Pills

Pickups

Hearts

Coins

Bombs

Keys

Batteries

Pills

Cards/Runes

Chests

Sacks

Pills are pickups that can provide useful or inhibiting effects. They take up the same slot as cards and runes.

At the start of each run, an effect is randomly assigned to each color of pill. The pill effect for each color will remain constant throughout the run. (However, it is possible for PHD, Virgo, False PHD, or Lucky Foot to reassign some of the effects, such that 2 different colored pills will have the same effect.) Pills start the game unidentified (unless the player is holding PHD or False PHD); their effect is shown as "???" when picked up. Upon using a particular pill for the first time, its effect will be revealed and all subsequent pills with the same color will have their effect shown as well. The set of pill effects for any given run is usually known as the pill pool.

• The pill pool for each run has increased from 9 to 13.

Pill Effects

ID	Pill	Polarity	Class	Effect	Horse Pill Effect
0	Bad Gas	N	1	Isaac farts, dealing 5 damage and poisoning enemies around him.	The poison affects all enemies in the room.
1	Bad Trip	-	2	Deals a full heart of damage to Isaac. Using a Bad Trip pill while Isaac only has a single heart left or less turns it into a Full Health pill. This doesn't count as damage for the purposes of Devil Room/Angel Room generation odds or score reduction.	Deals two hearts of damage. If Isaac would not survive, the pill becomes Full Health.
2	Balls of Steel	+	2	Grants Isaac two soul hearts.	Grants four soul hearts.
3	Bombs Are Key	N	2	Swaps the values of Isaac's Bombs and Keys. The effects of Golden Bombs and Golden Keys are also swapped.	The number of bombs and keys is increased by 50% while swapping.
4	Explosive Diarrhea	N	1	Spawns a lit bomb behind Isaac every second for five seconds.	Spawns more bombs with the effects of Mr. Mega and Bobby-Bomb.
5	Full Health	+	2	Refills every empty red heart container.	Fully heals and grants 3 soul hearts.
6	Health Down	-	3	Removes one red heart container. Acts as a Health Up pill if Isaac has one or fewer red heart containers. Characters who cannot have red heart containers will lose one heart.	Removes two heart containers. if Isaac has 0 or 1 heart containers, the pill becomes Health Up and if he has 2 with no other types of health, they are removed and he is given half a soul heart.
7	Health Up	+	3	Adds one empty red heart container.	Adds two empty red heart containers.
8	I Found Pills	N	0	Changes the appearance of Isaac's face. This pill is cosmetic only, and the effect disappears when Isaac leaves the room.	Isaac's face gets a permanent, very exaggerated expression resembling a horse.
9	Puberty	N	0	Causes Isaac to grow four hairs from the top of his head and zits on his face. This pill is cosmetic only and will stay for the rest of the run. Consuming three puberty pills will grant the Adult transformation, granting one red heart container and making Isaac's voice slightly deeper (one time effect).	Isaac gains very fluffy hair covering his entire head and even face.
10	Pretty Fly	+	2	Grants a fly orbital, up to 3 maximum, that circles the player, blocking projectiles and damaging fly-type enemies on touch.	Spawns a Big Fan. There is no upper limit. These Big Fans do not contribute towards the Beelzebub transformation.
11	Range Down	-	3	-2.00 range. -1.00 range.	-2.00 range.
12	Range Up	+	3	+2.50 range. +1.25 range.	+2.50 range.
13	Speed Down	-	3	-0.12 speed.	-0.24 speed.
14	Speed Up	+	3	+0.15 speed.	+0.30 speed.
15	Tears Down	-	3	-0.28 tears.	-0.56 tears.
16	Tears Up	+	3	+0.35 tears.	+0.70 tears.
17	Luck Down	-	3	-1 luck.	-2 luck.
18	Luck Up	+	3	+1 luck.	+2 luck.
19	Telepills	N	1	Teleports Isaac to a random room. Has a small chance to teleport Isaac to the I AM ERROR room, and an extremely small chance to teleport him to the Black Market, like Undefined. Unobtainable in Greed Mode. Using a Telepills in the mirrored version of Downpour/Dross II has a chance to teleport Isaac to an Ultra Secret Room.	No difference.
20	48 Hour Energy	+	2	Drops one to two Lil' Batteries and fully charges the spacebar item. Can be used with Placebo or D1 to generate infinite batteries.	Spawns 3-4 batteries.
21	Hematemesis	N	2	Sets Isaac's red heart health to 1, then spawns 1-4 Red Hearts. This fills Isaac's first red heart container (even if Isaac's red health is less than 1) and empties the rest, including Bone Hearts. This effect does not count as damage. If used without any red heart containers, no health will be deducted, but red hearts will still spawn. If used in aSuper Secret Room containing a Black Heart or Eternal Heart, it will spawn those types of hearts instead.	Spawns 4-7 hearts.
22	Paralysis	-	1	Prevents Isaac from moving and shooting for 2 seconds.	The effect lasts 4 seconds.
23	I can see forever!	+	2	Opens all entrances to the Secret Room and Super Secret Room for the current floor.	In addition to the normal effect, fully reveals the map like The Mind.
24	Pheromones	+	1	Charms all enemies in the room for a short period of time.	The charm is permanent, turning the enemies friendly.
25	Amnesia	-	2	Replaces the floor map with a ? for the rest of the floor, identical to the effect of Curse of the Lost. If no other curses are active for the floor, the Curse of the Lost will appear under the level name when the map key is held. This effect can be negated by picking up Black Candle, but will not prevent future uses of the Amnesia pill from giving the Curse of the Lost effect. Also the only pill to have its flavor text appear on a piece of paper as curses do.	No difference.
26	Lemon Party	N	3	Spawns a large yellow pool (similar to Lemon Mishap) around Isaac. Greatly damages any enemy that steps on it, for 22 damage per tick or 66 damage per second.	The puddle is larger, covering nearly the entire room if used near the center.
27	R U a Wizard?	-	1	Tears are shot diagonally outwards for 30 seconds, making it much harder to aim. This effect will persist between rooms until it wears off.	The effect lasts for 60 seconds.
Afterbirth
28	Percs!	+	1	For the duration of the room, taking damage only removes a half-heart from Isaac's HP, regardless of the source of the damage. (Similar effect toThe Wafer's) Unlocked by: Complete PAY TO PLAY (challenge #24).	No difference.
29	Addicted!	-	1	For the duration of the room, taking damage removes a full heart from Isaac's HP, regardless of the source of the damage. Also changes Isaac's appearance for the room. Unlocked by: Complete PAY TO PLAY (challenge #24).	No difference.
30	Re-Lax	N	0	Spawns Poop at Isaac's position for a few seconds. A higher speed stat means Isaac can cover more tiles in poop in the same time. A pun on laxatives. Unlocked by: Complete Have a Heart (challenge #25).	The effect lasts much longer.
31	???	-	1	Gives the Curse of the Maze effect for the remainder of the floor. The effect can stack with other curses. If no other curses are active for the floor, Curse of the Maze will appear under the level name when Tab is held. This effect can be negated by picking up Black Candle, but will not prevent future uses of the ??? pill from giving the Curse of the Maze effect. As the pill's name is "???", the same as what unidentified pills are referred to, it is easy to accidentally use it more than once per run. It is recommended to memorize its color upon first using it. Unlocked by: Complete Have a Heart (challenge #25).	No difference.
32	One makes you larger	N	1	Increases Isaac's size and decreases the pitch of his voice. This effect does not increase the size of Isaac's hitbox, but increases the size of The Forgotten's bone club. These pills contribute to the Stompy transformation.	Size increases by two steps.
33	One makes you small	N	1	Decreases Isaac's size and increases the pitch of his voice. This effect decreases the size of Isaac's hitbox; a small enough hitbox allows Isaac to walk "under" certain projectiles to avoid them.	Size decreases by two steps.
34	Infested!	+	1	Destroys all poop in the room and spawns a single blue spider under Isaac and on each destroyed poop.	Double the number of spiders spawned.
35	Infested?	+	1	Spawns blue spiders equal to the number of enemies in the room. If there are no enemies in the room, spawns 1-3 Blue Spiders.	Double the number of spiders spawned.
36	Power Pill!	+	1	Temporarily grants invulnerability, inflicts fear on enemies in the room, lets Isaac deal contact damage, and has a chance to replenish a Half Red Heart every time an enemy is killed, similar to The Gamekid.	In addition to the normal effect, grants Huge Growth for +7 flat damage and +3 range. The Huge Growth bonus persists after the Gamekid wears off.
37	Retro Vision	-	1	Applies a pixelating filter on the screen 3 times over 30 seconds. The effect continues between floors. Pixelates the screen and degrades colors for 30 seconds.	The effect lasts 90 seconds, with no breaks.
38	Friends Till The End!	+	1	Spawns three blue flies.	Spawns 12 blue flies.
Afterbirth †
39	X-Lax	-	0	Creates a pool of slippery brown creep underneath Isaac.	The pool lasts much longer.
40	Something's wrong...	+	0	Creates a pool of black creep beneath Isaac that slows enemies.	The pool lasts much longer.
41	I'm Drowsy...	N	1	Slows all enemies for the duration of the room. Applies the Stop Watch effect, slowing all enemies, Isaac, and the background music as well as additionally applying the Slowness status effect on every enemy for the duration of the room.	No difference.
42	I'm Excited!!!	N	1	Increases the speed of all enemies for the duration of the room. Increases the speed of all enemies, Isaac, and the background music for the duration of the room. The effect triggers again three additional times.	No difference.
43	Gulp!	+	2	Destroys any trinkets held by Isaac and grants their effects permanently. Unlocked by: Complete a Victory Lap by defeating The Lamb.	Heals one red heart per gulped trinket (Up to 2 at the same time with Mom's Purse). No effect for characters who cannot have red hearts. This counts for two gulp pills toward the Marbles achievement.
44	Horf!	N	0	Isaac shoots an explosive tear with the Ipecac effect that always deals 200 damage. Unlocked by: Participate in 31 Daily Challenges (they don't have to be consecutive; it will still count if Isaac dies in the first room).	Isaac shoots a cluster of 6 Horf! tears with 150-400 damage per tear, resulting in an average of 1650 damage if all tears or their explosions hit.
45	Feels like I'm walking on sunshine!	+	1	Temporarily makes Isaac invincible, similar to Unicorn Stump. Unlocked by: Collect every entry in the Bestiary (bugged v190 - Mobs that don't exist in the bestiary are being counted. This allows Sin Collector to be unlocked without a complete bestiary).	The effect is upgraded to The Gamekid's.
46	Vurp!	+	2	Spawns the last pill used. Will spawn itself if no other pills were taken beforehand, or if Vurp! was the last pill used. Unlocked by: Obtain 50 items in a run (duplicate passive items/familiars count towards the total, e.g., multiple Breakfast).	If the last pill was a normal pill, it becomes a horse pill. No further difference on horse pills themselves.
Repentance
47	Shot Speed Down	-	1	-0.15 shot speed.	-0.30 shot speed.
48	Shot Speed Up	+	1	+0.15 shot speed.	+0.30 shot speed.
49	Experimental Pill	N	3	Increases one attribute and decreases another randomly, with the same power as normal attribute up/down pills. Will not reduce any attributes if taken with Lucky Foot, PHD or Virgo. Will not increase any attribute if taken with False PHD. If a pill-improving item is combined with False PHD, the pill gives an attribute increase, a decrease and a damage up.	The two effects are doubled in power.

Pill Appearances

Normal Pills		Horse Pills
ID	Appearance	ID	Appearance
5.70.1		5.70.2049
5.70.2		5.70.2050
5.70.3		5.70.2051
5.70.4		5.70.2052
5.70.5		5.70.2053
5.70.6		5.70.2054
5.70.7		5.70.2055
5.70.8		5.70.2056
5.70.9		5.70.2057
Afterbirth
5.70.10		5.70.2058
5.70.11		5.70.2059
5.70.12		5.70.2060
5.70.13		5.70.2061
Repentance
5.70.14		5.70.2062

Pill Classes

Repentance introduces the mechanic of pill classes. Internally, pills are given a class from 0 to 3 and a polarity that reflects their influence:

Pills in class 0 have little to no impact on a run overall, while pills in higher classes are correspondingly more influential, class 3 pills having effects as significant as permanent stat changes. Classes that end with + or - denote a positive or negative effect, otherwise considered neutral.

This mechanic is used to balance the pill pool and avoid having too many negative or positive pills. Polarity is used by certain items to determine which pills to convert.

Gold Pills

Repentance introduces Gold Pills (or Golden Pills). Using them will give a random pill effect. Gold pills only have a chance to be "used up" upon using them, which means that you can often use them many times before they finally disappear.

• Unlocked by: Defeat Mega Satan as Tainted Cain.
• The possible effects are all effects that aren't in the run's pill pool, which means if you see an effect from a normal pill, you will never see it from a golden pill.
• Items such as PHD or Lucky Foot which alter pill effects also work on the effects of this pill, allowing many beneficial effects to be stacked with little risk. Effects altered by these items may overlap with the effects in the run's pill pool; for example, a run might have Tears Up in the pill pool and Tears Down outside of the pill pool, which will be turned into Tears Up due to the effects of the item.
• Gold Pills have an ID of 5.70.14.
• A Gold Pill can also be a Horse Pill. Golden Horse Pills use the Horse Pill effect on every use.
• Golden horse pills are most likely the rarest pickup in the game with a 0.06% chance of spawning instead of a normal pill.
• If a Golden Pill uses the 'Vurp' effect, and no other pill was used prior, another golden pill will drop.

Horse Pills

Repentance introduces Horse Pills. These are larger versions of the standard pills with a more powerful effect, but only appear very rarely. Unique sound effects can be heard when they are used, and the narrator's normal spoken voice lines are instead shouted using a different voice.

• Unlocked by: Defeat Mega Satan as Tainted Eve.
• All items that work with pills work identically with horse pills.
• A horse pill with a given effect has the same color as the normal pill does.
• Horse pills have an ID of the normal ID + 2048 (i.e. 1 << 11). For example, a white-blue pill has an ID of 2, so the horse pill version would have an ID of 5.70.2050.
• It is also possible to have a golden horse pill. (It has an ID of 5.70.2062.)

Probabilities

Pills that spawn with a sub-type of 0 (i.e. a random pill) will have the following probabilities:

• Random normal pill - 97.86%
• Specific normal pill - 7.53%
• Gold pill - 0.7%
• Random horse pill - 1.43%
• Specific horse pill - 0.11%
• Gold horse pill - 0.01%

Notes

• Among the attribute-modifying pill effects, only five of the seven visible attributes are covered: health, range, tears, speed, and luck. Both shot speed and damage can't be altered by pills.
  • Shot speed can now be altered with pills. Damage can now also be altered with pills with False PHD.
• If a "Health up" pill is used while Isaac has 11 empty red hearts and one non-red heart, the non-red heart will be replaced with an empty container, killing Isaac.
• Having Midas' Touch, Meconium, or Hallowed Ground and using a "Re-Lax" pill has a chance to spawn Golden Poop, Black Poop, or White Poop, respectively.
  • A similar synergy is observed when using the A Card Against Humanity item in conjunction with these other items as well.
• If the item PHD is picked up and then lost in any way, such as rerolling by the D4 or a Dice Room, or dropping it as Tainted Isaac, pills will remain fully identified for the rest of the run, but negative pills will not be converted.
• Pill effects have a chance to be narrated upon use, as do cards and runes.
• Currently, the "Retro Vision" pill effect can crash the game on some machines, resulting in restarting the current floor when the game is continued.
• The "Addicted!" pill will have no effect if Isaac has The Wafer.
  • Despite this, if Isaac takes both the "Addicted!" pill with "Percs!" in the same room, a full heart of damage will be taken from all sources.
• Using an "Infested!" pill on Red Poop will spawn blue spiders and the red poop will regenerate.
• If a Tiny or Large Champion monster drops a "One Makes You Small"/"Larger" pill and either pill is not in the current pill pool, an existing pill will be overwritten. If the chosen pill was already identified, the new pill will also be.
• "R U A Wizard" does not affect Lilith's Incubus.
• Isaac's hitbox can be reduced to 30% of original, which is achieved after 6 One Makes You Small pills. Further pills will only make him visually smaller, with no additional benefit.
• Using a "Gulp!" pill while holding two trinkets (with Belly Button or Mom's Purse) will cause both trinkets to be absorbed.
• Magdalene's starting pill will override one of the pills in the current run's pill set if it doesn't exist in it (Speed Up for Afterbirth+, or Full Health in Repentance). The pill that is converted is dependent on the run's seed.
  • This only applies if the run is started as Magdalene or if Magdalene is chosen as a Co-op partner, not if Isaac turns into Magdalene using Clicker.
• All golden pills in the run have a shared sequence of effects they activate, so reversing the effects of one golden pill through Glowing Hourglass and consuming another golden pill will activate the same effects.
• If a Vurp! effect is activated by a golden pill, it will spawn the last non-golden pill taken by Isaac, or a golden pill if no non-golden pills have been taken by Isaac in the run.
• If a Marked Skull is destroyed while Isaac is holding Little Baggy, it will spawn a Telepill instead of 0 - The Fool. If Telepills doesn't exist in the current run's pill set, one of the pills in the run's set will be turned into Telepills. The pill that is converted is dependent on the run's seed.
  • All other pills with the same color as the Telepill spawned will also be converted into Telepills for the rest of the run, even if they're currently being held by Isaac. This can also override Magdalene's starting Full Health pill.
• While transformed into The Lost by a White Fireplace, Health Down pills turn into Health Up pills, regardless of Isaac's number of red heart containers.
• Damage from "Bad Trip" pills can be negated if Isaac consumes the pill during invincibility frames.
• It is possible to use "Paralysis" in one room and its effect happening in the next room only if you time it frame-perfectly.

Strategy

• There are 24 good effects, 14 neutral (sometimes good/sometimes bad) effects, and 12 negative effects. This means that taking mystery pills is usually beneficial. However, you should consider not taking one if an effect like Hematemesis or Tears Down would ruin your run.
• Use of unidentified pills is recommended for outside of combat as Hematemesis, R U a Wizard?, Paralysis, Addicted!, X-Lax, and I'm Excited!!! can be detrimental mid-fight. However, I'm Drowsy..., Something's wrong..., Lemon Party, Bad Gas, and Pheromones are useless outside of combat.
• Percs! can be used in the Sacrifice Room to reduce the damage Isaac takes, potentially allowing him to do more sacrifices. However, if Isaac is teleported to the Devil/Angel room, he loses the effect.
• The invincibility effect from Power Pill and Feels like I'm walking on sunshine! can be utilized to get into Curse Rooms, play Blood Donation Machines and Confessionals, or use Devil Beggars and Hell Games without taking any damage.
  • Percs! can be used to reduce damage from these from chapter 4 onward.
• Endless Nameless can be used to effectively generate infinite golden pills, as the trinket's ability to respawn collectibles applies with every use.
• Taking only golden pills in a run can allow for infinite golden pill generation by repeatedly activating the Vurp! effect.

Unlockable Achievements

• 

  Huge Growth - Increase in size 5 times in a single run via Magic Mushroom, "One makes you larger" pills, XI - Strength, etc..

• 

  Marbles - Use 5 Gulp! pills in one run (Placebo uses count).

• 

  Lachryphagy - Collect 10 "Tears Up" items or pills in one run.

• 

  Lil Spewer - Have Isaac die to his own explosion from Ipecac, Bob's Rotten Head, or a Horf! pill.

Trivia

• The Vurp! pill is a portmanteau of the words vomit and burp.
• Power Pills activating the Gamekid effect is a reference to Pac-Man, in which the "Super-Pac" powerup is obtained by eating a Power Pellet.
• "I Found Pills (and Ate Them)," "R U a Wizard?," and "I can see Forever" are all image macro memes.
• The Feels like I'm walking on sunshine! pill is a reference to the 80s song Walking on Sunshine.
  • Furthermore, creator Edmund McMillen made in 2010 a video with the same name, although it doesn't feature the actual Walking on Sunshine song.
• Balls of Steel is a reference to Duke Nukem; it is one of Duke's more famous quotes.
• Explosive Diarrhea is extremely loud and forceful diarrhea. In the original game, the message that displayed when the pill was activated was "Oh No!". The pill name and effect are likely a reference to Atomic Bomberman where a pickup of the same name would cause the player to drop bombs behind them uncontrollably for a short duration.
• Shot speed effects were introduced in The Binding of Isaac: Eternal Edition, after the release of Rebirth. They were finally added to Rebirth in the Repentance DLC.
• Hematemesis is a medical term for vomiting blood.
• Lemon Party is a reference to internet shock site featuring a group of elderly men performing oral sex, peeing on each other.
• "Puberty" having a negative sound effect is a tongue in cheek connotation to how unpleasant that period in life can be.
• Friends Till the End! was originally in the Wrath of the Lamb but removed in Rebirth, then put back into Afterbirth.
• Friends Till The End! is the only non-narrated pill.
• 48 Hour Energy is a reference to the drink 5 Hour Energy.
• X-Lax is a reference to the anti-constipation medicine Ex-Lax.
• "One makes you larger" and "One makes you small" are references to Alice in Wonderland, and the specific wording is a reference to the song White Rabbit by Jefferson Airplane.
• "Percs" is a reference to a street name for the prescription drug Percocet, which is more generically known as Oxycodone. This drug is meant to be used to treat pain, but it is often abused for recreational purposes.
• The "???" is the only pill that has 3 different narrated voice lines.
• "Horse pills" is a slang term used to refer to large, hard to swallow pills, hence their sprites being larger than those of regular pills.

Gallery

• YouTube - Pills in Repentance - What is New? What Has Changed?
• YouTube - All Horse Pills/Giant Pills (With Sound)
• YouTube - NEW Horse Pills

Bugs

Bug!	Any blue flies and blue spiders created by pill effects can be multiplied when Glowing Hourglass teleports Isaac in a way that does not move him to a different room from the one he is currently in (such as by teleporting to the previous room then using it again).

The Binding of Isaac: Rebirth
Achievements Challenges Completion Marks Items Trinkets Characters Chapters Rooms Transformations Attributes Bosses Monsters Pickups Modes Curses Objects Seeds Effects Endings
Collection Item Pools Version History Modding Music