Probiotics Prevent SIBO in Proton Pump Inhibitor Users

Proton pump inhibitor (PPI) medications are one of most frequently utilised classes of medicines. Primarily used to treat gastro-oesophageal reflux disease (GORD), gastritis and peptic ulcer disease, use of these medications has risen sharply over the past two decades. In fact, utilisation has increased by over 1300% over this time! Commonly used PPIs include omeprazole (Losec), lansoprazole (Zoton), esomeprazole (Nexium), pantoprazole (Somac) and rabeprazole (Pariet). Nexium alone accounts for over 19 million prescriptions in the US annually. In Australia, during 2013-14 there were over 19 million prescriptions written for PPIs – quite impressive for a nation of only 24 million people!

The capacity of PPIs to increase risk of Small Intestinal Bacterial Overgrowth (SIBO) had been debated (at least in some circles) until a meta-analysis published in 2013 showed conclusively that PPI use increased the odds of developing SIBO. Pooled data showed over a 7.5-fold increased risk of SIBO development in PPI users.

Given the substantial SIBO-risk associated with their use and the massive frequency of utilisation, it is not surprising that SIBO diagnosis and awareness has increased dramatically over the past decade. This is even more worrying in light of data suggesting that up to 70% of patients taking PPIs are doing so inappropriately!

So, is there anyway to decrease the risk of SIBO development in those patients taking PPIs? It turns out that the right probiotic preparation is indeed capable of reducing the risk of SIBO development.

In a very recent randomised, controlled trial, 128 patients with GORD were allocated to receive either a probiotic supplement or placebo alongside their PPI over a 12-week period. The probiotic group received the strain Lactobacillus reuteri DSM 17938 at a dose of 5 drops per day of an oil preparation (containing a total of 1 x 10^8 CFU/day). SIBO assessment was done (via the Glucose Breath Test) at baseline and again after 12 weeks PPI treatment (esomeprazole). No patients tested positive for SIBO at baseline. Amazingly, SIBO developed in over 56% of patients taking the PPI in the placebo group in just 12 weeks! On the other hand, SIBO only developed in 6% of subjects in the PPI + probiotic group (group difference P<0.001). Additionally, significantly more children in the placebo group developed new gastrointestinal symptoms compared to those in the probiotic group (P=0.026).

This study clearly showed that the co-ingestion of this specific probiotic strain was capable of preventing SIBO from developing in patients taking PPIs. Is this something we could expect from just any probiotic preparation? The research suggests not, with a previous study finding an alternative probiotic preparation comprised of two probiotic strains (Lactobacillus rhamnosus R0011 & L. acidophilus R0052) prescribed at a higher dose (2.0 x 10^9 CFU/day combined) was unable to prevent SIBO development in PPI users. So, at this point, we’d have to conclude that this is an action potentially unique to the L. reuteri DSM 17938 strain.

So, how does this strain work to prevent SIBO from developing? It may have to do with the ability of this strain to produce an anti-microbial compound called reuterin. Reuterin has demonstrated broad action against a range of microorganisms that are commonly found to be overgrown in patients with SIBO – Escherichia, Proteus, Pseudomonas, Staphylococcus, Streptococcus, Enterococcus and Bacteroides spp..

I’ve always argued that probiotics can play pivotal roles in the treatment of SIBO and now we have excellent evidence showing that the right probiotic can prevent its development too.

Jason Hawrelak
ND, BNat (Hons), PhD, FNHAA, MASN, FACN
Chief Research Officer
Probiotic Advisor

Selected references:
Axelsson LT, Chung TC, Dobrogosz WJ, et al. (1989). Production of a broad spectrum antimicrobial substance by Lactobacillus reuteri. Microbial Ecology in Health and Disease 2(2):131-136.

Belei O, Olariu L, Dobrescu A, et al. (2018). Is it useful to administer probiotics together with proton pump inhibitors in children with gastroesophageal reflux? J Neurogastroenterol Motil 24(1):51-57. PMID: 29291607

Forgacs, I., & Loganayagam, A. (2008). Overprescribing proton pump inhibitors. BMJ, 336(7634), 2-3. doi: 10.1136/bmj.39406.449456.BE
Hollingsworth S, Duncan EL, Martin JH. (2010). Marked increase in proton pump inhibitors use in Australia. Pharmacoepidemoil Drug Saf 19(10):1019-1024.

Lo, W. K. and W. W. Chan (2013). “Proton Pump Inhibitor Use and the Risk of Small Intestinal Bacterial Overgrowth: A Meta-analysis.” Clinical Gastroenterology and Hepatology 11(5): 483-490.