inflammatory and motility-enhancing effects. | 2.5mg (diarrhoea types) or 5mg (constipation types) at bedtime | Bedtime timing deliberate — endorphin production peaks during sleep, maximising rebound effect. |

## Why Bedtime Stacking

The overnight fast (e.g. 4pm dinner to 7am breakfast = 15 hours) is the most important MMC window. Roughly 10 cleansing waves over the night. Stacking three prokinetics at bedtime with different mechanisms maximises the strength of those waves:

- **Iberogast (40 drops):** Herbal motility stimulation. Higher dose because no food triggers natural contractions overnight.
- **Ginger (1000mg):** Serotonergic pathway amplification during the longest fasting window.
- **LDN (2.5mg):** Endorphin rebound during sleep.

The morning bowel movement is the result — flushing out the debris swept by overnight MMC activity.

## Ginger Product Note

Nutricost Ginger Root Extract 550mg is a 4:1 concentrate — each capsule is equivalent to 2,200mg of raw ginger root. Only 1 capsule per day needed. This is stronger per capsule than ground root powder products (NOW Foods 550mg, Swanson 540mg) which require 2 capsules for ~1100mg of unconcentrated root.

Lifestream Ginger is a 1000mg extract per capsule — also good, available at Mr Vitamins AU.