Dapsone for Lyme Persisters. A Miracle Antibiotic?

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Dapsone for a Lyme disease treatment image from Marty Ross MD

Dapsone for Lyme Persisters

Dapsone, a leprosy drug, can help some with treatment resistant Lyme due to persister cells. In 2016, Horowitz and Freeman published research on 100 patients. The study showed 59 percent of people had improvements with dapsone. However, my experience with dapsone is mixed. While it helps some, it is also a very difficult medicine for many to take.

In this article I review

  • my experience with this novel medicine,
  • a specific antibiotic protocol that includes dapsone for Lyme persisters,
  • how to take decrease side effects and Herxheimer reactions on dapsone,
  • the risks of using dapsone, and
  • the chances for treatment success using a dapsone regimen.

Marty Ross MD on Dapsone for Persister Lyme Treatment


Persisters in Lyme

Lyme disease is difficult to treat. While a majority of people do get better following the standard one to two months of antibiotics recommended by the CDC and the IDSA in acute Lyme, many do not. If Lyme treatment starts more than a month or so after the acute infection, it appears harder to treat.

There are a number of reasons Lyme is difficult to treat. One idea that is getting a lot of current attention is Lyme, like tuberculosis and leprosy, can develop persister cells. Persisters in Lyme are composed of the spirochetes, cysts, and biofilm communities that grow very slowly or not at all. These persisters essentially go into hibernation where they ignore the antibiotics a person takes. Faster-growing Lyme is much easier to treat, but persisters evade the immune system and the antibiotics we send to poison them.

This article is about dapsone for treating persisters. Adding dapsone is one way to address persisters, but there are a number of persister and treatment resistant Lyme approaches. Read more in How to Treat Persister Lyme. What Works?

Why Dapsone?

Dapsone is an antibiotic used to treat slow-growing persister bacteria. Because of this, it is regularly used to treat leprosy and a form of skin inflammation called dermatitis herpetiformis. It can also kill malaria. Therefore, it could help treat those with a Babesia coinfection. Finally, dapsone can lower inflammation in Lupus. So, it could control inflammation in Lyme.

Warning: Dapsone is a Harsh Drug

Dapsone in Lyme is a hard medicine to take. In fact, in my Seattle practice I saw 30 percent of patients could not tolerate this medicine and had to stop taking it. At the November 2017 International Lyme and Associated Diseases conference in Boston, Richard Horowitz MD, the pioneer of the dapsone approach, spoke of similar findings in his practice during his conference presentation.

  1. Check G6PD Levels Before You Start. Do not use dapsone if you have low Glucose-6-phosphate dehydrogenase (G6PD) deficiency. This condition mostly affects men. If a person has G6PD deficiency and they take dapsone, it could cause hemolysis (the tearing apart of the red blood cells). Before starting this medication, your physician should measure a G6PD blood test.
  2. Dapsone Blocks Folate Metabolism. Dapsone works by blocking folate metabolism in germs, but it also blocks folate metabolism in red blood cells leading to severe anemia. To prevent this consider taking up to 30 mg of folate a day while you are on this medication.
  3. Dapsone Suppresses the Bone Marrow. Red blood cells are manufactured in the bone marrow. Dapsone makes it harder for the bone marrow to make red blood cells. Although this is a separate method from folate metabolism interference, it also can lead to anemia. If anemia is a problem, lowering the dapsone dose can help.
  4. Dapsone in Lyme Causes Severe Herxheimer Reactions. I have seen some severe Herxheimer reactions using dapsone. As a result, I started all of my dapsone treatments at low doses and raised them slowly.
  5. Dapsone Has Many Side Effects. The list of dapsone side effects reads like a list of Herxheimer reactions. It can cause fever, muscle pain, headache, fatigue, dizziness, nausea, and joint pains. In addition, it can cause neuropathy, severe allergic reactions, and other problems.

Because of these problems, dapsone in Lyme is not suitable for everyone.

When to Use Dapsone in Lyme

So, when is the right time to use dapsone in a Lyme treatment?

  1. Try a persister regimen, like dapsone, for any person who has tried various oral herbal and prescription antibiotic regimens for Lyme over the course of a year or more and did not have good improvements. Before doing so, I try various approaches to move the treatment forward that I outline in Can't Get Better? Do This.
  2. Use dapsone as an alternative to a trial of IV antibiotics.
  3. Finally, consider dapsone for a person who has tried IV antibiotics, but who did not have good improvements.
  4. As I mention above, a person must have a normal G6PD level to try dapsone.
  5. Before proceeding with dapsone, review the other persister regimens. Read more about these in How to Treat Persister Lyme. What Works?

The Dapsone Lyme Persister Regimen

  1. Dapsone 25 mg. Start 1 pill every other day for 1 week, then increase to 1 pill daily for a week, then to 2 pills every other day, alternating with 1 pill every other day for a week, then to 2 pills every day. 50 mg is the minimum effective dose. If a person can tolerate this for a week, then continue increasing slowly up to 100 mg a day.
  2. Cefuroxime 500 mg 1 pill 2 times a day. Use this to treat the cell wall of the persister spirochetes and for growing forms of the spirochetes. Using this is based on the persister research and Ying/Yang model of Ying Zhang, MD.
  3. Rifampin 300 mg 2 pills 1 time a day. Use this to treat intracellular Lyme and to treat cyst forms of the germ. If rifampin is not tolerated, a second choice for cyst Lyme is grapefruit seed extract 250 mg 1 pill 2 times a day.
  4. Minocycline 100 mg 1 pill 2 times a day or Doxycycline 100 mg 1 pill 2 times a day or Biaxin 500 mg 1 pill 2 times a day or Zithromax 500 mg 1 pill 1 time a day. These antibiotics block protein production to treat intracellular Lyme. In this regimen these drugs are interchangeable.
  5. Liposomal Curcumin 500 mg 1 pill 3 times a day. Use this as a nutritional support because it may limit Herxheimer die-off reactions. If a Herx is bad, then increase to 2 pills 3 times a day. Liposomal Curcumin, which is microscopically wrapped in fat to increase absorption is better than regular curcumin.
  6. Liposomal Glutathione 400 to 500 mg 1 pill 2 times a day. As a nutritional support this also may limit Herxheimer reactions and help with detoxification. Read more in Glutathione: The Great Fixer (treatlyme.net).
  7. 5 MTHF 5 mg 3 to 6 pills 1 time a day. This is a methylated folate that may overcome the blockage of folate metabolism caused by dapsone.

Additional Notes

It is critical when doing this regimen to take the three nutritional support supplements I list above. The curcumin and glutathione may dramatically improve the problems with Herxheimer reactions and the 5 MTHF (folate) decreases the chances of anemia.

For a sensitive person who may have increased side effects and Herxheimer reactions in this regimen, do not use the Cefuroxime until the second or third month of the regimen. At times, it is not necessary to use the Cefuroxime at all based on the improvements. It is necessary in the beginning months on this regimen to test blood for anemia, kidney, and liver function monthly. Try this regimen for a minimum of six months before deciding if it helps a person or not. If it is helping, keep using it as long as a person is improving.

Does Dapsone for Lyme Persisters Work?

I have seen some wonderful improvements on this regimen. My best situation is a nurse who did years of IV antibiotics with minimal improvements before transferring her care to my Seattle practice. On a ten-point scale, she had energy of six to seven. After using dapsone for a few months, she returned to work as a nurse, experienced improved energy levels to nine out of ten, and reported normal thinking. On average, however, people have improvements of 10 to 20 percent. And as I noted earlier, about 30 percent of patients cannot tolerate the dapsone at all due to side effects. Like Horowitz, I saw improvements in about 59 percent of my patients.

My experiences seem similar to those reported by Horowitz in his study of 100 patients using a dapsone regimen. This regimen does offer hope and a path to improved health for many. I am encouraged by the work of Horowitz and others like Zhang who are researching ways to treat Lyme persisters.


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.


View Citations

  1. Horowitz R, Freeman PR. The use of Dapsone as a novel “persister” drug in the treatment of chronic Lyme disease/post treatment Lyme disease syndrome. J Clin Exp Dermatol Res. 2016;7:3. doi:10.4172/2155-9554.1000345.
  2. Feng J, Auwaerter PG, Zhang Y. Drug Combinations against Borrelia burgdorferi Persisters In Vitro: Eradication Achieved by Using Daptomycin, Cefoperazone and Doxycycline. PLoS ONE. 2015;10(3): e0117207. doi:10.1371/journal.pone.0117207.
  3. 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;59:4616–4624. doi:10.1128/AAC.00864-15.

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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 where he treated thousands of Lyme disease patients in his Seattle practice through late 2018. Marty is currently on sabbatical in Austin, TX. Dr. Ross plans to reopen his Seattle Lyme practice in early 2020.

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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