Rifaximin - possible not to build up resistance to?

Not really. It is not absorbed, or poorly, if at all. Any antibiotic you take consistently is at risk of bacterial resistance. Bacteria that are constantly exposed to the same antibiotic will promote resistant strains. This is why antibiotic rotation is recommended, or at the very least, antibiotic "holidays." 

Since it is the gut bacteria we are intending to suppress, it does not matter that the rifaximin is not absorbed. The difference is that you are not exposed to systemic antibiotic effects and side effects. That is the primary reason for using rifaximin.

Jan

Antibiotics for pouchitis are more complicated than an infection with a single bacterial species. There are thousands of different kinds of bacteria in the gut. Different bacteria differ in their ability to develop resistance, and different antibiotics differ in their tendency to cause resistance. Long-term use of a single antibiotic isn't ideal, but it sometimes works fine, particularly in the several-year time-frame. If your son can find a couple of other antibiotics that work for him it might be better to rotate between them every 2-3 weeks. If he can't find any others that work, I empathize - that's my situation. So far, so good.

Thank you Jan and Scott. Given the long term usage we have been happy to keep him on rifximin because of the lack of absorption/impact outside the gut. But I guess we still run the risk of resistance. He did become resistant to Augmenting, even while we were rotating that. 

Rifaximin is one of the antibiotics that I used to have in the rotation but it became less and less effective over time and I've stopped it recently. I had tried upping the dosage but it still worked no where near as well as Cipro (my most effective antibiotic) or Flagyl (my 2nd most effective). I also stopped Augmentin long ago for the same reasons. My pouch likes to be difficult I guess.

I had mixed feelings about this as Rifaximin should be the "easiest" on the system overall for side effects and I had the least amount of worry about long term usage with it, but on the other hand it was really expensive and I had to pay for it and that was hurting too. That said, I'd pay almost anything for a pill that "fixed me 100%".......still waiting on that one though, haha.

I built up a resistant 2 times on rifaximim and both times could not get my pouchitis under control and had to switch to a bio drug. I loved being on it. I felt great. The first time I got about 2.5 years. Went back on after 3 years and got about 1.5 years. Hope your don stays healthy.

ah such an interesting discussion. i am curious for those who take Xifaxan whats your dosing?

10 years ago it was used as one of 3 rotating antibiotics monthly, the other two were Augmentin and Flagyl. i wasn't convinced back then that it did much for me, and as i vaguely recall i was on a lower dose than i tried in December. curiously in December while i initially saw benefit by the end of the 2 week course i would argue i had lost efficacy.

this last time i was taking 2x 550mg. i wonder if my dosing should be higher?

My son had tried rifaximin 2x and it had not worked. Dr. Shen suggested trying a very high dose.  My son went on 2200 a day with cipro ( which had worked for him). He titrated off cipro and then slowly ( cannot remember exactly how long but probably longer than a month) titrated down to 550 rifaximin daily.  He has now been on  it since March 2014 ( along with humira and methotextrate since October 2014, and final step of J pouch April 2013).

Boys mom, why keep the rifaximim if he's on humors snd methotrstrate. After both my flares on rifaximim I was only on Remicade and this latest now I'm only on Entyvio. 

I took 550 x 2

going up while flaring and adding other UC meds did nothing.

im convinced that taking antibiotics just ruin your gut flora and leads to no good. Not that I like taking a bio drug but I'd rather keep my pouch.

My son did not do well after he had the third step of the J pouch surgery  in April 2013 at age 12.  He was feeling ill, not sustaining his weight and having inflammation, so in October 2013 we added humira and methotextrate ( after severe allergic reaction to remade). He continued  to feel unwell, though humira did improve his labs. (We were even considering a re-do of his pouch because we learned at Cleveland Clinic that his surgeon had left too much rectum. ) It wasn't really until he both changed his diet which he started doing in November 2013 and got on rifaximin steadily in March 2014 that he really started feeling better and was able to participate in life more fully. 

So, I think about taking him off rifaximin and was investigating other possibilities ( herbs like coptus or berberine that I think would fight SIBO issues) but we are a bit scared to do anything --when everything is going well and he still needs to get through puberty.  I actually thought he could go off humira perhaps, since to me it seemed like the rifaximin and diet were so key. But we tried spacing out humira and inflammation seemed to be creep back in. Then he got 1 antibody when his humira was low and the doctor got nervous. So now that it looks like he won't go off humira I would like to get him off methotextrate. However, anytime things seem stable to try something new - something happens - campylobacter, a cold, a little unexplained inflammation - and the terror of having him not be well in puberty has prevented any changes. 

Allykat, I appreciate your asking though - and I will continue to think about ways that he can make a change, especially hearing that the rifaximin stopped working at various points for you. Thanks.

Boys Mom as a mother myself I pray that your little boy continues to do well. ((( healing hugs)))

You may want to make inquiries about a pouch advancement surgery. It sounds like the retained rectal cuff is a big source of his problems. Pouch advancement is not as major as a pouch redo. You keep the pouch and they just remove the remaining rectal cuff. Usually it does not eve require an abdominal incision, as it is done transanally. The main concern is whether his mesentery can "reach." Perhaps the original surgeon left too much rectum because of the lack of reach. His records should reveal that info.

Jan

Thank you Jan. The original surgeon will not acknowledge that he left too much rectal cuff.  The Cleveland Clinic surgeon said he would require a whole pouch redo - I think if they cut the cuff now, there would be not enough length to do the reconnection.  It seems that so much risk is involved whether things would work right and then the mental stress as well - that once he reached a stable point where he could get to school we stopped thinking about surgery. I am still very concerned that he is on all these drugs though from such a young age.

the drugs keep us alive! lol. just kidding but trying to balance our natural instinct to resist taking drugs. in an ideal world we would live a high or reasonable quality of life without any meds but alas many of us are not so destined to do so.

I think your strategy of weaning with observation is a good one. I shall presume that while on Humira and Methotrexate that he has the joy of taking monthly blood work to monitor?

I am unclear what happened with Remicade but perhaps reflexively the doc decided to add Methotrexate to ward the potential buildup of antibodies? I believe this is one of the factors that explain the success of pairing a biologic with an immunomodulator per the SONIC trial. The risk of stopping a biologic med that is working is that your son develops antibodies to that biologic and you lose a med that had been effective. for whatever reason, we each respond potentially differently to meds. if we find one that is effective I would really be gun shy about stopping it. I have seen many a patient that thought they could stop and restart, with biologics it is not that simple. not sure about immunomodulators.

Responding re the remicade - My son had a severe allergic reaction to remicade ( went by ambulance from dr's office to hospital). So that is another factor that worries me about trying to go off humira - if he needed to go back on serious drugs - few options. We are trying him off methotextrate now - monitoring his humira levels. Maybe try going off rifaximin later...

There are other biologics than Humira and Remicade. Remicade is the main one that allergic reactions and antibody production is a concern. This is because it is based on mouse protein (it is on of the earliest biologics). All the others are fully humanized proteins (except Enbrel, which isn't for IBD anyway).

Failure of one biologic does not mean you will fail others. But, even if you do, you can just keep trying for better results. I am on my fourth biologic, and never even tried Remicade. The main reason I went off Humira was because I really disliked the sting during injection, and I needed weekly injections. I am currently on Cimzia, which I take every two weeks.

Jan

Candidly it might have been an overzealous reaction to pair methotrexate to ward potential reaction given his stark reaction to Remicade, but given the circumstances perhaps understandable. But as Jan already described the more violent reactions tend to happen with Remicade because of the mouse component. 

Regardless of water under the bridge. I wholeheartedly agree with some of what you seem to be expressing. I would personally discourage eliminating biologic therapies if they are working. I have seen numerous switches, often for convenience only to discover the new med isn't effective. while in some respects these meds are interchangeable, if a med is working, I would really be hesitant to switch.

That said, there are new biologics coming to market, Simponi, Entyvio, Stelara were all not available until recently. And there are more promising ones in the pipeline. But I wouldn't be discarding meds when they work. Quality of life is important factor in weighing the use of meds from my point of view.