Dapsone for Lyme Persisters. A Miracle Antibiotic?

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Dapsone for a Lyme disease treatment image from Marty Ross MD

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% 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.

Persisters in Lyme

Lyme disease is hard to treat. While a majority of people do get better following the standard 1 to 2 months of antibiotics recommended by The US Centers for Disease Control and Prevention and The Infectious Diseases Society of America in acute Lyme, many do not. And if Lyme treatment starts more than a month or so after the acute infection, it appears harder to treat.

Persisters in Lyme

Lyme disease is hard to treat. While a majority of people do get better following the standard 1 to 2 months of antibiotics recommended by The US Centers for Disease Control and Prevention and The Infectious Diseases Society of America in acute Lyme, many do not. And 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 hard 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 forms 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 I address persisters. But there are a number of persister and treatment resistant Lyme approaches I use in my practice. 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 also can kill malaria. So it could help treat those with a babesia coinfection. Finally, it 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 practice I see that 30% of people cannot tolerate this medicineand have 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.

  • Check G6PD Levels Before You Start. Do not use Dapasone if you have low Glucose-6-phosphate dehydrogenase (G6PD) deficiency. This condition mostly effects men. If a person has G6PD deficiency and they take Dapsone, it could cause hemolysis (tearing apart of the red blood cells). So before starting this medication, your physician should measure a G6PD blood test.
  • 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. So you should take up to 30mg of folate a day while you are on this medication.
  • 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. This is a separate method from folate metabolism interference that also can lead to anemia. If anemia is a problem, lowering the Dapsone dose can help.
  • Dapsone in Lyme Causes Severe Herxheimer Reactions. I have seen some severe herxheimer reactions using Dapsone. Because of this I now start all of my dapsone treatments at low doses and raise them slowly.
  • 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 to these it can cause neuropathy and severe allergic reactions in addition to other problems.

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

When to Use Dapsone in Lyme

So when do I use Dapsone in my practice?

  • I recommend 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 who are not having good improvements. Before doing so I also try various approaches to move the treatment forward that I outline in the chapter Can't Get Better? Do This.
  • I also recommend it as an alternative to a trial of IV antibiotics for such people.
  • Finally I recommend it for a person who has tried IV antibiotics but who did not have good improvements.
  • As I mention above, a person must have a normal G6PD level to try Dapsone.

Before proceeding with Dapsone, I also review the other persister regimens I use in my practice. Read more about these in How to Treat Persister Lyme. What Works?

The Dapsone Lyme Persister Regimen

1. Dapsone 25mg. 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. I find 50mg is the minimum effective dose. If a person can tolerate this for a week, then I continue increasing working slowly up ot 100mg a day.

2. Cefuroxime 500mg 1 pill 2 times a day. I use this to treat the cell wall of the persister spirochetes and for growing forms of the spirochetes. I have chosen this based on the persister research and Ying/Yang model of Ying Zahng MD. (REFERENCE)

3. Rifampin 300mg 2 pills 1 time a day. I 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 250mg1 pill 2 times a day.

4. Minocycline 100mg 2 times a day or Doxycyline 100mg2 times a day or Biaxin 500mg1 pill 2 times a day or Zithromax 500mg1 pill 1 time a day. These antibiotics block protein production to treat intracellular Lyme. In this regimen, I consider them interchangeable.

5. Liposomal Curcumin 500mg 1 pill 3 times a day. I use this to limit herheimer die-off reactions. If a herx is bad, then increase to 2 pills 3 times a day. I prefer liposomal curcumin which is microscopically wrapped in fat to increase absorption. Read more about how to limit herxheimer reactions in Herxheimer Reactions: Inflammation Run Amok.

6. Liposomal Glutathione 400 to 500mg 2 times a day. This also limits herxheimer reactions and helps with detoxification. Read more in Glutathione: The Great Fixer.

7. 5 MTHF 5mg 3 to 6 pills 1 time a day. This is a methylated folate used to overcome the blockage of folate metabolism caused by Dapsone.

Additional Notes

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

At times, if I am concerned about how a person will handle side effects and the herxheimer reaction in this regimen, I may not use the Cefuroxime until the second or third month of the regimen. At times, I do not find it necessary to use the Cefuroxime at all based on the improvements I see. It is necessary in the beginning months on this regimen to test blood for anemia, kidney and liver function monthly. At this time I try this regimen for a minimum of 6 months before I decide if it helps a person or not. If it is helping, I will 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. To date my best situation is a nurse who I treat who did years of IV antibiotics before transferring her care to me with minimal improvements. She had energy on a 10 point scale of 6-7/10. After using Dapsone for a few months, she is now returning to work as a nurse and experiencing improved energy levels of 9/10 and normal thinking. However, on average people I try on this regimen have improvements of 10 to 20%. And as I noted earlier, about 30 percent of patients cannot tolerate the Dapsone at all due to side effects. Like Horowitz I do see improvements in about 59% of my patients.

My experiences seem similar to those reported by Horowitz in his study of 100 patients using a Dapsone regimen. But 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.

References

1. Horowitz, Richard & Freeman, Phyllis R.. (2016). The Use of Dapsone as a Novel “Persister” Drug in the Treatment of Chronic Lyme Disease/Post Treatment Lyme Disease Syndrome. Journal of Clinical and Experimental Dermatology Research. 07. 10.4172/2155-9554.1000345.

2. Feng J, Auwaerter PG, Zhang Y (2015). Drug Combinations against Borrelia burgdorferi Persisters In Vitro: Eradication Achieved by Using Daptomycin, Cefoperazone and Doxycycline. PLoS ONE 10(3): e0117207. https://doi.org/10.1371/journal.pone.0117207

3. Sharma B, Brown AV, Matluck NE, Hu LT, Lewis K. (2015). Borrelia burgdorferi, the causative agent of Lyme disease, forms drug-tolerant persister cells. Antimicrob Agents Chemother 59:4616–4624. doi:10.1128/AAC.00864-15

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