Approaches to the management of Lyme disease in practice

Official view of LD

Lyme disease is a rare or at least uncommon condition which is relatively easy to treat.

ILADS view of LD

Lyme disease may be quite common; the prevalence is unknown.
Some cases are very difficult to treat.

Lyme disease clinical presentations

Two extremes:
1) Asymptomatic carrier.
2) Complex polymicrobial disease with highly variable presentation and severity of illness.

Presence of other conditions does not mean that Lyme disease is not present !

There is no established best way to treat Lyme disease and there is no test to prove cure of the condition.

Some non antibiotic aspects of treatment

Explanation and reassurance where possible.
Avoidance of smoking, alcohol and ‘stress’.
Avoid CNS depressants and stimulants.
Avoid steroids.
Consider nsaids, antidepressants.
Rest / exercise.
Nutrition.

General considerations relating to pharmacological Rx

Borrlia sensitive to many different antibacterial agents in vitro
Borrelia can be recovered after prolonged antibiotics in vivo
Treatment period of CLD measured in months or years
Duration of illness prior to ABx may be important
Open ended treatment may be needed
Combination therapy may be needed
Pulse therapy?
Some cases may settle without treatment.

Involvement of patient in decision making

Many Lyme patients know more about LD than their treating doctors.
Doctor must attempt to give balanced opinion emphasising the large holes in our current knowledge.

Ethical and legal issues

Consent to treatment: Written / verbal.
Highest ethical conduct of treating doctor essential.
Two standards of care: developing area in USA.

Examples of approach to treatment of LD

1) Simple monotherapy approach.
2) Combination therapy approach

Monotherapy

Examples of agents used:
Amoxicillin
Augmentin
Cephalosporins
Tetracycline
Doxycycline
Minocycline

Doxycycline as monotherapy

Well tolerated
Long half life
Experience of long term use
Inexpensive
Some intracellular activity.
Co –infection activity: Activity against Erhlichia and Bartonella. Synergism.
Backed by some clinical trials

But:
Poor CNS penetration

Monotherapy - example

Suspected CLD
Doxycycline 200-400mg for 6 -12 months

Not improved - Reconsider diagnosis, Lab tests

Improved

Cyclical Sx, E M Rash, continue Doxycycline 200-400mg for 6 -12 months.

No Cyclical Sx, E M Rash - Stop: review 3-6/12

Side effects of doxycycline

Usually a well tolerated drug.
Common side effect: Sun induced rash.

Other side effects of doxycycline

Candidiasis
Diarrhoea – If severe and abdo pain present consider C. difficile
Nausea, dysphagia, oesophageal irritation,
Abnormal LFTs, hypersensitivity reactions,
Benign intracranial hypertension

Indications for IV antibiotics

ILADS guidelines:

Failure of oral treatment.
Neurological Lyme (encephalitis, myelitis, meningitis)
Lyme arthritis with effusions.

Agents used

Ceftriaxone most common.
Duration of treatment ?

Accessing Lyme treatment

Authorities demand strong evidence that a condition is present and strong evidence that treatment is effective.
The result has been a general failure of Lyme patients to access proper care.

Combination therapy – before starting

History
Physical examination
Basic lab work
Other work up as indicated eg. Endocrine tests, MRI of brain
Lyme orientated tests:
Borrelia IgG IgM WB, serial Borrelia PCRs
Serology and serial PCRs for co-infections
Also may include:
CD57 Lymphocyte counts
SPECT or PET Scans

Rationale for combination therapy

Some slow bacteria require combination therapy for effective treatment eg. Mycobacter.
Presence of co-infections

Favoured combinations

Amoxicillin and clarithromycin
Ceftiraxone and azithromycin
Amoxicillin and metronidazole
Where Babesia thought to be present:
Atovaquone and azithromycin
Clindamycin and quinine

Other therapies

Hyperbaric oxygen therapy
Marshall protocol:
Initial Complete ACE blockade with Benicar (Olesartan), low vit D diet, sunlight avoidance and low dose minocycline followed by other antibiotics – long term!
IV Glutathione?