Fecal Microbiota Transplantation (FMT)

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This is Doctor Talks, real talk from real doctors on the issues that matter to you most. What is FM t like? What? What even is it? What does it stand for? And then we'll go on from there. FMT as you said, it stands for fecal microbiome biota transplant. And what that looks like is we take stool from a healthy donor. We transfer that into another person with the goal of, bringing in healthy microbes into that recipient's get. Yeah, yeah. So it's the same as, like a blood transfusion or, you know, it's the same

What FMT Is and Its History 1:12

as an organ transplant to in terms of like the idea behind it, where you have somebody who's sick, somebody who's healthy and you're taking a healthy person's stool and implanting it into the sick person's GI tract in the hopes of getting them better. Yeah. A and we obviously don't do this for every disease, but like, what are the ones that are, you know, what are the ones that make sense and have research behind them where we would use FMT to actually treat them? Yeah. So right now the FDA only approves FMT for treatment resistant CDA.

So that's the most common that we see FMT used for. But there's also research to support it for the use of inflammatory bowel disease, which is a lot of what we do at modern med. There is some research and we can get into it with IBS. And Sibo as well. But those are the main ones there. Yeah. And for those who don't know, C diff is an infection of the intestinal tract that results in pseudo membranous colitis. What else do you have to say about that going to be life threatening, especially in elderly patients?

Yeah. So we typically think about that. It's after developing, after antibiotic use or after a stay in a hospital is the classic. And, there's a specific odor to see, infection that many people, they've had a C diff infection are very familiar with. And recognizable. Yeah. How do you describe the odor? Bad. It's it's a really strong foul odor. Yeah. Interesting. And diarrhea is common with you too. Yeah, yeah. I'm like, really bad about watery diarrhea. Okay. And then how did FMT come to be here?

What's the history of it? Because it's much longer, than I think a lot of people would think. Yeah. So the first use, documented use of FMT was in the fourth century. So a very long time ago in China by a Chinese physician. And, he used it for people who had diarrhea. He would take a healthy donor stool. In this case, he would take that stool and he would make a broth out of it, and it was taken orally. So there's a little bit of a joke that it did not last, because not a lot of people like to steal.

And that's essentially what it was. So that was the first documented use. And then we can do we do see it throughout history again. With veterinary medicine, farming, a lot of cattle would, would be given, stool from other cattle if they had any, metabolic or gastrointestinal diseases. And then in the more recent history, in about 1950s, there was a study done where pseudo members colitis, which we talked about with, food of infection above was treated in for patients with FMT, and successfully.

And at that point we did not know it was death because it was not, connected until the 1970s. But, when that study was completed and we saw a benefit that pushed for more studies in FMT. And then in the early 2000, about the turn of century, a new question came about that was rampant. And, more intense. And so that pushed more research on both FMT and the microbiome. And then most recent, in about 2013, the FDA said that they were going to start to, regulate FMT as an investigational new drug. And then in November of this past year, 2022, the first FMT product called re biota was approved.

And that is a rectal suspension, form. And then in April of this year, Daoust, which is an oral capsule FMT product, was approved for both of those, as you said, about for that prevention of treatment resistance here. Yeah, I love that you just covered from the fourth century to three and yeah, which is also the name of the broth. You said it was like yellow soup is what they called it. I think that's fascinating. The other thing I think is really interesting, and I don't know if you've thought about this.

I know nothing about veterinary medicine. So this is me just being a layperson when I discuss this. But, dogs will eat other dogs poop. And I always wonder, I'm like, I feel like there's something to that where maybe they're trying to get something or like, treat themselves. But maybe not. Maybe it's just like a thing that animals do. But I think it's pretty common in a lot of animals, right? Yeah. It is. I actually was looking into this recently, I think. So there's a little bit of an unknown. And is that are they trying to get beneficial.

And then I guess to some animal digestive tract they do better if they digest fiber twice. And so eating the fiber out of this store. But other animal can be helpful too. But interesting. Yeah. There's a name for it too.

FMT for C. Diff and Legal Access 6:00

It's like core of fascia or something like that. Where. Yeah, yeah, I don't, I don't know, I mean, sounds familiar, but I'm not. We're getting into today's word scope. Yeah. Just really interesting that there's, you know, this exists in other species in a very different way, which we would not recommend for humans. Any reasons. But but interesting to talk about nonetheless. Yeah for sure. So let's go into like first you said, see, right now is the only condition that's approved to be treated with FMT in the United States.

So let's just talk about like what does that mean then? Like, what can people with ulcerative colitis or Crohn's get FMT or, you know, how does this whole thing work from a legal standpoint as well? Yeah. Yeah. So unfortunately that designation makes it difficult to get it if you do not have that treatment resistant status and those who do treatment resistant, it means that somebody has a CF infection treated it with an antibiotic that is warranted with their vancomycin or a deficit and did not respond and did not create infection.

And so that's what can get you access to those stool banks and, be able to use these products at the FDA has approved you do not fit that category, which unfortunately is most of the patients that we see. That means that you're not able to be, to receive stool from a donor stool bank that is regulated, and or use re biota or both. Approved by under an approved designation. What ends up happening is typically people will do FMT if they're interested in doing it with these conditions at home. Finding a donor on their own.

And what we do at Manor Med is help people, find a donor, screened the donor so that they can do it safely, and then help them through the steps of what that looks like at home so it can be done in a safe manner. Yeah, yeah, yeah, I view this as harm reduction. So as one of the things that I'm passionate about, harm reduction, I have a huge passion and you know, in terms of harm reduction from overdoses as well. But this is just a different category of harm reduction where people have been doing FMT at home for IBD for very like a lot of years.

And when it goes unregulated, there becomes safety concerns where if you're going to do this, you could possibly get an infection or something more serious. And so our view at Modern Med is that we want to make this the safest avenue possible for people, and we would rather provide a service of screening their donors versus have them do it on their own and not screen any of their donors, which is, you know, makes sense to me. It's like giving a teenager a condom versus telling them not to have sex.

I think, yeah, we can kind of view it in that point to make sense. Yeah, absolutely. So let's go into we talked about CTF. But what about ulcerative colitis. Let's talk about that one first with the use of FMT because it's probably one of the most common things we, we see in our practice that come in with them. At least the curiosity about FMD. Yeah. Yeah. So there are, about four major studies that we look at for benefit in about 2015 to 2017. And from those four studies, we see about a 25 to 35% of those who received that FMT intervention compared to the placebo group had, reached remission.

And so that's both clinical, which would be symptom remission and endoscopic remission, which means not seeing any form of disease on colonoscopy. So that's huge. That's really big. That's the goal we want to reach. And ascorbic remission, histologic remission. And so very, very positive there. Yeah. So 25 to 35% benefit compared to, about 8 to 10% of that reaching remission in placebo groups with FMT, and ulcerative colitis. There is a little bit of a range of how that FMT is done. So in some of the studies they use a single donor versus a multi donor.

So one person donating that stool versus the blend of a few donor mix. And then how they deliver that study I mean deliver that stool donor stool is different. So I can do it through a kaleidoscope. So colonoscopy enema was done as well as endoscopy or news or whatnot in going through the nose and going into the small intestine or going through the mouth into the small intestine and delivering it there. So mixed there, when we talk about doing it at home for, you see, we obviously don't have access to a kaleidoscope or endoscopy.

But that's okay. With the enema, we see that, that the benefit is still within that, that range. And, and enemas are really safe and easy to use at home if done correctly. Yeah. Okay. And in in studies you're referencing what was the basic protocol. I don't mean specifics, but in terms of how many were this is a single FMT installation where they just did it one single day or do they do multiple days of FMT. Yeah, it is mixed. So some were single day one time through Corona scope. Some were one study was when they did it through colonoscopy and then they had them due to enemas in the weeks following.

And then some were more frequent. What? And we can talk about it a little bit more, further on too. But typically what we've taken from the research, which I've taken for the research, is about for those with, IBD, colonic IBD in general, what I find best about ten treatments consecutively or several consecutively. So over a ten, 14 day period, seems to be the where we get the best outcomes, but that can vary. And be individualized to. Yeah. Okay. So really interesting. They're getting such great results with just one like that's surprising to me.

And said you said about like it was about 25% versus the placebo group was around 10%. So you're getting an additional 15. Is that right. Yeah. 25 to 35. 8 to 1035. Okay. Got it. And what is what are they comparing the FMT group to. Like what are the placebos? I'm guessing they're receiving some treatment. Of course. Yeah. Typically that placebo is what we call autologous stool. So they take the stool from the person and then re implant it from whichever form that they were and whichever delivery method they were using.

So no real change that we expect from the microbiome. But you still go through the same process. Yeah. And when you have these two groups where they also on like Matt Salame, like was there a baseline treatment that they were, you know, both going through at the time? Yeah. So generally speaking with these studies we do have patients on other medications because it's not great to take people off medications. But that is things that they looked at in, in some of the studies is

FMT for Ulcerative Colitis 13:00

were you able to reduce your medications, come off certain medications? Typically speaking, in the research realm of FMT, they like to avoid patients being on biologics. And so a lot of the studies will be, on patients who are either on the cell mean or steroids or. Yeah, non biologic drugs. And any studies that have shown FMT versus a biologic for first of all just describe what a biologic is. Just really briefly so people know maybe some examples too. Yeah. So biologics are drugs that are developed from human like tissue.

And they are one of the common drugs that are used for autoimmune disease, including inflammatory bowel disease. So things like Stelara, Humira, all biologics, the common biologics that are used, and first part of that question. Yeah, I was just seeing, you know, are there any studies that show, you know, FMT is this effective to be putting people into remission versus a biologic like Wheter. Yeah, it's just apples to oranges. Or can we make some comparison there? Yeah. So I am not aware of any direct studies between biologics and FMT.

But if we look at biologic improvements we typically see that number around 15%. So it is similar if you're looking at that 8 to 10 versus 25 to 35%. However biologics do come with risk factors. That can be pretty significant. And there is also a cost associated with biologic. They're a long term therapy. And they have can have a large financial cost to. Yeah, okay. And then what about Crohn's disease. So, you know, we have a video. So I want to refer people back to that. But there's a big difference between Crohn's and colitis in terms of the location, which I feel like is important when we talk about FMT.

First you just talk about the difference in that location with Crohn's and you see, and then, you know, let's get into the FMT stuff around. Yeah. Yeah. So ulcerative colitis we typically see or we do see that inflammation in the colon. Crohn's disease. That information can be anywhere in the digestive tract. The most common place for that to be is the end of the small intestine. I do see, and from my experience with FMT is those people with Crohn's who have the inflammation at the end of the small intestine or in that colon, which where can we as well.

We do have the best effect with FMT, especially when we're doing it via enema because we're in the colon. That's where we're kind of modulating that microbiome. But there is a difference there. Can be anywhere along that tract. And, and so with that, to a lot of the research with Crohn's disease is on Crohn's disease that is located in the colon. But there is a lot of benefit that we do see. I think so in the research, about 57 in a recent meta analysis, they found that 57% of patients, adult patients with Crohn's disease, who, completed FMT, had clinical remission, at the end of 2 or 4 weeks, which is very significant.

The one asterisk here is that they did not see endoscopies change. So you throughout is going to be looking at the small intestine, upper part of small intestine. You don't see that end of the, small intestine through an escapee. They did not see change. And at the end of, for 8 or 12 weeks, depending on when they looked on the patient population. But as far as benefit, we do see it symptom wise, inflammation wise, and so can definitely still be a really good option for those with occurrences. Yeah.

How many how many times did they do a FMT. And I'm sorry. Do you remember know answer. So that was a study that was looking at like almost ten studies. That was a so it was a varied of how they did it. And again, it was similar to the you see that you can location, etc. delivery method, number of donors. And I mean, as far as kind of what I see is like if there is inflammation in the, colon with that Crohn's disease, we have similar, similar benefit as you see. And typically ish, those numbers look like like, 75% will have 50 to 75% will have a positive response, in some sort, whether it's symptoms, inflammation and, reduction in information numbers or a or about a third to a half can reach clinical remission, which is, pretty significant.

And that includes histologic remission too. Yeah, that's really significant. It's I mean, and this just really shows how important it is that we do more research too. So it feels like we're on to something. And with Crohn's, you know that that the active disease is deeper in the tissue. So I just wonder like do they have to do a longer course of treatment. More of them to then end up seeing the endoscopic remission as well as with clinical like, are we starting to see it. But it's just not enough. Not long enough or what.

What is it. Yeah. Yeah. And that's a good point to the ten treatments that we that I typically start with is more than that is done in research that is higher than we see in those numbers. But it's what we found to be the most expected I mean, the most effective, long lasting, durable. Yeah. Improvement. Okay. And we're going to go into more about like, what does this look like? The protocol a little bit, but I just want to stay in terms of the different conditions. And so I want to move on because we have this all the time where people, do complimentary calls with us and they ask about, you know, I have constipation or I have IBS or I have Sibo, I want to do FMT.

It kind of feels to me when I, when I talk to people is like, it's it's the Hail Mary. Right? And it's like I have tried everything else. I don't know what to do. Can this help me? Any research when it comes to to any of these? More like functional bowel disorders. Yeah. So there's some research on IBS. There is, there's three study, three major studies that were placebo, double blind. The one did not show any benefit. And that was done with oral capsules. And then two showed positive benefit, both of which or one was done via endoscopic delivery into the small intestine, one via colon scope into the colon.

And both showed pretty significant improvement in symptoms, compared to placebo, I think, as far as what I've seen in practice, two with people coming IBS, it is a little bit of a Hail Mary. It's not my first go to. It's when we've kind of exhausted some of the other options. And we can definitely see benefit. It's not with those same positive numbers that I see with IBD, but definitely possible. The other thing I think about too, is that in the functional bowel disorders, everything kind of gets clumped as IBS.

Even though sometimes functionally we have some differentiators and we think about different forms of treatment. So they're all getting the same FMT treatment of, however, frequency, etc., etc., when maybe it would make sense to tailor it to the individual a little bit more. And those studies into that can maybe account for the mixed response or there. Yeah. And anti-bacterial. Oh sorry. No it's okay. So you're saying that they are treating they're doing these studies on IBS in general. They're not pulling out IBS constipation retirement IBS and IBS.

Yeah. Yeah. That seems like a big like there needs to be a ton more research because those are different. Like they have some humanities in them. But it would be really interesting to do more specific protocols for each. Yeah. Oftentimes to I think you've probably seen that patients will come in with an IBS diagnosis. And we'll do a little bit more digging. And it could be Sibo being responsible for that and that we do see actually from there was a China study,

FMT for Crohn's Disease 21:00

that showed benefit with capsule FMT in the symptoms, of Sibo. So that might be one that is more responsive for Sibo still very, very early on research. But there was some promise there. Benefit. Yeah. What do you think the mechanism would be there. Because with Sibo it's an overgrowth of normal bacteria in the small intestine. So putting, you know just different microbes in from somebody else. What do you think's going on there. Yeah, it's a good question and something that needs to be investigated further.

My kind of thought process is that the overgrowth is Sibo is from quote unquote good guys. But maybe that balance is incorrect. And even some of those good guys can overgrow without control. And if we have add in some different quote unquote good guys that can that help keep that balance a little bit. And then also to like different immune responses that I would imagine is a big part of it are, the diversity of our microbiome is important for how our immune system responds. And we're learning more and more about how that matters for things like digestive symptoms, motility, etc..

So I would imagine that plays a role in it as well. Yeah, absolutely. And just the diversity is what you're getting at right where it's, you know, enhancing the diversity of the gut microbiome to, to allow it to balance itself more. That makes a lot of sense to me. And then there's always definitely at least a few times a year, I get a call about people that are interested in weight loss, and they've heard that FMT may lead to weight loss, and that's why they want to do FMT. How do you answer those questions and any research behind it as well.

Yeah. So this is a tough one because weight loss is such a sensitive subject subject. And people often have tried a lot of things for that. There are research to support that. Certain bugs may be, present in those who have a higher BMI or be more present in higher numbers. But we don't have any true research that FMT is beneficial for that weight loss. I typically, do not recommend an FMT for weight loss. It is we'll go through the process. It takes screening and it is it is a significant process.

So not my first go to for that typically recommend against. Yeah. Yeah. It's not even like my 100th thing. Yeah yeah yeah yeah. But there was that I like the rat study. Do you remember it? I can I can go through it too. Yeah. Refresh my memory. Yeah. So there was, I think it was a mouse study that was done. I don't know any of the specifics, but basically the real basics of it is they had an obese mouse, and they took the stool from the obese mouse, and they transplanted it to the lean mouse. That was normal body weight.

And the lean mouse became obese. And then they reversed it. And the opposite also happened where they took the, the stool from the lean mouse and implant it in the obese mouse. And the obese mouse lost weight. And so this is where I think a lot of people are getting it from where, you know, things have been written in the media saying FMT causes weight loss. It's like this miracle thing. And, you know, if you're overweight, then it's all due to your gut microbiome. And these blanket statements have been made.

But we haven't seen it in humans yet is the big thing, which is what we need to see to actually prove any efficacy when it comes to treating obesity in human populations. Yeah. But interesting nonetheless that it even happened. So, I think definitely more research. And it gets back to, you know, whenever I talk to any researchers on this, this idea of like, what is the optimal microbiome for any of these conditions, I think likely that we're going to figure out that there's something called like a super donor where, you know, they get better results from this one person being the donor for multiple people.

And what is it about that person's stool specifically that is effective in treating ulcerative colitis or crowns or or what have it? Yeah. And that's definitely hopefully where we're going with research. I think we do know as far as diversity is very helpful. But that's as far as like the claim that, yeah, we can go back. That makes sense. Okay. So let's go through general protocol. In terms of if somebody is looking to get FMT for ulcerative colitis or Crohn's disease and they they're not approved for rebound or vast, well, what would that process look like if they were to do that.

Yeah. So that first process, first part is finding a donor, and screening a donor. So typically if you want to dive into what screening looks like, we're generally looking for a healthy person who is having a bowel movement, at least one bowel movement daily. And hopefully eating a diet that is supportive of a healthy microbiome. So it doesn't have to be anything perfect. But, regularly consuming fruits and vegetables, fiber, things that would promote a healthy, diverse, microbiome. With that. So then with screening, we do, both blood and stool screening.

It is possible to transmit infection through stool. So that's why we need to do that screening, with blood or looking for things like HIV, viral hepatitis, syphilis are big ones. And then with stool testing, we're looking for active, any common enteric pathogens or parasites. It's very possible for people to have a colonization of a pathogen, but not have any symptoms. So definitely always, always want to do the stool testing there. Some people will forgo the blood testing if it is an intimate partner or a child.

But always, always, always want to do that. That's still testing. And then so we go through the donor screening to find, an appropriate donor. Next steps would be to take the donor stool, collect the donor start. We blend that with either sadly filtered water, in a blender that you don't plan to use again or one that you have not used prior. And then you take that, we filter out the larger particles, and we call that solution the fecal slurry. And then we take that, we go slurry and we put it into an enema bottle.

And then we use that for a retention enema, to insert, deliver to the colon. Typically try and hold on to a for about 4 to 6 hours. But that, is something we can talk about if it's difficult with any of your current symptoms, etc.. There's options there. And then like I said above, we typically start with roughly ten consecutive or semi consecutive treatments and then go from there, depending on how one responds. Sometimes we continue with more frequent, sometimes we start to taper it off, depending on how somebody responds.

Yeah. Yeah. Interesting.

FMT for IBS, SIBO, and Weight Loss 28:00

And, and I like the comment about how you're not going to use this blender for smoothies tomorrow, so I'm totally separate. Yes. Yeah. Yeah. This is a dairy one. I had a patient set up like a workshop in her garage, almost like this, like sterile area. That was by her kind of lab that she used, which seems to work. Well, yeah. So with FMT, when they're going through this, try to and mentioned, child briefly. Can children be used as donors and like what. Because the microbiome changes hugely from the day you're born until, you know, when you become an adult.

So what what's the cutoff there? And how do you talk to patients about that. Yeah. So you can use your child as a donor at around three years old is when we see that microbiome becomes more like an adult microbiome. As far as diversity goes, however, there are still benefit from those 0 to 3 years we've had patients use their newborn babies, and have significant benefits. So it might not be that kind of quote unquote perfect diverse microbiome that we're looking for, but we see benefit. So definitely can use any, any, any age.

The one thing with kiddos is that, oftentimes, I think it's around 30% under two year old, two years old, can have a C diff present in their gut. And so that's again, even if child always, always, always want to do that stool testing. Yeah. Is that something we want to transfer. Yeah, absolutely. And then when somebody is watching this video, they may be like, this is a no brainer. I'm going to do it. But what are the potential risks, as there are with everything with FMT? And have there been any like severe cases in terms of death or anything that's, you know, scary. Yeah.

So the three things that we think about with safety for FMT is one transfer of infection. And so we do our best to screen for that. And that has been generally preventative. Transferring pathogens. However, we can't test for everything. There's always going to be that, possibility that we transfer something that we can't test for that we don't know about. There's thousands and thousands of pathogens we can't test for every single one. Historically. So, FDA and I think 2019 ish put out a, a, kind of press release that there was two people who passed away that were immunocompromised and had received stool that had, antibiotic resistant bacteria present in there.

And so from their stool banks, have started screening for those, antibiotic resistant, bacteria strains. And that is something that we can do to, for how FMT you can stream, strain for the screen for those strains. And it's more important to, especially if somebody is immunocompromised because they do not have that, immune system to fight off. Yeah, yeah, yeah. You said that was 2020. I remember that turning point to where we were doing most of our donor screening through Quest Diagnostics. And then when that came out, quest doesn't run those resistant genes of what what Doctor Sheila's talking about is that there's certain bacteria that are resistant to things like vancomycin.

And so if somebody is present with those, then, they would not be an ideal donor for for the person for sure. Especially in immunocompromised person, because, but there's other labs that do run them. And we're hoping quest gets their stuff together and can actually do those eventually. One down. Yeah. Fingers crossed. Yeah. But so outside of infection, other one that we think about is allergens. So it is possible to pass along allergens, to the recipient. So if somebody has a true allergy to that food allergy, we do recommend that the donor avoid, those allergies for a week prior to donation to prevent that from happening.

And then, last risk would be, what we call mechanical complication, which is, complication from the tube itself in the delivery method. So if you are doing a nasal 1 or 2 of the, the tube that goes through the nose into the small intestine or, endoscopic, that tube itself can perforate the esophagus, stomach, small intestine, and then again kaleidoscope. Same thing with that. You can perforate the colon and you can do that with the enema as well. Very, very low risk for all of those things. But it is possible.

So like to make sure that patients are aware of that with the enemas. Do we talk about if there's it shouldn't be painful. So if you're feeling any pain then we need to pull back a little bit and kind of investigate something that's going on, to, prevent that. Yeah. Yeah. Okay. And I had a question then I got too into listening to you, so I'm trying to remember it, but with the complications, you were saying, oh, the allergen piece. So what you're saying there is that you have a donor who has an allergy or recipient who has an allergy recipient.

So if the recipient is allergic to peanuts, we would ask the donor to avoid peanut products for a week prior. Okay. That makes sense. So you're not passing. You're not like transmitting an allergy from one person to the other. Oh no no, no. Yeah, I ask the recipe and, yeah, if you're exposed to the antigen like the peanut or something, then you could have a reaction to it potentially. Right. So there's an empty digestion that's happened. Yeah. Yeah. Makes sense. And then can you go over any case studies that you've had in terms of like somebody walked into your practice with either let's, let's do maybe a Crohn's and a UC patient if you have one or IBS, whatever you think would be a valuable thing for people to hear about in terms of what that looked like in the results.

Yeah, I can talk about, maybe one positive, one negative for both sides of the spectrum. So I had a Crohn's patient, it was a male in his. He was male, in his 30s. And he, had, moderate Crohn's disease. He had, been on, a biologic before decided to come off on his own because he did not, no longer wanted to be on the biologics for, whatever reasons. And then he did the ten treatments that we talked about, and had significant benefit and symptoms, and we saw his inflammatory markers coming down almost immediately.

And so he had the kind of classic perfect response that we want to see improvement in how he was feeling, improvement in those markers, inflammation that we're seeing. And then with time, after the ten treatments that held his, symptom improvement, a complete resolution, actually, and inflammatory markers stayed low. And then when he had, endoscopy, all, signs of Crohn's disease were, we're not present. So his, he met both the histologic remission and the clinical remission following those ten treatment.

And now we monitor, about every he's on about a six months. We'll take a look at some of those inflammation markers, pay attention to symptoms. If he feels a little bit like he's, not 100%, he has, he has kept some of the donor stool and he will do 1 or 2 treatments, and that is enough for him to maintain that remission. And so he responded really positively, and continues to respond positively. And I think that's been probably around two, two and a half years now. Yeah. And then and then the other patient, I'm going to jump in really quick.

Yeah. Because I want to ask about that patient. He kept the donor stool. How long can you actually keep the donor stool? You know, I'm guessing you're freezing it, but how long would you tell somebody that you can keep it before it's useless? Yeah. So the one important thing with donor stool is that it cannot be a home freezer because we have, home freezers, have frosty frozen type defrost cycles that does not support the viability of the stool. So he has a medical grade freezer that he just keeps in his freeze, in his basement.

And then he also still knows his donor, so, he will they will occasionally, retest, about every six months or so just to kind of maintain stock. But as far as viability, I would say probably around a year

How FMT Is Done and Safety Considerations 36:30

is what I would do if they're keeping in a medical grade freezing. Yeah. Okay. Really interesting. And I cut you off. So case number two that you're going to review. Oh yeah. So case number two is 20 year old female with ulcerative colitis. And she has moderate you see pan colitis. So the inflammation is throughout her colon. And we started she was a family member as a donor. And we started with those ten treatments. She did not have any benefit. Symptomatically, we retested the inflammatory markers, and they were not changing.

They were, staying, elevated. And what are our next steps? We had discussed were potentially changing donor. However, she was having pretty significant pain at, at the anus and with insertion and so that we had to stop and we couldn't continue moving forward. She did not want to, move forward with that. So unfortunately no benefit there. Despite that ten treatment now. Yeah. Yeah, I've seen the same thing as well. I've even seen one patient where they got an improvement from their donor the first time they did it, and then they had to redo it about six months to a year later and didn't get improvement with the same donor.

Have you ever seen that? Yes. Yeah, I have seen that. And so, switching donors is an option to, and frequency. There's things that we can discuss there too. Yeah. I'm really excited about ribavirin and mouse. Mostly because I, I'm hoping and I'm interested in what you think about this, but I'm hoping it's going to open the door for this to be approved for IBD in the future. Just because, I mean, how medicine works is when there's money behind something, right? Then there's more lobbying power. Like there's more an effort to actually get it approved for multiple conditions, because those companies would obviously make a lot more money.

But it would also open expansion just in terms of people being able to get those that really, really need it and not have to go through these measures. What do you think about. Yeah. No, I, I completely agree. I think anything that increases access to FMT, is generally a positive thing. And there are I don't recall the actual names of the, the companies that are doing it, but there are research, studies that are currently in progress for on, on FMT products for IBD. And so hopefully that comes out pretty relatively quickly.

So that's definitely in the pipeline, something that will be in our future. It's a matter of time, which would be huge. Like we don't want to have to go through this, but our patients, we're just doing it because we want to make sure if they're if they're going to do it on their own, they're going to do it safely. How great would it be that we were just right? In order for re biota and so many picked it up and then, you know, they administer we administer an office. And that's the extent to which we need to do this.

I also feel like we'd be able to get so much more data points. Right at that point. But, we are using Rivera and Boustead Modern men for cedar free currency diff infections. Like Doctor Sheela said. And it's just really nice to have that option now and not having to, like, find a donor stool bank even with FMT, just to have something that's more accessible and more scalable as well across the country. Yeah. And I think too, right now we were only discussed as far as coverage goes, that you were able to give it get coverage for that.

And so that's a, that's a large part. Two of these things getting approved. Is that just hoping that that coverage maintains and then it becomes cost accessible to patients. Yeah. Yeah. The last question that we just got for most is thinking that they're going to pay between 0 and $65. What's interesting about most is it's 12 capsules. So you get what is that? I think it's four capsules over three days. Which is much lower than what we've seen in the past. You know, when we were doing, I think, seed, if we were doing like 30 capsules or something.

Right. What are your thoughts about, yeah. With seed, I for, like central bankers typically doing 30 to 35 one day and then occasionally doing the second, the second day of that depended. And that's just to be thorough. We have everything ready. I think that's great. I mean, that's the most accessible, accessible I patient, tend to have mixed opinions about taking capsule, fmt for some that oral capsules, they'd rather just take a few capsules and drink it down and have benefit. Others would prefer not to orally take FMT and think that that enema is, more palatable, because obviously with FMT there is a little bit of that X factor.

But oftentimes once we when somebody starts the treatment or does the treatment, they are it's not as gross as they had anticipated to be in a lot more manageable and are open to it again down the road. Should they need it, require it. Yeah. So that's the why we don't recommend it for like IBS right away. We don't recommend it at all for weight loss. But like there's so many things here and there is potential rest for it as well. Yeah. I do see though with oral capsules, is that sometimes the side effects of the, abdominal distension, gas, bloating can be a little bit more significant or more prevalent for those with oral capsules.

However, it's usually self-limiting, no big deal. Mild compared to what, symptoms are experiencing from either the IBD or Skydeck. But with that oral capsule, we do see a little bit higher, you know, frequency of side effects. Yeah. Okay. I really interesting there's a few questions that came in because I asked people earlier, and so I wanted to ask you, those from some of our followers on Instagram. Do you recommend antibiotic use prior to follow? No. I think the question is, is using antibiotics prior to FMT?

So I think we're talking about in a donor here. So one of the things that, you know, Doctor Schiller would do is have a consult with the donor and go through and ask them all these questions. And if somebody has been on an antibiotic, are they, a potential donor for somebody? Yeah. We like to weigh at least six months, from the donor receiving antibiotics, different story for the recipient, but for the donor. Want to wait at least six months in a perfect world, has had infrequent antibiotic use.

Again, just because we want that diverse microbiome that antibiotics can sometimes affect. Yeah, absolutely. I do think that there's other question, though, about using an antibiotic prior to FMT use, which I think is directly for the recipient. So somebody comes in with IBD, should they use the antibiotic before they get the donor stool just to like wipe out their microbiome for better results or what are your thoughts on them. Yeah. And so this is something that I do kind of on an individual basis.

There is research to support some of those studies did use antibiotics prior to FMT and can be really effective. I tend just again because the whole process, it's usually not my first step unless somebody for IBD specifically, unless somebody has been on an antibiotic recently and had to make an improvement from those, improvement in GI symptoms from being on an antibiotic, then sometimes we'll think about it. More commonly, we'll use it in somebody when it is that IBS functional disorder.

Case Examples and Closing Thoughts 44:00

And they've had benefit before. Just to try to do everything we can to, to see benefit there. But an option not necessarily required really depends on the person. Yeah. Okay. With valsartan re Biore. You, you do use an antibiotic before them for C for C diff. That's like great for prescribing. But that probably makes sense. Any other things that we haven't talked about that you think are so important or interesting that you want to talk about at this point? Yeah. I mean, I think I would just say I love FMT.

I think it's a really, really great therapy. There is that X factor. And sometimes it can be difficult to find a donor. But that's also something that we can discuss to. I do have resources for people to share with people they know to explain kind of asking somebody to use their poop as medicine is not the easiest question to do. So I have some resources that can make that easier and kind of share some, shed some light on to a potential donor who might not be familiar with this at all. So there is options if you are kind of sitting there and being like, who stool would I use?

We can talk through that. I think FMT can be super, super effective and definitely worth considering. Yeah. Would you ever just use FMT with somebody that comes in with Crohn's disease or colitis? Or is this usually part of a larger. Yeah, yeah, yeah. Typically not what I use alone. There's some people who come specifically to me, and they just want me to walk through what that looks like, which is totally fine. But we have a lot of tools that I think we mentioned some of those in our previous video that we can use for inflammatory bowel disease.

So I like to use what we can to get, somebody into remission or, improvement in their symptoms. I think it does. If we start multiple things at one time, it can muddy the waters a little bit. So that's something we consider. Do we want to do a little bit of FMT first and then see where we are. Really dependent on the person. Where are we. Do we need to get things down ASAP sometimes in that case we'll start with herbs. That can be really potent and fast acting and then bring in a FMT. It's really dependent but generally like to use the tools that we have.

Yeah, yeah. Totally agree. And you know, just listening to this video, I think the biggest take home is don't do this on your own. Don't put yourself at risk, because you don't have to definitely make sure you screen your donor if you're going to go about this. Make sure also that the condition you're looking to treat has some research for FMT. Because there's so many other treatments available for many, many, issues. And to I think that's research based is definitely important. Yeah, absolutely.

Thank you so much for taking the time, doctor. Sheila, if you're listening to this and you have IBD or you want to have a consult with Doctor Sheila, you can actually go to the link in our bio if this is Instagram, or you can go to our website, which you'll see below. Schedule a complimentary 15 minute phone call with Doctor Sheila's. He wouldn't be like working with her one on one. She has her license in California, Arizona and Maryland. So with any of those states, she has a full scope of practice.

So please reach out if you want to work with her one on one. And, we'll be posting more videos about all things get health coming up. And, let us know if you have questions. Thank you for tuning in to Doctor Talks. We hope today's episode has enlightened and inspired you on your path to optimal health. Each day is a new opportunity to make choices that empower your well-being. For more insights and strategies, subscribe to our podcast and visit our website w ww di doctor talks.com. Stay connected, stay healthy and join us next time on Doctor Talks.

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