Binding of Isaac: Complete Item Tier List & Synergies

Items are everything in Binding of Isaac. This guide ranks every major item and explains the best synergies.

S-Tier Items (Game-Changing)

• Sacred Heart: +1 damage, homing tears, +0.5 HP. One of the best items in the game.
• Brimstone: Charge shot that fires a blood laser. Massive damage.
• Moms Knife: Throwable knife that pierces enemies. High damage, fast fire rate.
• Tech X: Laser ring that grows over distance. Clears entire rooms.
• Godhead: Homing tears + damage aura. Nearly unkillable with good build.

A-Tier Items (Very Strong)

• Epic Fetus: Calls down missiles from the sky. Massive AoE damage.
• Dr. Fetus: Bombs replace tears. Good for crowd control.
• Chocolate Milk: Charge shot with high damage. Slow fire rate but worth it.
• Ipecac: Explosive tears. High damage but risky (you can hurt yourself).
• Ludovico Technique: Floating tear that you control. High skill ceiling.

B-Tier Items (Good)

• Polyphemus: Giant tears with high damage. Slow fire rate.
• Dead Eye: +25% damage per hit (up to +100%). Scales well.
• Magic Scab: +1 HP + damage. Good for sustain.
• Blood Clot: +1 damage + tear size. Good for early game.
• Sacrificial Dagger: Orbiting dagger that blocks enemy tears. Good for defense.

C-Tier Items (Situational)

• Cups: +1 HP + damage. Decent but outclassed by better items.
• Pentagram: +1 damage + devil chance. Good for devil builds.
• Cube of Meat: Orbiting meat cube. Blocks enemy tears.
• Roid Rage: +1 HP + tear size. Decent but boring.
• Growth Hormones: +1 damage + speed. Good for aggressive builds.

F-Tier Items (Avoid)

• Poop: Spawns poop. Useless.
• The Virus: Poison on touch but slows you down. Terrible.
• Its Alive: Orbiting poop. Blocks tears but does nothing else.
• A Dollar: Spawns pennies. Useless.
• A Quarter: Spawns nickels. Useless.

Best Item Synergies

Brimstone Synergies

• Brimstone + Sacred Heart: Homing blood laser. Never miss.
• Brimstone + Ipecac: Explosive blood laser. Screen-clearing damage.
• Brimstone + Technology: Laser + blood laser. Double damage.

Moms Knife Synergies

• Moms Knife + Sacred Heart: Homing knives. Never miss.
• Moms Knife + Epic Fetus: Missile + knife combo. Massive damage.
• Moms Knife + Dr. Fetus: Bomb knives. Explosive damage.

Tech X Synergies

• Tech X + Sacred Heart: Homing laser ring. Never miss.
• Tech X + Brimstone: Laser + laser ring. Double damage.
• Tech X + Ipecac: Explosive laser ring. Screen-clearing damage.

Godhead Synergies

• Godhead + Sacred Heart: Homing tears + damage aura. Nearly unkillable.
• Godhead + Brimstone: Blood laser + damage aura. Massive damage.
• Godhead + Tech X: Laser ring + damage aura. Screen-clearing damage.

Item Transformations

Transformations occur when you collect 4+ items from the same set.

Beelzebub (Fly items)

• Items: Hive Mind, Mutant Spider, etc.
• Effect: You fly and shoot homing tears
• How to get: Collect 4+ fly items

Lord of the Flies

• Items: Hive Mind, Mutant Spider, etc.
• Effect: You spawn orbiting flies that block enemy tears
• How to get: Collect 4+ fly items

Conjoined

• Items: Polyphemus, etc.
• Effect: Your tears are connected by a damage beam
• How to get: Collect 4+ conjoined items

Spun

• Items: Growth Hormones, etc.
• Effect: You gain speed and damage
• How to get: Collect 4+ spun items

Bob

• Items: Rotten Baby, etc.
• Effect: Your tears poison enemies
• How to get: Collect 4+ bob items

Advanced Tips

• Sacred Heart is the best item in the game. Always pick it up.
• Brimstone has the highest damage potential. Master the charge shot.
• Moms Knife is the fastest weapon. Good for aggressive play.
• Tech X clears rooms quickly. Good for crowd control.
• Godhead is the best defensive item. Nearly unkillable with good build.
• Avoid F-tier items unless you have no other choice.
• Build around synergies. Items that work together are better than random S-tier items.