MAC big 3 meds dietary restrictions

Posted by beverlylynn @beverlylynn, Jun 2, 2025

I am just starting the azithromycin, ethambutal and riframycin for MAC. I am reading things like no caffeine, no alcohol, dairy 3 hours after meds, no white bread, stay away from sweets, no grapefruit , etc. I am wondering how those on the meds are managing their diets. Thank you

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Profile picture for Sue, Volunteer Mentor @sueinmn

Could someone share their documentation about dietary restrictions? I would be especially interested in a dietary plan provided by a nutritionist associated with a specialty clinic like NJH.
I was not only treated by a Pulmonologist and an ID Doc who did not give me restrictions, but my treatment plan was reviewed with a Clinical Pharmacist.
Other than no alcohol to spare the liver, timing issues like no antacids within x hours of this med, and per Pharm D no iron during an active infection unless prescribed for anemia, I truly don't remember specific dietary restrictions.
Obviously, a healthy diet is always beneficial, but with the weight-loss and appetite-loss issues many of us suffer with a MAC infection and the side effects of the meds, unnecessarily restricting ones diet can make this even harder. So I want to be sure what we are sharing is soundly based in science/research, not just from comments other have made on Connect or other MAC and Bronchiectasis sites.
Thanks for helping share the best possible information in our group!
Sue

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Sue-
I don't believe there is anything saying you cannot have dairy while on antibiotics. What I have understood was the timing of having dairy (calcium) foods with consideration of the timing and taking of the antibiotics.
Don't know if this is worthy from National Library of Medicine: https://www.ncbi.nlm.nih.gov/books/NBK361005/
Quote: "What food can you take antibiotics with?
Antibiotics are usually taken with water because taking them together with fruit juices, dairy products or alcohol can affect how the body absorbs some of them. Dairy products include milk, butter, yogurt, and cheese. After taking an antibiotic you may need to wait for up to three hours before eating or drinking any dairy products. Grapefruit juice and dietary supplements containing minerals like calcium may also lessen the effect of antibiotics."
Barbara

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Profile picture for debbie620 @debbie620

I was daily free 100% of the time on meds.
Yes the avoid all sugars was to avoid yeast which infections feed on.
We have to remember it's temporary. I was a huge dairy eater before and lost my taste for it good. Just recently added back plain yogurt

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I have osteoporosis, so calcium is an essential part of my diet. Best to get calcium from foods and not from lab created sources.
Thought?

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Profile picture for deb182 @deb182

I have osteoporosis, so calcium is an essential part of my diet. Best to get calcium from foods and not from lab created sources.
Thought?

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You do NOT need to avoid calcium foods while taking the Big 3 - using the Drugs.com Interaction Checker (https://www.drugs.com/drug_interactions.html) I entered Arithromycin, Ethambutol and Rifampin.

The NIH document cited by @blm1007blm1007 was a good general explanation of using antibiotics, but since we take the "Big 3" in combination and for a long time, it is good to know the specific requirements for each medication.
Here is what I found.
Rifampin There were no cautions to avoid calcium, but there is a list of a few foods to avoid. And a caution to take it one hour before or two hours after a meal.

Azithromycin There were no cautions about specific foods. Mixed results regarding use of aluminum containing antacids. Recommended taking one hour before or two hours after a meal. (Mixed results with current macrolide study. https://pmc.ncbi.nlm.nih.gov/articles/PMC11531826/)

Ethambutol Take with food to avoid stomach irritation. Do not use aluminum containing antacids within 4 hours of dosage.

I am still looking for the research-based dietary restrictions. Of course if one is allergic to certain foods, they should be avoided, and a healthy diet is always a good idea.

One long-held belief is that dairy products thicken mucus, and should thus be avoided by people with mucus producing conditions. According to Dr Pamela McShane, that theory is more folk medicine than reality. So unless you are lactose intolerant or allergic to milk, enjoy it!

But there are few, if any absolutes. I lost my taste for coffee while on the Big 3, but soon after I resumed drinking my mug of cafe con leche every morning, and do have the occasional second or third cup - but my essential tremor reminds me to avoid doing so very often. Also, avoiding alcohol is a sound precaution because both it and rifampin are hard on the liver.

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Profile picture for Sue, Volunteer Mentor @sueinmn

You do NOT need to avoid calcium foods while taking the Big 3 - using the Drugs.com Interaction Checker (https://www.drugs.com/drug_interactions.html) I entered Arithromycin, Ethambutol and Rifampin.

The NIH document cited by @blm1007blm1007 was a good general explanation of using antibiotics, but since we take the "Big 3" in combination and for a long time, it is good to know the specific requirements for each medication.
Here is what I found.
Rifampin There were no cautions to avoid calcium, but there is a list of a few foods to avoid. And a caution to take it one hour before or two hours after a meal.

Azithromycin There were no cautions about specific foods. Mixed results regarding use of aluminum containing antacids. Recommended taking one hour before or two hours after a meal. (Mixed results with current macrolide study. https://pmc.ncbi.nlm.nih.gov/articles/PMC11531826/)

Ethambutol Take with food to avoid stomach irritation. Do not use aluminum containing antacids within 4 hours of dosage.

I am still looking for the research-based dietary restrictions. Of course if one is allergic to certain foods, they should be avoided, and a healthy diet is always a good idea.

One long-held belief is that dairy products thicken mucus, and should thus be avoided by people with mucus producing conditions. According to Dr Pamela McShane, that theory is more folk medicine than reality. So unless you are lactose intolerant or allergic to milk, enjoy it!

But there are few, if any absolutes. I lost my taste for coffee while on the Big 3, but soon after I resumed drinking my mug of cafe con leche every morning, and do have the occasional second or third cup - but my essential tremor reminds me to avoid doing so very often. Also, avoiding alcohol is a sound precaution because both it and rifampin are hard on the liver.

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Thank you, Sue, for doing this work. I think it's important for us to remember not to generalize information about drugs. They are different compounds with different interactions and the precautions needed vary from drug to drug.

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