Disulfiram for Lyme Disease: Lessons Learned

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Disulfiram for Lyme Image by Marty Ross MD

Updated: 5/9/2022

About Disulfiram and Lyme Disease

For 30 percent of people with chronic Lyme disease, disulfiram is a game changer. This is a medicine historically used to treat people with alcoholism. Ground-breaking research from Dr. Rajadas’ Stanford University lab in 2016 showed disulfiram kills persister and growing forms of Lyme germs. Based on Rajada’s research, disulfiram is being repurposed as a Lyme antibiotic.

In alcoholism, disulfiram prevents the breakdown of a toxic alcohol by-product called acetaldehyde. As acetaldehyde builds up, it makes a person sick with severe abdominal pains and even headaches. In alcoholism, a person takes this medicine daily to prevent them from drinking out of fear it will cause severe illness if they drink alcohol.

In Lyme disease, we do not know the mechanism of how disulfiram works. But we do know in the laboratory that it kills Lyme persisters and is moderately effective at treating growing Lyme too. We also theorize that it breaks up biofilm slime layers that protect the germs.

Marty Ross MD Discusses
Lyme Growth States, Forms, & Disulfiram Outcomes

 
 
 
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Lyme Terminology 101

So, Lyme exists in two growth states. One state is replicating growing Lyme. The other is a hibernating (persister) state. A persister germ slows its metabolism way down and ignores the world around it - including regular antibiotics and the immune system. Also, in a persister state, the germ forms cover themselves in biofilms to hide from the immune system.

One reason, some people with Lyme do not recover is regular antibiotics may only treat the growth state of Lyme. Experiments published in 2016 from Dr. Lewis’ lab at Northeastern University showed that 20 percent of Lyme spirochetes and 20 percent of Lyme cyst forms assume the persister growth state when they are exposed to continuous antibiotics.

To be clear, Lyme has two extracellular forms and two growth states. The extracellular forms are spirochetes and cysts. These spirochetes and cysts are either growing or hibernating (persisters). Lyme also has an L-form that lives in cells. The L-form does not have a covering. It is not clear if disulfiram works on L-forms inside of cells.

Disulfiram Treatment Outcomes

The pioneer of treating Lyme disease with disulfiram is Dr. Ken Liegner. In May of 2019, he published a case study of three patients showing success using disulfiram. In 2020, he went further and published a paper documenting his outcomes treating nearly 70 patients. His data and experience is similar to what I see in my practice. Dr. Liegner's review of his patient's charts shows:

  • 92.5 percent of people have varying degrees of improvements
  • 36.4 percent - enduring remission (clinically well for 6 months without anti-infectives)
  • 49.3 percent - fatigue as a side effect
  • 31.3 percent - psychiatric problems like anxiety, depression, hallucinations
  • 14.9 percent - neuropathy
  • 14.9 percent - liver enzyme elevation
  • 50 percent - unable to reach the target dose due to side effects (see dosing section below)

The overwhelming majority of Dr. Liegner’s patients use no other antibiotics while they are on the disulfiram. And his patients had already been on numerous antibiotics in the past.

Even if a person cannot reach the target dose, in my experience many get benefit by staying at a dose they can tolerate for at least 4 months.

When to Use Disulfiram

On Previous or Current Antibiotics

I am using disulfiram in patients who do not fully recover after using prolonged antibiotics targeting growing Lyme for a year or more. One reason these patients may not recover is that persister forms of the Lyme germ develop that are missed by regular antibiotics. In these patients, I use disulfiram alone. For some of these patients, if they do not respond to disulfiram alone, I am also using antibiotics that target growing forms of the Lyme germ better than disulfiram. You can read about these antibiotics in A Lyme Disease Antibiotic Guide.

Disulfiram Doesn’t Work for Bartonella

Based on my experience and laboratory experiments from Dr. Lewis’ lab at Johns Hopkins University, disulfiram does not work for persister Bartonella. Read Kills Bartonella: A Brief Guide for approaches to persister Bartonella.

Disulfiram May Help Babesia

Disulfiram can treat growing Babesia. But I find it to be a weaker agent, so I prefer other treatment approaches. See Kills Babesia: A Brief Guide for Babesia treatments.

Untreated Chronic Lyme

At this point, based on Dr. Liegner’s data and my own clinical experience treating patients, disulfiram should not be used alone as the first antibiotic a patient takes to treat Lyme. There are several reasons I say this.

  • First, disulfiram is very hard to take with many side effects and may even leave a person with lasting nerve injury.
  • Second, there are more effective antibiotics at treating growing Lyme.
  • Third, we do not know if disulfiram treats intracellular L-form Lyme effectively.
  • Finally, there are other alternatives to treat persisters that are easier to take including my favorite liposomal cinnamon, clove, and oregano combination capsules.

For more information about these other persister options see How to Treat Persister Lyme & Bartonella.

Acute Tick Bite

We have no data to suggest disulfiram is effective for an acute tick bite. I do not use it in this situation. For more information see How to Treat Acute Tick Bites.

Intestinal Yeast Overgrowth

Intestinal yeast can produce acetaldehyde. As I discussed above, disulfiram blocks the breakdown of acetaldehyde which is why it is used to treat alcoholics. If acetaldehyde builds up it leads to severe abdominal pain, headaches, nausea and more. Before starting disulfiram, it is important to see if someone has yeast overgrowth in the intestines. If they do, then the yeast should be treated first. For more information about diagnosing and treating yeast see A Silent Problem - Is It Yeast? and Kills Yeast: A Brief Guide.

Antabuse (Disulfiram) Dosing and Duration

An average treatment length for Disulfiram is eight months. Disulfiram triggers a large Herxheimer reaction in many people. Because of this, the medicine is started low and slow working to a target dose. It can take up to four months to reach the target dose in many patients. Once a person reaches the target dose, or a lower dose they can tolerate, they stay at that dose for four months.

The target dose for disulfiram is based on your weight. If a person can tolerate it, I try to reach 4 to 5 mg/kg a day. To figure out how many kilograms you weigh, divide your weight in pounds by 2.2. Here is the calculation of the target dose for a person weighing 150 pounds:

  • 150 lb/ 2.2 = 68 kg
  • 68 kg X 4 mg/kg = 272 mg
  • 68 kg X 5 mg/kg = 340 mg

For this weight I choose a target dose of 312.5mg which is between 4 to 5 mg/kg. Disulfiram is manufactured as a 250 mg and 500 mg pill. It is also compounded as a 62.5 mg pill. One and ¼ 250 mg pill or five of the 62.5 mg pills equal 312.5 mg.

 I usually start patients at 62.5mg mg every 3rd day for 10 days, then I advance to 62.5 mg every other day for 10 days, then to 62.5 mg 1 time a day. Based on the response in the first month, I decide how rapidly I will increase the dose from there.

If a person has a very sensitive stomach with symptoms like nausea, I will have the capsule compounded and put into an enteric coated pill. These pills deliver the disulfiram to the small intestines without breakdown of the medicine in the acid of the stomach. If I use enteric coated pills, I adjust the above target and starting doses by a factor of 2.6. This means if my target dose is 250 mg for regular disulfiram, I would adjust the target dose to 100mg (250 mg / 2.6). One more note, I do not find any benefit is using liposomal forms of this medication over regular forms. And I only use the enteric coated form if someone has stomach or nausea issues. I do not find the liposomal or enteric coated forms prevent any of the disulfiram side effect issues like headaches or neuropathy.

Suggested Supplements

Disulfiram may cause intense herxheimer reactions. To prevent this and to manage it, I recommend

  • Liposomal curcumin 500 mg 1 to 2 pills 3 times a day. My suggested product for this is Meriva 500 SF by Thorne.
  • Liposomal glutathione 400 to 500 mg 1 to 2 times a day. My suggested product for this is Tri-Fortify Orange or Watermelon by Researched Nutritionals.

For more ideas about how to limit Herxheimer reactions see Herxheimer Reactions: Inflammation Run Amok.

Disulfiram may also lead to neuropathy. To limit this I recommend supportive supplements

  • Multi Vitamin B Complex 1 pill 1 time a day
  • Zinc Picolinate 30 mg 1 pill 1 time a day
  • Liposomal glutathione 400 to 500 mg 1 to 2 times a day. My suggested product for this is Trifortify Orange or Watermelon by Researched Nutritionals.

Avoid

Do not have food, medicines, skin care products or mouthwash with alcohol. Read labels of anything in a bottle. Alcohol detox is blocked by the disulfiram.

  • alcohol beverages including spirits, wine and beer
  • alcohol-based herbal tinctures and vanilla extracts
  • fermented foods like sauerkraut, kombucha, kefir, worcester sauce and kimchi
  • mustard
  • vinegars
  • soy sauce
  • sugar alcohols like mannitol (Alka Seltzer Gold), sorbitol, isomalt, maltitol, lactitol, xylitol and erythritol

If you find yourself reacting to the disulfiram even with these food restrictions, then consider removing sources of polyphenols which includes coffee and green tea.

Additional Resources

For more information about Lyme persisters and treatment options see How to Treat Persister Lyme & Bartonella.

Disclaimer

The ideas and recommendations on this website and in this article are for informational purposes only. For more information about this, see the sitewide Terms & Conditions.

References

View Citations

  1. Alvarez-Manzo HS, Zhang Y, Shi W, Zhang Y. Evaluation of Disulfiram Drug Combinations and Identification of Other More Effective Combinations against Stationary Phase Borrelia burgdorferi. Antibiotics (Basel). 2020;9(9):542. Published 2020 Aug 26. doi:10.3390/antibiotics9090542 (View)
  2. Gao J, Gong Z, Montesano D, Glazer E, Liegner K. "Repurposing" Disulfiram in the Treatment of Lyme Disease and Babesiosis: Retrospective Review of First 3 Years' Experience in One Medical Practice. Antibiotics (Basel). 2020;9(12):868. Published 2020 Dec 4. doi:10.3390/antibiotics9120868 (View)
  3. Lewis KKS. Lyme Disease in the Era of Precision Medicine. Available online: https://www.youtube.com/watch?v=aUlKTnrGPgc (Accessed July 22, 2019)
  4. Liegner KB. Disulfiram (Tetraethylthiuram Disulfide) in the Treatment of Lyme Disease and Babesiosis: Report of Experience in Three Cases. Antibiotics (Basel). 2019;8(2):72. Published 2019 May 30. doi:10.3390/antibiotics8020072 (View)
  5. Liegner KB. (2020, September 11) Disulfiram In The Treatment Of Lyme & Babesiosis - Retrospective Review Of First 3 Years' Experience In One Medical Practice. 2020 ILADS Annual Scientific Conference, Virtual.
  6. Pothineni VR, Wagh D, Babar MM, et al. Identification of new drug candidates against Borrelia burgdorferi using high-throughput screening. Drug Des Devel Ther. 2016;10:1307–1322. Published 2016 Apr 1. doi:10.2147/DDDT.S101486 (View). 
  7. Potula HSK, Shahryari J, Inayathullah M, Malkovskiy AV, Kim KM, Rajadas J. Repurposing Disulfiram (Tetraethylthiuram Disulfide) as a Potential Drug Candidate against Borrelia burgdorferi In Vitro and In Vivo. Antibiotics (Basel). 2020;9(9):633. Published 2020 Sep 22. doi:10.3390/antibiotics9090633 (View)
  8. Scheibel LW, Adler A, Trager W. Tetraethylthiuram disulfide (Antabuse) inhibits the human malaria parasite Plasmodium falciparum. Proc Natl Acad Sci U S A. 1979;76(10):5303–5307. doi:10.1073/pnas.76.10.5303 (View)
  9. Sharma B, Brown AV, Matluck NE, Hu LT, Lewis K. Borrelia burgdorferi, the Causative Agent of Lyme Disease, Forms Drug-Tolerant Persister Cells. Antimicrob Agents Chemother. 2015;59(8):4616-4624. doi:10.1128/AAC.00864-15 (View)
  10. Zheng X, Ma X, Li T, Shi W, Zhang Y. Effect of different drugs and drug combinations on killing stationary phase and biofilms recovered cells of Bartonella henselae in vitro. BMC Microbiol. 2020;20(1):87. Published 2020 Apr 10. doi:10.1186/s12866-020-01777-9 (View)
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About the Author

Marty Ross, MD is a passionate Lyme disease educator and clinical expert. He helps Lyme sufferers and their physicians see what really works based on his review of the science and extensive real-world experience. Dr. Ross is licensed to practice medicine in Washington State (License: MD00033296) where he has treated thousands of Lyme disease patients in his Seattle practice. 

Marty Ross, MD is a graduate of Indiana University School of Medicine and Georgetown University Family Medicine Residency. He is a member of the International Lyme and Associated Disease Society (ILADS) and The Institute for Functional Medicine.

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