The SIBO Struggle: Treatment, Part 1

I talked in my previous post about my SIBO diagnosis. The TL;DR recap is that after nearly 8 years of stomach issues I finally received a diagnosis of SIBO, which is a fancy way of saying there was too much bacteria in my small intestine and it was causing a whole bunch of health problems. My naturopath and I crafted a treatment plan to repair and restore good gut bacteria. The treatment has three stages:

1. Antibiotic treatment (2 weeks)
2. Low-FODMAP elimination diet and supplements (8 weeks)
3. Low-FODMAP reintroduction diet (indeterminate)

You'll learn more than you ever wanted to know about FODMAPs in future posts, but for now I'm going to focus on the first part of the plan: antibiotic treatment.

The frustrating thing about SIBO is that there's no way of knowing exactly what caused it. In my case it was likely a combination of things: multiple courses of antibiotics, a few bouts of verified food poisoning, moderate alcohol consumption, oral birth control pills, and who knows what else.

Photo courtesy of The Commons.

I bring this up because the thought of using antibiotics to treat a condition that may have been caused by antibiotics is more than a little counter-intuitive. Even my naturopath acknowleged this, but made a point to explain to me that the particular antibiotic she would be prescribing (Xifaxan) is unique int hat it fights bacterial infection only in the intestines. And because Xifaxan treats only the intestinal tract, it will not treat infections of other parts of the body.

The problem with Xifaxan is that even with health insurance, it's expensive. When I first tried to fill my prescription the pharmacist told me that my copay would be $597. I'm willing to invest in my health, but there's no way I was going to be able to afford that. Although it would later be approved for the treatment of irritable bowel syndrome with diarrhea (IBS–D), when I was prescribed Xifaxan it was only approved for reduction in risk of hepatic encephalopathy (HE), and so I don't blame my health insurance for balking at the high price tag (I have no way of knowing for sure but I've heard that a course of Xifaxan costs approximately $1000). As far as my health insurance was concerned I didn't need this particular antibiotic, and this high copay was my health insurance's special little way of yelling at me. There are drugs that cost $1,000, there are drugs that cost $5. When you're insured, you don't care. You don't even know. So the insurers put a $30 copay on one and $10 copay on the other. They're giving you a hint that there is a difference in the drug's total cost.
 
I understand this, but in my case (and I'm sure in most people's cases), I really did need this particular drug. Luckily my naturopath had warned me that this might happen and instructed me to contact her if I ran into any problems at the pharmacy. She helped enroll me in a patient assistance program, and a few weeks later Salix (the manufacturer of Xifaxan) provided me with a coupon that knocked $500 off my copay. $97 is still a lot to pay for a medication, but it was way more feasible than $597, so I bit the bullet and filled the prescription.

My naturopath had instructed me to take a supplement called NAC in conjunction with the Xifaxan. My understanding is that NAC is an amino acid that has bactericidal properties, meaning it helps to kill bacteria by breaking down bacterial biofilms. I dropped $30 on NAC at my local Pharmaca, which put the initial cost of my treatment at $127, to say nothing of my office visit copays or hydrogen breath test. I mention this because I really hate spending money, and since I'd already sunk $127 into this process, I was determined to do it right. I was worried that I would screw up the course of antibiotics by forgetting doses or neglecting to take them on time, because I have a bad track record for that and between the Xifaxan and the NAC I would be taking seven extra pills each day on top of the medications I was already taking! Luckily, I think the upfront cost was a good motivator for me, because I managed the medications just fine. I felt unusually tired the first week of the treatment, but the first week also coincided with an unprecedented heat wave for our region, so it's hard to say if that was an effect of the medication or just an effect of being too damn hot.

The two week course of Xifaxan was a good way to ease into the second phase of the treatment plan, which consisted of a huge diet overhaul. I spent those two weeks reading cookbooks, blogs, and clearing out our fridge, freezer, and pantry in preparation. I wasn't joking earlier when I said that  you'll learn more than you ever wanted to know about FODMAPs in future posts; stay tuned for a crash course in low-FODMAP living.