11 Jun 2021
Author
toliveagain
Title

Rifampin

Body

Hi Norman,

If you are still here and able to find it, can you repost this post:

27 Apr 2018 Author Norman Yarvin

Rifampin and food

I recently went back on rifampin, after having been off it for a while due to liver function test issues. The instructions for rifampin are to take it on an empty stomach...

The website ghosts ate the rest of the post and I am about to start rifampin... looking for any and all info.

Thank you :)

Comments

This website really needs to get moved to a platform less afflicted with old-age dementia than Drupal is.

Anyway, here's most of the contents of my 'rifampin posts' file:

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As for rifampin and the liver, rifampin differs from most of the other antibiotics used for Cpn in that it is absolutely known to mess with the liver simply by chemical action: it speeds up Phase 1 detoxification. With other antibiotics it could be that their liver effects are due mainly to killing Cpn infecting the liver, not to chemical action; but with rifampin, there's a lot of chemical action. (Speeding up detoxification may sound like a good thing, but speeding up just Phase 1 of it throws the system out of balance: the results of Phase 1, which themselves are toxins, can accumulate and poison the liver.) In one of Jim K's posts, he stated that it's Stratton's practice to reserve rifampin for after one has become comfortable with continuous metronidazole; and rifampin's liver effects seem like a good reason for that practice. It's a good idea to put bacteria under as many different types of stresses as possible, but it's not a good idea to do the same to your liver. I was taking rifampin for a while, but had to stop due to elevations of liver enzymes; now that I'm restarting antibiotics, I plan to build up to continuous metronidazole, and only when comfortable with that to resume rifampin.

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I recently went back on rifampin, after having been off it for a while due to liver function test issues.  The instructions for rifampin are to take it on an empty stomach; but being the lazy guy that I am, I decided to test whether I could get away with taking it with a breakfast of cereal and skim milk.  The reasoning was that drug instructions are written to err on the side of caution, that it's unlikely that absolutely every food absorbs rifampin, and that with rifampin in particular, one can test whether it's being absorbed by looking at the urine, to see whether it gets turned the appropriate shade of red.  In my case, taking it with that breakfast didn't seem to make much difference.

Then I went to look at the scientific literature, to see if it said anything about what sorts of foods I really should be avoiding taking with it. I found the article Pharmacokinetics of Rifampin Under Fasting Conditions, With Food, and With Antacids by Peloquin et al. The authors found that:

  • Antacids did nothing. So this isn't a drug that gets precipitated by calcium, magnesium, or such, like the tetracyclines are. One doesn't, for instance, have to worry about taking it too close in time to calcium pyruvate. (Strictly speaking, they didn't test calcium, only aluminum and magnesium; but aluminum, being in Group III of the periodic table, is usually a tougher test than calcium, so calcium probably isn't an issue either.)
  • Taking it with a high-fat meal reduced the maximum concentration (Cmax) by 36%, but reduced the area under the curve (AUC) by only 6%.

The article also summarizes the results of four other studies:

Siegler et al ... showed a 25% reduction in Cmax, 100% increase in Tmax, and 23% reduction in AUC when RIF[AMPIN] was administered with a high-fat meal. Zent and Smith administered RIF to 27 patients with active tuberculosis, and blood was collected at baseline and 12 time points over 8 h, plus a 24-h postdose. When RIF was given with a carbohydrate meal, a 15% reduction in Cmax, 19% increase in Tmax, and 4% reduction in AUC were shown. In contrast, when RIF was administered with a high-fat meal, these authors showed no significant effect of RIF's Cmax, Tmax, and AUC.
Polasa and Krishnaswamy studied six healthy men, dosing them with 10 mg/kg of RIF. Blood was collected at seven time points over 8 h postdose. A wheat-based breakfast consisting of 565 calories, including 9 g protein, 109 g carbohydrate, and 11 g fat was administered on one of two occasions. Com- pared with the fasting treatment, food reduced the mean Cmax by 30%, doubled the Tmax to 4 h, and reduced the AUC by 26%. Finally, Hagelund et al studied six patients with tuberculosis, in addition to six gastrectomized patients, collecting blood at 1, 3, 5, and 7 h postdose. They compared fasting conditions with a breakfast of bread with butter and marmalade, meat, cheese, one egg, and coffee or tea with milk. This meal delayed absorption, but showed only minor effects on Cmax and AUC in the nongastrectomized patients.

On the basis of all this, the authors recommend that rifampin be taken without food. This rather surprised me. Even a 25% reduction in area under the curve -- the worst number they cite -- isn't that much. As for the decrease in maximum concentration, that might be good or bad, depending on whether it is better to deliver a sudden shock to the pathogen, or to keep up the pressure on it steadily. In any case, I'll no longer be treating the instruction to take rifampin without food as an absolute rule, but rather as a rule I can bend according to the dictates of convenience.

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The 25% reduction in AUC basically is a straightforward one-quarter reduction. It's not good, but that's the worst number reported. (It's the reduction in Cmax which is more ambiguous in its impact.) From the strong language in the warnings I'd seen, I'd figured they must be talking about a 50% or 75% reduction in AUC, at least; they made it sound like if you'd eaten, you might as well not even bother taking the stuff. With a possible 25% loss, it's still worth avoiding food, all other things being equal; but they often aren't equal. Going hungry imposes its own stresses on the body, which also are worth avoiding; so this is a tradeoff.

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Have a look at my post here for some more detail on rifampin and food. Giving it only a 30-minute lead really shouldn't be a problem. By the way, since making that post, I think I have noticed a difference between taking it at the same time as food, and giving it a 30-minute lead; it's more potent if you give it the half-hour of head start, and that's what I'm doing now. But even taking it at the same time doesn't entirely destroy its efficacy.

Thank you Norman. I love reading your posts from the past. So much information. I decided to hold off on Rifampin for a little while. I was afraid it would be too much for me right now.

I recently changed Minocycline for Docycycle and feel tons better.Plan is to continue on Roxy, Mino with Flagyl pulses and all supplements. I also take Clemestine/Tavegil 4-8mg/d. The study on Clemestine was 10mg/d, but it's too expensive. 

I ordered some Ivermectin and will start that once it arrives. I haven't gone through the posts here to see if it was ever discussed. I watched a video by Dr. Steven Phillips, author of the new book "Chronic". He is mainly a Lyme disease guy but treats MS with Ivermectin and Doxy. He says people can get the die off flare pretty significantly so he starts slow, and with some people it takes a year to get to full dose. Sounds allot like a medication that works. I am looking for research articles.

If anyone has info on ivermectin in MS, please post.

Have a great day everyone... well, every day we wake up is a great day. Hugs

CAP on my own since 04/20. Roxi 300/Doxy 200/Flagyl or Tini pulses every 3-4 wks/20+ supplements adjusted monthly. Battling die off & porphyria often. First improvements noted @ 8 months.