How to Use Sacharromyces boulardii to Treat Diarrhea
Laurie 2023
We recommend using an S boulardii combined with mannanoligosaccharides (“MOS”). We typically recommend Jarrow brand, but there are many reputable brands out there. AnimalBiome has one combined with FOS and PreforPro. We can’t speak to its use in the manner we suggest using here. It would be best to get the diarrhea under control as presented here using a boulardii with MOS. If you want a product combined with the PreforPro prebiotic, once the diarrhea is resolved, then if you like, move to using the AnimalBiome product for maintenance mode and use it according to instructions.
These instructions relate to boulardii combined with MOS only. Please see links to articles on the science of each at the end of these instructions. The articles share research focused on the importance of their respective roles in restoring a healthy microbiome, as the use of boulardii and MOS also cause physical repair to the intestines and modulate immune system response. There are many, many studies on the use and efficacy of S boulardii as it is one of the most researched probiotics out there. Our focus is its role in IBD and things we need to manage in the guts of our kitties.
IMPORTANT TO NOTE
1) This group has not yet seen something that S boulardii (especially with MOS: mannanoligosaccharides) does not manage better than metronidazole or tylosin, the typical vet go-tos for diarrhea. And a growing body of literature supports this. Vets tell us information based on old marketing and likely company-conducted research that has been recently proven wrong. They tell us it does not damage the microbiome as other antibiotics do (it does – 2020 research), and that it has anti-inflammatory properties (it doesn’t. Same research). And it doesn’t even have proven efficacy for non-specific diarrhea.
2) If following these instructions does not result in resolution of the diarrhea, get a fecal PCR done. Boulardii with MOS does not treat everything that can cause diarrhea: just a very wide range of things that do.
3) If your cat has diarrhea due to an underlying disease – e.g. exocrine pancreatic insufficiency, hyperthyroidism, or your cat has low B12 – nothing will resolve the diarrhea other than proper treatment. You need proper diagnostics.
INSTRUCTIONS FOR USING S BOULARDII with or without MOS
We recommend using a boulardii combined with MOS. You may need to include PreforPro, a specific prebiotic that helps manage and treat e coli, a common overgrowth in cats (no matter what food they eat, nothing to do with food format). Dr. Tobias brand has a prebiotic that is simply the trademarked product, PreforPro. These instructions are for the boulardii and MOS only. Ask for PreforPro instructions in the group as the Dr Tobias product is for humans, but it can be (and is often appropriate to be) used in conjunction with the S boulardii with MOS.
Summary. You need to get the gut flushed full of S boulardii (with or without MOS) for it to work. The challenge is getting enough in the gut to do the job, especially if diarrhea is liquid and frequent. Instructions focus on getting enough in there the first day, two or three (the “loading” phase) and then keeping it flushed full of boulardii for it to continue to do its job. As the diarrhea resolves – usually seen in less frequent bowel movements – it takes less boulardii to keep the gut flush with it because kitty is pooping less so more of it stays in the gut.
The most common reason for failure of boulardii to resolve diarrhea is not getting enough in the gut or keeping enough in the gut during the loading phase.
Safety. Saccharomyces boulardii goes from mouth to poop. This is also true of the MOS. These are not metabolized, they do not work systemically. This is what makes them so safe. S boulardii is deemed safe for use in premature babies, where hospitals around the world use it to quickly stop diarrhea. The brand, Florastor, is also used in hospitals worldwide for humans of all ages, both as a therapy for treatment of antibiotic-associated diarrhea and as adjunct therapy in treatment for antibiotic-resistant Clostridium difficile.
USE. Doses are not based on the size of the dog or cat. This is not a medicine. This is not metabolized and is not systemic - it works by simply being in the gut in sufficient quantity. Thus, the dose is individual and based on the specific circumstances of your dog and your cat: the challenge is getting enough IN the gut to be effective. It needs to be front-end loaded: FLUSH THE GUT FULL OF IT and then maintain it. The instructions are about how to do that.
Why is getting enough in the gut a challenge? When we first started using S boulardii, the dose was based on use by U.C. Davis in an antibiotic-resistant C difficile outbreak in their vet clinic back in 2001. The case study was published, and the dose of boulardii used was based on that information of efficacy. We find this dose (that equates to ½ capsule of 5bn CFU capsule 2x/day) often no longer works. Why? Easy answer: S boulardii used to be optimized with strains resistant to stomach acid. Now most companies have moved to more effective strains encapsulated in a time-release capsule. Time-release capsules target use in humans well, but not cats. So now we have capsules that don’t necessarily release as needed in the right place in a cat gut OR we take them out of the capsule, and the probiotic is killed to differing extents in each cat by the stomach acid. And therein lies the issue – and why we find it so important to emphasize safety in the use of as much S boulardii as needed. Again, it is not a medicine, it is not metabolized, and because it goes from mouth to poop, we don’t need to worry about liver or kidney toxicity.
It only works while in the GI tract. So how much to use is based on whether kitty has soft stools once or twice a day, or watery explosive diarrhea 7, 8 or more times a day. The number one reason S boulardii does not seem to work is not enough is staying in the gut TO work - or the problem is the food so move to a bland diet. Thus, the first step you should take is put your kitten or cat on a bland diet of just plain poached meat or meat-only baby food, preferably a protein your cat has had little exposure to. You can do this concurrently while starting administration of S boulardii. FYI, adult cats like adult humans can safely eat unbalanced plain meat for a few weeks. Kittens, like babies and toddlers, should go no more than a few days. Feed the poached meat or meat-only baby food and get started on getting the S boulardii into kitty.
As discussed, the goal is to get the gut flushed "full" of it, this is the only way it will work. There are any number of ways to do this. Instructions in our other articles say to give one-half capsule every two hours the first few days. But we have found that may work for some and not others. These are NOT hard and fast “rules.” The rule of thumb is simply: If you do not see improvement but things haven’t gotten worse, increase the amount you are using. Try an entire capsule every 2 hours (during your awake hours) and see if you start to see improvement in less frequency of stool (which is the first thing you'll see and an indication it's working). Or if there is really bad, watery diarrhea, give an entire capsule each time there is a bowel movement. With frequent watery diarrhea, everything is moving through the GI tract so fast, your kitty is just pooping out the capsule contents. It that doesn’t result in slowed frequency and/or firming poop, give a capsule after each bowel movement and then another one one-half hour later.
As soon as you see a reduction in frequency of bowel movements, you know it’s starting to work. Keep going until you see it forming. Once kitty is pooping cow-patty stools with a normal frequency – or if your kitty had soft stools and you see them forming – then you can start to scale things back. If poop gets sloppy / frequent again, increase the boulardii again. But if you got enough in there to work quickly, and kitty hasn’t had a bowl movement at all overnight or into the morning, slow the amount: you were giving six capsules to stop it? Give three. You gave four capsules? Give one morning and one night. This is guesswork for us as much as it is for you, but you’ll get the feel for how your kitty is reacting to it quickly. If you need to move up the frequency again, you’ll see it. Dose according to what you see as the response in your cat. You may need to dose whole capsules this frequently for several days. You may be able to taper down to a full capsule three times a day. Or two times a day within a day or two of starting it. You need to adjust the dosage based on what you are seeing as the response in your cat. That is the ONLY “rule.” Again – to reassure you that you are NOT harming your cat – unlike metro, it is not in there destroying the gut, it is also actually working on repairing it and getting kitty's immune system to help. See the reference links at the end of this discussion.
Bottom line? You can start with ½ capsule every two hours as instructed in the website articles on “Emergency Stop Diarrhea” instructions. But if that doesn’t change anything or doesn’t completely slow the frequency or completely firm up the poop, it isn’t enough. Give more. Either a higher dose with the same frequency, or the same dose with increased frequency (every hour), or a full capsule after every bowel movement, or a full capsule every two hours AND a full capsule after every bowel movement OR a full capsule after every bowel movement AND a full capsule one-half hour later. There is no “right” way to approach it, work with your schedule and your ability to observe your cat and your ability to get it INTO your cat. The ONLY point is? If it isn’t working, you likely need more, and potentially much more the first 1 to 3 days. There is no need to worry about how many pills it takes. But if you’re up to 6 full capsules a day and you’re on day three with zero change in frequency or texture, you need a fecal PCR. Or a bland diet.
Once you have formed stool and more normal bowel frequency, THEN you can slow down and see how it goes with two capsules per day. If it's not enough, then bump it to three. Again - the main thing? Slowly decrease the amount, find the lowest effective dose to control it once stool has returned to normal - and that lowest effective dose may change after a few days to a week or so. Point: Once the diarrhea has resolved, you need to find the right dose for your cat for maintenance mode or step-down mode.
Maintenance mode. Dosing MUST be twice per day to keep it “steady state” in the GI system. So whether maintenance mode is ½ capsule 2x a day or a full capsule 2x a day – as with everything S boulardii – is individual. If your kitty hasn’t pooped for a day, then lower the dose! So while this is not an antibiotic, it helps clear all kinds of infections and bacterial / fungal / even some amoebic overgrowths, you do need to keep your kitty on a month-long maintenance dose the first time you use it. It doesn’t get in the gut and kill everything, it needs time to do its job and to get to the point where it can do no more. Find the dose that keeps your kitty’s poop formed but pooping regularly, and keep your kitty on that dose for a month. If tapering down after that month results in softer stool, then keep kitty on it longer. There is no one timeline, there is no one effective dose. But the first time you use especially for resolving long term diarrhea, you do need to keep kitty on it for at least a month.
Final summary is the same as the one at the start: Don’t worry about “too much.” Find the amount your cat needs at the beginning to get the diarrhea slowed then formed. Then keep it at “high” dose for the first few days after diarrhea resolution so long as kitty keeps pooping and THEN work to find the lowest effective dose on which to keep kitty for at least a month while the probiotic continues to work.
***************************
Primary group articles: Prebiotics and Probiotics for Cats: A Cornerstone of Health & Healing in IBD (does need updating again) is the heart and soul of this group. It is hosted on the website in the discussion of the importance of a healthy microbiome and its role in controlling inflammation – the group’s emphasis being on restoring health to the gut and the microbiome. This article has the older “Emergency Stop Diarrhea” instructions near the end, but obviously required clarification. https://www.rawfeedingforibdcats.org/probiotics-for-cats---why-and-which-ones.html. The other go-to article is hosted on the Food Fur Life website, My Cat Has Diarrhea! What do I do? This article has a more detailed overview of managing diarrhea specifically and steps to take to resolve it with – as always – a species-appropriate approach combining an emphasis on healing the gut, not just managing the symptoms: https://www.foodfurlife.com/my-cat-has-diarrhea---what-do-i-do.html#/
The Science: The Science of S boulardii https://www.rawfeedingforibdcats.org/s-boulardii---review-of-the-science.html
The Science of Mannanoligosaccharides (MOS) https://www.rawfeedingforibdcats.org/mannan-oligosaccharides-mos---review-of-the-science.html
We recommend using an S boulardii combined with mannanoligosaccharides (“MOS”). We typically recommend Jarrow brand, but there are many reputable brands out there. AnimalBiome has one combined with FOS and PreforPro. We can’t speak to its use in the manner we suggest using here. It would be best to get the diarrhea under control as presented here using a boulardii with MOS. If you want a product combined with the PreforPro prebiotic, once the diarrhea is resolved, then if you like, move to using the AnimalBiome product for maintenance mode and use it according to instructions.
These instructions relate to boulardii combined with MOS only. Please see links to articles on the science of each at the end of these instructions. The articles share research focused on the importance of their respective roles in restoring a healthy microbiome, as the use of boulardii and MOS also cause physical repair to the intestines and modulate immune system response. There are many, many studies on the use and efficacy of S boulardii as it is one of the most researched probiotics out there. Our focus is its role in IBD and things we need to manage in the guts of our kitties.
IMPORTANT TO NOTE
1) This group has not yet seen something that S boulardii (especially with MOS: mannanoligosaccharides) does not manage better than metronidazole or tylosin, the typical vet go-tos for diarrhea. And a growing body of literature supports this. Vets tell us information based on old marketing and likely company-conducted research that has been recently proven wrong. They tell us it does not damage the microbiome as other antibiotics do (it does – 2020 research), and that it has anti-inflammatory properties (it doesn’t. Same research). And it doesn’t even have proven efficacy for non-specific diarrhea.
2) If following these instructions does not result in resolution of the diarrhea, get a fecal PCR done. Boulardii with MOS does not treat everything that can cause diarrhea: just a very wide range of things that do.
3) If your cat has diarrhea due to an underlying disease – e.g. exocrine pancreatic insufficiency, hyperthyroidism, or your cat has low B12 – nothing will resolve the diarrhea other than proper treatment. You need proper diagnostics.
INSTRUCTIONS FOR USING S BOULARDII with or without MOS
We recommend using a boulardii combined with MOS. You may need to include PreforPro, a specific prebiotic that helps manage and treat e coli, a common overgrowth in cats (no matter what food they eat, nothing to do with food format). Dr. Tobias brand has a prebiotic that is simply the trademarked product, PreforPro. These instructions are for the boulardii and MOS only. Ask for PreforPro instructions in the group as the Dr Tobias product is for humans, but it can be (and is often appropriate to be) used in conjunction with the S boulardii with MOS.
Summary. You need to get the gut flushed full of S boulardii (with or without MOS) for it to work. The challenge is getting enough in the gut to do the job, especially if diarrhea is liquid and frequent. Instructions focus on getting enough in there the first day, two or three (the “loading” phase) and then keeping it flushed full of boulardii for it to continue to do its job. As the diarrhea resolves – usually seen in less frequent bowel movements – it takes less boulardii to keep the gut flush with it because kitty is pooping less so more of it stays in the gut.
The most common reason for failure of boulardii to resolve diarrhea is not getting enough in the gut or keeping enough in the gut during the loading phase.
Safety. Saccharomyces boulardii goes from mouth to poop. This is also true of the MOS. These are not metabolized, they do not work systemically. This is what makes them so safe. S boulardii is deemed safe for use in premature babies, where hospitals around the world use it to quickly stop diarrhea. The brand, Florastor, is also used in hospitals worldwide for humans of all ages, both as a therapy for treatment of antibiotic-associated diarrhea and as adjunct therapy in treatment for antibiotic-resistant Clostridium difficile.
USE. Doses are not based on the size of the dog or cat. This is not a medicine. This is not metabolized and is not systemic - it works by simply being in the gut in sufficient quantity. Thus, the dose is individual and based on the specific circumstances of your dog and your cat: the challenge is getting enough IN the gut to be effective. It needs to be front-end loaded: FLUSH THE GUT FULL OF IT and then maintain it. The instructions are about how to do that.
Why is getting enough in the gut a challenge? When we first started using S boulardii, the dose was based on use by U.C. Davis in an antibiotic-resistant C difficile outbreak in their vet clinic back in 2001. The case study was published, and the dose of boulardii used was based on that information of efficacy. We find this dose (that equates to ½ capsule of 5bn CFU capsule 2x/day) often no longer works. Why? Easy answer: S boulardii used to be optimized with strains resistant to stomach acid. Now most companies have moved to more effective strains encapsulated in a time-release capsule. Time-release capsules target use in humans well, but not cats. So now we have capsules that don’t necessarily release as needed in the right place in a cat gut OR we take them out of the capsule, and the probiotic is killed to differing extents in each cat by the stomach acid. And therein lies the issue – and why we find it so important to emphasize safety in the use of as much S boulardii as needed. Again, it is not a medicine, it is not metabolized, and because it goes from mouth to poop, we don’t need to worry about liver or kidney toxicity.
It only works while in the GI tract. So how much to use is based on whether kitty has soft stools once or twice a day, or watery explosive diarrhea 7, 8 or more times a day. The number one reason S boulardii does not seem to work is not enough is staying in the gut TO work - or the problem is the food so move to a bland diet. Thus, the first step you should take is put your kitten or cat on a bland diet of just plain poached meat or meat-only baby food, preferably a protein your cat has had little exposure to. You can do this concurrently while starting administration of S boulardii. FYI, adult cats like adult humans can safely eat unbalanced plain meat for a few weeks. Kittens, like babies and toddlers, should go no more than a few days. Feed the poached meat or meat-only baby food and get started on getting the S boulardii into kitty.
As discussed, the goal is to get the gut flushed "full" of it, this is the only way it will work. There are any number of ways to do this. Instructions in our other articles say to give one-half capsule every two hours the first few days. But we have found that may work for some and not others. These are NOT hard and fast “rules.” The rule of thumb is simply: If you do not see improvement but things haven’t gotten worse, increase the amount you are using. Try an entire capsule every 2 hours (during your awake hours) and see if you start to see improvement in less frequency of stool (which is the first thing you'll see and an indication it's working). Or if there is really bad, watery diarrhea, give an entire capsule each time there is a bowel movement. With frequent watery diarrhea, everything is moving through the GI tract so fast, your kitty is just pooping out the capsule contents. It that doesn’t result in slowed frequency and/or firming poop, give a capsule after each bowel movement and then another one one-half hour later.
As soon as you see a reduction in frequency of bowel movements, you know it’s starting to work. Keep going until you see it forming. Once kitty is pooping cow-patty stools with a normal frequency – or if your kitty had soft stools and you see them forming – then you can start to scale things back. If poop gets sloppy / frequent again, increase the boulardii again. But if you got enough in there to work quickly, and kitty hasn’t had a bowl movement at all overnight or into the morning, slow the amount: you were giving six capsules to stop it? Give three. You gave four capsules? Give one morning and one night. This is guesswork for us as much as it is for you, but you’ll get the feel for how your kitty is reacting to it quickly. If you need to move up the frequency again, you’ll see it. Dose according to what you see as the response in your cat. You may need to dose whole capsules this frequently for several days. You may be able to taper down to a full capsule three times a day. Or two times a day within a day or two of starting it. You need to adjust the dosage based on what you are seeing as the response in your cat. That is the ONLY “rule.” Again – to reassure you that you are NOT harming your cat – unlike metro, it is not in there destroying the gut, it is also actually working on repairing it and getting kitty's immune system to help. See the reference links at the end of this discussion.
Bottom line? You can start with ½ capsule every two hours as instructed in the website articles on “Emergency Stop Diarrhea” instructions. But if that doesn’t change anything or doesn’t completely slow the frequency or completely firm up the poop, it isn’t enough. Give more. Either a higher dose with the same frequency, or the same dose with increased frequency (every hour), or a full capsule after every bowel movement, or a full capsule every two hours AND a full capsule after every bowel movement OR a full capsule after every bowel movement AND a full capsule one-half hour later. There is no “right” way to approach it, work with your schedule and your ability to observe your cat and your ability to get it INTO your cat. The ONLY point is? If it isn’t working, you likely need more, and potentially much more the first 1 to 3 days. There is no need to worry about how many pills it takes. But if you’re up to 6 full capsules a day and you’re on day three with zero change in frequency or texture, you need a fecal PCR. Or a bland diet.
Once you have formed stool and more normal bowel frequency, THEN you can slow down and see how it goes with two capsules per day. If it's not enough, then bump it to three. Again - the main thing? Slowly decrease the amount, find the lowest effective dose to control it once stool has returned to normal - and that lowest effective dose may change after a few days to a week or so. Point: Once the diarrhea has resolved, you need to find the right dose for your cat for maintenance mode or step-down mode.
Maintenance mode. Dosing MUST be twice per day to keep it “steady state” in the GI system. So whether maintenance mode is ½ capsule 2x a day or a full capsule 2x a day – as with everything S boulardii – is individual. If your kitty hasn’t pooped for a day, then lower the dose! So while this is not an antibiotic, it helps clear all kinds of infections and bacterial / fungal / even some amoebic overgrowths, you do need to keep your kitty on a month-long maintenance dose the first time you use it. It doesn’t get in the gut and kill everything, it needs time to do its job and to get to the point where it can do no more. Find the dose that keeps your kitty’s poop formed but pooping regularly, and keep your kitty on that dose for a month. If tapering down after that month results in softer stool, then keep kitty on it longer. There is no one timeline, there is no one effective dose. But the first time you use especially for resolving long term diarrhea, you do need to keep kitty on it for at least a month.
Final summary is the same as the one at the start: Don’t worry about “too much.” Find the amount your cat needs at the beginning to get the diarrhea slowed then formed. Then keep it at “high” dose for the first few days after diarrhea resolution so long as kitty keeps pooping and THEN work to find the lowest effective dose on which to keep kitty for at least a month while the probiotic continues to work.
***************************
Primary group articles: Prebiotics and Probiotics for Cats: A Cornerstone of Health & Healing in IBD (does need updating again) is the heart and soul of this group. It is hosted on the website in the discussion of the importance of a healthy microbiome and its role in controlling inflammation – the group’s emphasis being on restoring health to the gut and the microbiome. This article has the older “Emergency Stop Diarrhea” instructions near the end, but obviously required clarification. https://www.rawfeedingforibdcats.org/probiotics-for-cats---why-and-which-ones.html. The other go-to article is hosted on the Food Fur Life website, My Cat Has Diarrhea! What do I do? This article has a more detailed overview of managing diarrhea specifically and steps to take to resolve it with – as always – a species-appropriate approach combining an emphasis on healing the gut, not just managing the symptoms: https://www.foodfurlife.com/my-cat-has-diarrhea---what-do-i-do.html#/
The Science: The Science of S boulardii https://www.rawfeedingforibdcats.org/s-boulardii---review-of-the-science.html
The Science of Mannanoligosaccharides (MOS) https://www.rawfeedingforibdcats.org/mannan-oligosaccharides-mos---review-of-the-science.html