Rifampicin (Rifampicin)
Also sold as: Rimactane, Rifadin, R-Cinex, Forrest
Pregnancy
Cat C
Lactation
Caution
Schedule
H1
Forms
Capsule 150mg +4
Indications
- Tuberculosis (first-line DOTS regimen)
- Leprosy (multibacillary and paucibacillary)
- Meningococcal prophylaxis
- Staphylococcal infections with biofilm or device involvement (adjunct)
- Brucellosis (with doxycycline)
Adult Dosing
Tuberculosis — intensive phase (2 months)
10 mg/kg OD (max 600 mg)
Once daily for 2 months (intensive phase)
Part of DOTS regimen with isoniazid, pyrazinamide, ethambutol; take on empty stomach 30 min before food
Tuberculosis — continuation phase (4 months)
10 mg/kg OD (max 600 mg)
Once daily for 4 months (continuation phase)
With isoniazid; directly observed therapy preferred
Meningococcal prophylaxis
600 mg BD
Twice daily for 2 days
Post-exposure prophylaxis for close contacts of meningococcal disease
Leprosy (multibacillary)
600 mg once monthly (supervised)
Monthly for 12 months (with dapsone + clofazimine)
Part of WHO multi-drug therapy (MDT) for leprosy
Staphylococcal biofilm/device infections (adjunct)
300–450 mg BD
Duration per specialist guidance
Always used in combination; never as monotherapy due to rapid resistance development
Pediatric Dosing
For TB: 15 mg/kg OD in children is standard; syrup formulation available
Renal Dose Adjustment
| CrCl / eGFR | Dose Adjustment |
|---|---|
| CrCl ≥30 mL/min | No dose adjustment required |
| CrCl <30 mL/min | Use with caution; not significantly renally cleared — standard dose usually used |
Hepatic Adjustment
Contraindicated in severe hepatic impairment. Use with caution in mild-to-moderate hepatic disease; reduce dose or extend interval. Monitor LFTs closely. Avoid if bilirubin >2× ULN at baseline.
Pregnancy & Lactation
Pregnancy: Category C
Use when TB treatment benefit outweighs risk. Rifampicin used in standard DOTS regimen in pregnancy. May cause neonatal bleeding — give vitamin K to mother and neonate near term. Avoid in first trimester if possible.
Lactation: Caution
Excreted in breast milk in small amounts. Generally considered acceptable during TB treatment — WHO supports breastfeeding with TB therapy. Monitor infant.
Top Drug Interactions
| Interacting Drug | Effect | Severity |
|---|---|---|
| Warfarin | Potent CYP450 inducer — markedly reduces warfarin levels; INR may fall dramatically within days of starting rifampicin | Major |
| Oral contraceptive pills (OCPs) | Induces CYP3A4 — significantly reduces OCP efficacy; use non-hormonal contraception throughout TB treatment and for 1 month after | Major |
| Antiretrovirals (PIs, NNRTIs) | Dramatic reduction in antiretroviral levels; rifabutin preferred over rifampicin in HIV-TB co-infection when on ART | Major |
| Azole antifungals (fluconazole, itraconazole, voriconazole) | Rifampicin induces CYP3A4/2C9 — reduces antifungal plasma levels by up to 90%; combination generally avoided | Major |
| Phenytoin | Reduces phenytoin levels via CYP2C9/2C19 induction — monitor levels and increase phenytoin dose as needed | Major |
| Methadone | Rifampicin induces CYP3A4 — can precipitate opioid withdrawal; substantial dose increases of methadone often required | Major |
| Digoxin | Induces P-glycoprotein — reduces digoxin levels; monitor digoxin and titrate dose | Moderate |
| Isoniazid | Additive hepatotoxicity — used together in TB regimen but monitor LFTs monthly | Moderate |
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Side Effects
Common
- Orange-red discoloration of urine, tears, sweat, sputum, and other body fluids (harmless — warn all patients)
- Nausea and vomiting (take on empty stomach or with light meal if intolerable)
- Headache, dizziness
- Flushing
- Pruritus (itching) without rash
Serious / Discontinue If
- Hepatotoxicity (transaminase elevation, jaundice, fulminant hepatic failure — rare but fatal)
- Thrombocytopenia (especially with intermittent high-dose regimens)
- Flu-like syndrome — fever, chills, myalgia (more common with intermittent dosing)
- Haemolytic anaemia
- Acute renal failure (rare, immune-mediated — with intermittent dosing)
- Drug reaction with eosinophilia and systemic symptoms (DRESS)
Contraindications
- Severe hepatic impairment or active liver disease
- Hypersensitivity to rifamycins
- Concurrent saquinavir/ritonavir ART (without expert guidance)
- Jaundice (do not start until resolved)
Available Indian Brands
| Brand | Manufacturer | Price (approx) |
|---|---|---|
| Rimactane 150mg | Novartis | ₹28/10 tab |
| Rifadin 300mg | Sanofi | ₹45/10 tab |
| R-Cinex (Rifampicin+Isoniazid combo) | Lupin | ₹32/10 tab |
Monitoring Required
- Baseline LFTs (ALT, AST, bilirubin, ALP) before starting
- Monthly LFTs during treatment — stop if ALT >3× ULN with symptoms or >5× ULN asymptomatic
- FBC — watch for thrombocytopenia
- Review all concurrent medications for drug interactions at every visit
- INR monitoring if on warfarin (check weekly when starting/stopping rifampicin)
- OCP counselling — switch to non-hormonal contraception
Patient Counseling Points
- Your urine, tears, sweat, and saliva will turn orange-red — this is harmless and expected; do not be alarmed
- Soft contact lenses will be permanently stained orange — avoid wearing them during treatment
- Take on an empty stomach (30 minutes before food) for best absorption
- Never stop this medicine without telling your doctor — stopping and restarting can cause serious reactions
- Tell your doctor about ALL medicines, including vitamins and herbal products — rifampicin interacts with many drugs
- If you use the pill (OCP) for contraception, you must use additional non-hormonal protection during treatment and for 1 month after stopping
- Report immediately: yellowing of eyes/skin, dark urine (not the expected orange), unusual bleeding or bruising, high fever
- Complete the full course — stopping early causes drug resistance which is very difficult to treat
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Clinically reviewed by: Dr. Anand Kumar, MD (Pulmonology), Chest Physician, TB & Chest Hospital, New Delhi
Last reviewed: 2026-04-30
References
- WHO Treatment of Drug-Susceptible Tuberculosis Guidelines, 2022
- Revised National Tuberculosis Control Programme (RNTCP) DOTS Guidelines, India
- WHO MDT Guidelines for Leprosy, 2018
- Central TB Division, Ministry of Health & Family Welfare, India — National Strategic Plan for TB Elimination 2017–2025
- Micromedex Drug Interactions — Rifampicin, 2024
- BNF (British National Formulary) — Rifampicin monograph, 2024