When it does not respond: non-response and retreatment

Not everyone responds in the same way and at the same speed. If symptoms stay longer than expected, it is not a dead end: there is a clear plan. In this chapter you will learn to recognise an inadequate response, and understand the logic of retreatment — from the maximum dose to switching to a different LOT.

How you know the response is inadequate

The most important sign you can read from your diary is the consistency of the stool over time. One milestone of treatment is that around the tenth day the Bristol value^[G] begins to approach the 3–4 target band. If, however, even after the tenth day the stool stays persistently watery, formless — that is, with a Bristol value of 6–7 — and the daily stool count does not fall appreciably either, that is the sign of an inadequate response^[G]. This is not about a single bad day, but about improvement being durably absent.

It is important to tell slow improvement apart from genuine non-response. In many patients recovery is gradual, and it is completely normal if not everything returns at once. We speak of an inadequate response when, within the set time frame — typically after the tenth day — there is simply no meaningful movement in the right direction. This is not for you to decide alone: your diary supplies the facts, and your doctor pronounces on it based on the whole picture.

This is exactly why accurate, daily recording is so valuable. The trend in stool count, Bristol value, bloating and bloody stool together maps out whether your body is reacting. If the numbers show the same thing day after day for longer than expected, that is the signal that a step is needed — and that is exactly what the next section is for.

The logic of retreatment: dose, repeat course, different LOT

If the response is inadequate, retreatment has a clear, stepwise logic. The first step is usually raising the dose back to the maximum: if we have meanwhile already reduced the dose, or if you started at a lower level, your doctor can reset the maximum daily capsule count and repeat the whole course. This is often enough for engraftment^[G] to get going and for the symptoms to finally give way.

If even after the repeated, maximum-dose course the improvement is not durable, the next step follows: switching to a different LOT. The LOT denotes a particular, identifiable batch of the product, made from the screened flora of a specific donor. It happens — entirely naturally — that a particular donor's microbiome composition does not fit a particular patient perfectly, and another batch "takes" better. Switching LOT therefore does not mean the first product was bad; only that biological fit is individual, and there is another option.

This stepwise plan is reassuring because it shows: an inadequate response is not a dead end, but a fork for which we are prepared. Your job in this is to continue accurate diary-keeping and to stay in contact with your treating physician — every decision (dose escalation, repeat course, LOT switch) is made on their judgement, relying on the data in your diary.

🍽️ Eating during these days

The theme of these days — inadequate response and retreatment — is primarily about the dose and the capsule, but eating works in the background here too: the varied, fibre-rich plate helps the delivered flora engraft and helps colonisation resistance recover — this is the background work that matters even when the dose has to be raised. The concrete eating task for the three days is simple and unchanged: keep the familiar morning intake on an empty stomach with plenty of water, replace fluids after every looser stool with an extra glass, and every day work the day's plant into at least one meal.

For these days (67–69), the Plant Calendar (Appendix F) brings one fermented drink and two algae: kombucha (67), nori (68) and spirulina (69). The kombucha brings live cultures, and the algae bring further plant variety and minerals into the diet. In the second half of the programme (about days 61–90) the goal is to maintain full diversity and fermentable fibre sources: the more kinds of plant source reach the plate, the more kinds of beneficial bacteria you feed, and the more short-chain fatty acids (including butyrate) are produced, which support the gut barrier and colonisation resistance. A diverse, stable flora is more resilient — and it is precisely this resilience that works alongside recovery even in the case of an inadequate response. Introduce the new sources (especially the kombucha) in small portions, and if you do not tolerate one of them, leave it out and come back to it later.