Rifampin for lyme treatment: A Quick Guide

A recently reported case highlights an important safety concern for people taking multi-drug regimens for post-treatment Lyme disease syndrome (PTLDS): medication combinations can matter.

The case involved a 62-year-old woman with PTLDS who was taking dapsone, hydroxychloroquine (HCQ), doxycycline, rifampin, and ivermectin. She went to the emergency department with shortness of breath and low oxygen levels. Her oxygen saturation was 88% on room air, although she was otherwise clinically stable.

Testing found that her methemoglobin level was elevated at 11.2%. Methemoglobinemia is a medication-related complication that affects the blood’s ability to carry oxygen. A blood smear also showed oxidative hemolysis, supporting medication-induced methemoglobinemia.

According to the report, dapsone and HCQ are known to cause methemoglobinemia. The authors also noted that rifampin may enhance this effect. This does not mean rifampin alone caused the problem. Rather, the concern was the combination of dapsone, HCQ, and rifampin, particularly because dapsone and HCQ can each increase methemoglobin levels and rifampin may add to that risk.

The care team also tested the patient for glucose-6-phosphate-dehydrogenase (G6PD) deficiency, a known risk factor for methemoglobinemia. She did not have G6PD deficiency. This is notable because the complication occurred even without that specific risk factor.

Her Lyme total antibody test was negative, confirming that she did not have an active infection. She improved after receiving supplemental oxygen and ascorbic acid and after dapsone, HCQ, ivermectin, doxycycline, and rifampin were discontinued.

The key takeaway for people considering or taking rifampin-containing regimens for PTLDS is that medication review, risk assessment, and monitoring are important. The case report specifically cautioned that rifampin may increase the methemoglobinemia-inducing effects of dapsone and HCQ when these drugs are used together.

The authors also emphasized that there is no strong evidence supporting anti-infective treatment for PTLDS, whether used for a short or long period. Potential harms should be carefully weighed when considering multi-drug approaches.

Shortness of breath and low oxygen saturation were the main symptoms in this case. Anyone taking dapsone, HCQ, rifampin, or a combination of medications who develops concerning symptoms should seek prompt medical evaluation. Do not start, stop, or change prescribed medicines without speaking with a qualified physician.