Liver diseases pose significant global health challenges, ranging from autoimmune disorders like primary biliary cholangitis (PBC) to genetic conditions such as Gilbert syndrome. Traditional treatments often fall short in managing symptoms like chronic itching, jaundice, and bile acid imbalances. However, recent research has unveiled a surprising ally in the fight against these conditions: ​rifampicin, a decades-old antibiotic best known for combating tuberculosis. Beyond its antimicrobial properties, rifampicin’s ability to modulate bile acid metabolism is offering new hope for patients with complex liver disorders.

​1. How Does Rifampicin Work in Liver Diseases?​​

Rifampicin’s therapeutic potential in liver diseases stems from its role as a ​pregnane X receptor (PXR) agonist. By activating PXR, this drug enhances the activity of enzymes and transporters involved in bile acid detoxification and elimination. Key mechanisms include:

• ​Induction of UDP-glucuronosyltransferase 1A1 (UGT1A1)​: Boosts the conversion of toxic bile acids into water-soluble forms for excretion.
• ​Upregulation of multidrug resistance-associated proteins (MRPs)​: Facilitates bile acid clearance from liver cells.
• ​Inhibition of cholesterol-7α-hydroxylase (CYP7A1)​: Reduces the production of bile acids, easing the burden on compromised livers.

These actions collectively alleviate symptoms like pruritus (itching) and hyperbilirubinemia (high bilirubin levels) while improving overall liver function.

​2. Applications Across Liver Disorders​

​a. Primary Biliary Cholangitis (PBC)​​

PBC is an autoimmune disease marked by progressive bile duct damage and severe itching. Standard treatments like ursodeoxycholic acid (UDCA) often fail to fully control symptoms. Rifampicin steps in as a ​second-line therapy​ by targeting the root cause of itchiness:

• ​Suppressing autotaxin (ATX)​: Lowers levels of lysophosphatidic acid, a key driver of itch-inducing bile acids.
• ​Modifying gut microbiota: Alters bile acid recycling in the intestines, reducing reabsorption.

Clinical trials show rifampicin (150–600 mg/day) significantly improves quality of life for PBC patients suffering from intractable pruritus.

​b. Persistent Hepatocellular Secretory Failure (PHSF)​​

PHSF is a rare, life-threatening condition characterized by massive bile accumulation. Rifampicin acts rapidly here:

• ​Activating OSTα/β transporters: Enhances bile acid clearance from liver cells.
• ​Short-term safety: Studies demonstrate normalization of bilirubin levels in 77% of patients within 1–10 weeks, with minimal side effects when used briefly (<2 weeks).

​c. Genetic Metabolic Liver Diseases​

• ​Gilbert Syndrome: This inherited disorder impairs UGT1A1 activity, causing harmless yet distressing jaundice. Rifampicin “tests” for the condition by temporarily boosting UGT1A1 activity, offering both diagnostic and therapeutic value. Long-term use (300–600 mg/day) normalizes bilirubin in severe cases.
• ​PFIC-1/BRIC-1: Mutations in the ATP8B1 gene disrupt bile flow. Rifampicin compensates by amplifying alternative detoxification pathways, reducing pruritus and hyperbilirubinemia in pediatric and adult patients alike.

​d. Intrahepatic Cholestasis of Pregnancy (ICP)​​

ICP endangers fetuses through premature birth and stillbirth. While UDCA is the first-line treatment, rifampicin offers synergistic benefits:

• ​Adjunct therapy: Combining rifampicin (300–1200 mg/day) with UDCA improves bile acid clearance in 54% of refractory cases.
• ​Safety profile: Unlike older therapies, rifampicin shows no teratogenic effects in pregnancy, though close monitoring is advised.

​3. Balancing Benefits and Risks​

While rifampicin’s efficacy is promising, its long-term use raises concerns about ​hepatotoxicity, particularly in patients with preexisting liver conditions. Experts recommend:

• ​Short-term use: Prioritize rifampicin for acute flare-ups or as adjunct therapy.
• ​Genetic screening: Tailor dosages based on patients’ PXR and CYP450 genotypes to optimize efficacy and minimize toxicity.
• ​Monitoring: Regular liver function tests are essential to detect early signs of liver stress.

​4. The Future of Rifampicin in Hepatology​

Current research highlights rifampicin’s versatility, but further studies are needed to refine its applications:

• ​Precision medicine: Develop gene-based dosing guidelines for optimal outcomes.
• ​Combination therapies: Explore synergies with other bile acid modulators (e.g., fibrates, obeticholic acid).
• ​Expanded indications: Investigate rifampicin’s role in non-alcoholic steatohepatitis (NASH) and other metabolic liver diseases.

Research on the Application of Rifampicin in Liver Diseases

1. Introduction

Rifampicin, a rifamycin-class antibacterial drug, inhibits bacterial DNA-dependent RNA polymerase and is active against various bacteria. It remains a commonly used drug for treating tuberculosis and atypical mycobacterial infections. However, its application in other diseases is limited due to potential liver damage during antituberculosis treatment. Recent studies have shown that rifampicin, as a pregnane X receptor (PXR) agonist, can promote glucuronidation and improve bile acid metabolism. Therefore, its application in chronic liver diseases has gradually increased.

2. Application in Different Liver Diseases

2.1 Primary Biliary Cholangitis (PBC)

PBC is an autoimmune cholestatic liver disease characterized by significant bile duct damage, chronic cholestasis, and eventual development of cirrhosis or liver failure. Approximately 60%-70% of patients experience itching, leading to fatigue, sleep disorders, depression, and even suicidal tendencies. Rifampicin is recommended as a second-line treatment for pruritus in cholestatic liver diseases. Its anti-itching effect is believed to be mediated by inducing biological transformation in the liver and intestines, downregulating the expression of autotaxin (ATX) in human liver-derived cell lines, and altering the metabolism and excretion of potential pruritogens. Additionally, rifampicin may change the gut microbiome, affecting the metabolism and absorption of bile salts and pruritogens.

2.2 Persistent Hepatocellular Secretory Failure (PHSF)

PHSF is a rare but life-threatening complication caused by drugs, toxins, infections, or transient biliary obstruction. A study by VAN DIJK et al. involving 13 PHSF patients treated with rifampicin (300 mg daily for 1-10 weeks) showed that 10 patients’ bilirubin levels returned to normal. Rifampicin induces organic solute transporter alpha/beta (OSTα/β) in human liver and intestinal cells in a PXR-dependent manner, enhancing the clearance of cholestatic toxins. It also downregulates cholesterol-7α-hydroxylase 1 (CYP7A1), reducing bile salt resynthesis. Short-term use of rifampicin (less than 2 weeks) appears safe for chronic cholestatic patients, while prolonged use (4-12 weeks) may lead to hepatotoxicity.

2.3 Genetic Metabolic Liver Diseases

2.3.1 Gilbert Syndrome

Gilbert syndrome is a benign genetic disorder characterized by elevated unconjugated bilirubin due to mutations in the uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1) gene. Rifampicin can induce cytochrome P450 (CYP450) enzymes and compete with the liver’s excretory pathways. The “rifampicin test” (measuring bilirubin levels before and after administering 900 mg of rifampicin) can help confirm Gilbert syndrome. Long-term use of rifampicin has been reported to reduce bilirubin levels in patients with severe unconjugated hyperbilirubinemia.

2.3.2 Progressive Familial Intrahepatic Cholestasis Type 1 (PFIC-1) and Benign Recurrent Intrahepatic Cholestasis Type 1 (BRIC-1)

PFIC-1 and BRIC-1 are rare autosomal recessive genetic diseases caused by ATP8B1 gene mutations, characterized by jaundice and pruritus. Rifampicin activates the PXR receptor, regulating CYP3A4 transcription and enhancing multidrug resistance-associated protein 2 (MRP2) expression. This reduces bile acid levels and alleviates symptoms such as jaundice and pruritus. Oral rifampicin (10 mg/kg/day or 300 mg/day) for 1-7 weeks has been shown to significantly decrease bilirubin levels in these patients.

2.4 Intrahepatic Cholestasis of Pregnancy (ICP)

ICP is a pregnancy-specific liver disease that can lead to adverse fetal outcomes. Ursodeoxycholic acid (UDCA) is the primary treatment, but some patients do not respond well. Rifampicin, as a CYP450 inducer, enhances bile acid detoxification and efflux, improving pruritus. Combined with UDCA, rifampicin (300-1200 mg/day) has been shown to improve serum bile acid levels in 54% of women with refractory ICP, with no significant adverse effects. Rifampicin has been safely used in pregnant women with tuberculosis, and no teratogenic, abortive, or preterm birth effects have been observed in current studies.

3. Conclusion

Recent studies have shown that rifampicin can improve chronic liver diseases by inducing bile acid excretion through various mediators such as UGT1A1, CYP450, and CYP3A4. While long-term use of rifampicin is associated with hepatotoxicity, short-term use in chronic liver diseases is safe and effective. Future research should focus on detecting drug-metabolizing enzyme gene polymorphisms to personalize dosing and administration intervals, maximizing efficacy while minimizing adverse reactions. Further high-quality clinical studies are needed to explore the indications for rifampicin in liver diseases.

Rifampicin’s journey from an antibiotic to a liver disease breakthrough underscores the power of repurposing existing drugs. By harnessing its unique ability to recalibrate bile acid metabolism, clinicians can now offer targeted relief to patients with PBC, PHSF, genetic cholestasis, and ICP. As research advances, rifampicin may soon become a cornerstone in personalized liver care—ushering in a new era where old drugs unlock innovative solutions for complex health challenges.