The Treatment Of Early Lyme Disease
Christie Choo-Kang, PharmD, BCPSNephrology and Renal Transplant Clinical SpecialistBoston Medical Center
Eileen Tang, PharmD Candidate 2011College of Pharmacy and Allied Health Professions, St. John’s UniversityNew York, New York
Arun Mattappallil, PharmD Candidate 2011College of Pharmacy and Allied Health Professions, St. John’s UniversityNew York, New York
Lyme disease, also known as Lyme borreliosis, is the most common vector-transmitted illness in the United States.1,2 The disease was first recognized in 1975 in a number of children in Lyme, Connecticut, who were initially diagnosed with juvenile rheumatoid arthritis because of overlapping signs and symptoms.1 In 1982, Willy Burgdorfer, PhD, discovered that a spirochete isolated from Ixodes scapularis, a deer tick, was the same spirochete found in patients with Lyme disease.
Confirmed cases of Lyme disease are defined as erythema migrans greater than 5 cm in diameter or one or more objective late manifestations of Lyme disease with laboratory confirmation in patients with possible exposure to ticks. Healthy People 2010 set a goal of a 44% decrease in the incidence of Lyme disease by 2010. Since 2000, the CDC has contributed more than $3.5 million per year for new research on Lyme disease.2
What Is Neurologic Lyme Disease
Neurologic symptoms of Lyme disease occur when the Lyme disease bacteria affect the peripheral or central nervous systems.
- Cranial nerve involvement: When the cranial nerves are affected, facial palsy can occur on one or both sides of the face.
- Peripheral nerve involvement: When the peripheral nerves are affected, patients can develop radiculoneuropathy which can cause numbness, tingling, shooting pain, or weakness in the arms or legs.
- Central nervous system involvement: When the central nervous system is affected, Lyme meningitis can cause fever, headache, sensitivity to light, and stiff neck.
Out of every 100 patients whose cases are reported to CDC, 9 have facial palsy, 4 have radiculopathy, and 3 have meningitis or encephalitis. Because of reporting practices, this statistic may overestimate how often these manifestations are seen by clinicians.
Treatment For Erythema Migrans
People treated with appropriate antibiotics in the early stages of Lyme disease usually recover rapidly and completely. Early diagnosis and proper antibiotic treatment of Lyme disease can help prevent late Lyme disease.
Treatment regimens listed in the following table are for the erythema migrans rash, the most common manifestation of early Lyme disease. These regimens may need to be adjusted depending on a persons age, medical history, underlying health conditions, pregnancy status, or allergies. Consult an infectious disease specialist regarding individual patient treatment decisions.
|100 mg, twice per day orally||N/A|
|500 mg, three times per day orally||N/A|
|500 mg, twice per day orally||N/A|
|4.4 mg/kg per day orally, divided into 2 doses||100 mg per dose|
|50 mg/kg per day orally, divided into 3 doses||500 mg per dose|
|30 mg/kg per day orally, divided into 2 doses||500 mg per dose|
*When different durations of antibiotics are shown to be effective for the treatment of Lyme disease, the shorter duration is preferred to minimize unnecessary antibiotics that might result in adverse effects, including infectious diarrhea and antimicrobial resistance.
NOTE: For people intolerant of amoxicillin, doxycycline, and cefuroxime, the macrolide azithromycin may be used, although it is less effective. People treated with azithromycin should be closely monitored to ensure that symptoms resolve.
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About Disulfiram And Lyme Disease
For 30 percent of people with chronic Lyme disease, disulfiram is a game changer. This is a medicine historically used to treat people with alcoholism. Ground-breaking research from Dr. Rajadas Stanford University lab in 2016 showed disulfiram kills persister and growing forms of Lyme germs. Based on Rajadas research, disulfiram is being repurposed as a Lyme antibiotic.
In alcoholism, disulfiram prevents the breakdown of a toxic alcohol by-product called acetaldehyde. As acetaldehyde builds up, it makes a person sick with severe abdominal pains and even headaches. In alcoholism, a person takes this medicine daily to prevent them from drinking out of fear it will cause severe illness if they drink alcohol.
In Lyme disease, we do not know the mechanism of how disulfiram works. But we do know in the laboratory that it kills Lyme persisters and is moderately effective at treating growing Lyme too. We also theorize that it breaks up biofilm slime layers that protect the germs.
Key Points For Healthcare Providers
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Hunting For Alternative Drug
Frustrated by the lack of treatment options for Lyme disease patients with lingering symptoms, Rajadas and his team began hunting for a better alternative in 2011. In 2016, they published a study in Drug Design, Development and Therapy that listed 20 chemical compounds, from about 4,000, that were most effective at killing the infection in mice. All 20 had been approved by the Food and Drug Administration for various uses. One, for instance, is used to treat alcohol abuse disorder.
In this most recent study, azlocillin, one of the top-20 contenders, was shown to eclipse a total of 7,450 compounds because it is more effective in killing B. burgdorferi and causes fewer side effects. Lyme disease affects more than 300,000 people annually, according to the Centers for Disease Control and Prevention. It can affect various organs, including the brain, skin, heart, joints and nervous system, and cause heart problems and arthritis if untreated. Symptoms include fever, headaches, chills, and muscle and joint pain.
Traditional antibiotics, such as doxycycline, are effective as an early course of treatment for the infection in the majority of patients, but it remains unclear why these drugs fail to treat 10% to 20% of patients, Rajadas said.
For Memory Concentration And Focus
Improving memory is a challenge. In Lyme disease, short-term memory problems and word-retrieval problems are common. These often improve substantially with appropriate antibiotic therapy. Over time, most patients regain their cognitive function.
When memory is a problem, consider that this could due to a primary problem with attention or with mood. An individual who can’t focus won’t be able to remember because he/she didn’t “attend” to the item in the first place. This happens to all of us when we hear someone’s name at a party if we don’t focus on the name and perhaps make a mental association to the name to enhance memory storage, we will forget that name within minutes. Patients with depression often experience problems with memory and verbal fluency when the depression is resolved, the memory and verbal fluency typically resolve as well.
- Medications: Attention can be improved with certain medications, such as bupropion , atomoxetine , modafinil , or stimulants . Medications that temporarily slow cognitive decline in Alzheimer’s disease or memantine ) have not been studied in Lyme disease.
- There is some evidence that online brain training programs can enhance concentration or processing speed.
- Neurofeedback may be helpful in improving attention, as well as in improving sleep and reducing pain. This has been studied for migraines, fibromyalgia, and ADHD.
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What Is Post Treatment Lyme Disease
Post Treatment Lyme Disease represents a research subset of patients who remain significantly ill 6 months or more following standard antibiotic therapy for Lyme disease. PTLD is characterized by a constellation of symptoms that includes severe fatigue, musculoskeletal pain, sleep disturbance, depression, and cognitive problems such as difficulty with short-term memory, speed of thinking, or multi-tasking. In the absence of a direct diagnostic biomarker blood test, PTLD has been difficult to define by physicians, and its existence has been controversial. However, our clinical research shows that meticulous patient evaluation when used alongside appropriate diagnostic testing can reliably identify patients with a history of previously treated Lyme disease who display the typical symptom patterns of PTLD.
What Are The Symptoms
The main feature of Lyme arthritis is obvious swelling of one or a few joints. While the knees are affected most often, other large joints such as the shoulder, ankle, elbow, jaw, wrist, and hip can also be involved. The joint may feel warm to the touch or cause pain during movement. Joint swelling can come and go or move between joints, and it may be difficult to detect in the shoulder, hip, or jaw. Lyme arthritis typically develops within one to a few months after infection.
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Iv Antibiotic Regimen: Cephalosporin Plus Azole Plus Liposomal Cinnamon Clove And Oregano
- ceftriaxone 2 gm IV 2 times a day for 4 days on and 3 days off
- tinidazole 500 mg taken orally 1 pill 2-3 times a day for 4 days on and 3 days off in 7-day cycles
- liposomal cinnamon, clove, and oregano capsules 1 pill 2 times a day
- Various antibiotics can be used as IV. I use this one most commonly because it is the easiest to administer and one of the lowest cost IV regimens. The ceftriaxone is given in a syringe and injected over 10 minutes. This is also a pulse dose regimen . Ceftriaxone could be given daily instead as 2 gm IV 1 time a day.
- I have found various pulse dose regimens of tinidazole to work. These include 2 weeks on and 2 weeks off or in the regimen seen here.
Why Are Antibiotics The First Line Of Treatment For Lyme Disease
The use of antibiotics is critical for treating Lyme disease. Without antibiotic treatment, the Lyme disease causing bacteria can evade the host immune system, disseminate through the blood stream, and persist in the body. Antibiotics go into the bacteria preferentially and either stop the multiplication of the bacteria or disrupt the cell wall of the bacteria and kill the bacteria . By stopping the growth or killing the bacteria the human host immune response is given a leg up to eradicate the residual infection. Without antibiotics, the infection in Lyme disease can evade the host immune system and more readily persist.
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Lyme Has Two Growth States
Research published in 2015 shows that Lyme has two different growth states. There is a growing phase of the germs and there is a persister phase. Think of the persisters as germs that are in hibernation. These persisters – hibernating phase germs – ignore regular standard antibiotics we traditionally use to treat Lyme.
What To Expect At Home
Home care for dogs with Lyme disease is relatively straightforward. Doxycycline is usually given by mouth twice daily for at least 30 days. Improvement in the dogs symptoms should be noted within 24-48 hours. If the dogs condition fails to improve in 72 hours or worsens at any time, call your veterinarian.
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History And Physical Examination
The clinical diagnosis of Lyme disease can be straightforward in patients with a history of tick exposure and the characteristic finding of an erythema migrans rash.12 The CDC has defined erythema migrans rash as an expanding red macule or papule that must reach at least 5 cm in size .11 According to the Infectious Diseases Society of America guidelines, erythema migrans rash is the only clinical manifestation sufficient to make the diagnosis of Lyme disease in the absence of laboratory confirmation.20 Although one study concluded that primary care physicians in a Lyme diseaseendemic area of France correctly identified erythema migrans in 72 percent of patients,22 the study was limited by lack of complete clinical information for the participants.
A number of conditions resemble erythema migrans however, the rapid and prolonged expansion of an erythematous lesion is unique to erythema migrans.11 Lesions most often occur at anatomic sites that are unusual for cellulitis and other conditions that mimic erythema migrans therefore, a complete skin examination should be performed before excluding erythema migrans.20
What Is Lyme Disease
Lyme disease is a bacterial infection that is spread by ticks. It was first recognized in 1975. Large numbers of children around the town of Lyme, Connecticut, were being diagnosed with juvenile rheumatoid arthritis. Researchers investigated and found that tick bites were causing the illnesses.
Lyme disease is carried by black-legged ticks . These ticks are typically about the size of a sesame seed. They live mostly in certain areas of the country:
- Northeast and mid-Atlantic .
- North central states .
- West Coast .
However, Lyme disease can be found in other parts of the United States. While you are more likely to get it in the above regions, cases of Lyme disease were reported in almost every state in 2017. The disease is also found in Europe, Asia, and Australia.
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Herbal And Rx Antimicrobials That Treat Persisters
This is a newer area in Lyme treatment. To help justify these various antimicrobial options, I describe the experimental basis behind my recommendations. These options are ones I am using with various degrees of success in my Seattle practice. They all have either laboratory experiments supporting their use or published human experiments.
Laboratory-Based Experiment Options
Here is a list of prescription and herbal medicine options shown in lab experiments to kill persisters that I am incorporating into my treatments of Lyme and/or Bartonella.
- Disulfiram – work slowly up to 4 to 5 mg/kg body weight 1 time a day.
- Methylene Blue 50 mg 2 times a day.
- Liposomal Oregano, Cinnamon, and Clove Oils 1 capsule 2 times a day.
- Cryptolepis 5 ml 3 times a day.
- Japanese Knotweed½ tsp 3 times a day – start at ¼ tsp 1 time a day and then increase after two weeks to ½ tsp 3 times a day.
- Cats Claw 30 drops 2 times a day.
Human-Based Experiment Options
Here is a list of prescription medications shown in human experiments to help with persister Lyme.
- Disulfiram – work slowly up to 4 to 5 mg/kg body weight 1 time a day.
- Dapsone – work up to 100 mg or 200 mg 1 time a day.
Medicines To Treat Lyme Disease
The first option for treating Lyme disease will always be the use of antibiotics. The form of administration of the same can vary depending on the stage of the disease, being oral in the initial stages and intravenous when the disease has advanced.
At the same time, the use of other drugs such as non-steroidal anti-inflammatory drugs may also be necessary. Theyre used to treat the symptoms of certain complications of the disease, such as Lyme arthritis.
In this sense, within the main prescriptions used for the treatment of Lyme disease, the following stand out:
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Antimicrobial Herbs That Kill Growing Phase Spirochetes & Cysts
Intracellular and Extracellular
Based on my observations, these herbal combination options have as good of a chance as the prescription options. They appear to kill intracellular and extracellular Lyme too based on the clinical benefit I see in my medical practice.
- Cats Claw and Otoba Bark Tinctures 30 drops of each 2 times a day. Start at 5 drops 2 times a day and add 1 drop per dose per day until you reach 30 drops 2 times a day. If you get a Herxheimer reaction, stop increasing the dose until it has passed.
- Cats Claw and Japanese Knotweed 30 drops of Cats Claw 2 times a day and ½ tsp of Japanese Knotweed 3 times a day. Work up to these doses over 30 days. Start Cats Claw at 5 drops 2 times a day and add 1 drop per dose per day until you reach 30 drops 2 times a day. Start the Japanese Knotweed at ¼ tsp 3 times a day and in two weeks increase to ½ tsp 3 times a day.
Tetracycline Plus Rifamycin Plus Disulfiram
- minocycline 100 mg 1 pill 2 times a day
- rifampin 300 mg 2 pills 1 time a day
- disulfiram 4 to 5 mg/ kg body weight. Work up to this dose slowly over 2 months then remain on the disulfiram at the peak dose for 4 months before tapering off.
- This minocycine and rifampin in this combination are as useful for treating a Bartonella co-infection. Co-infections are other germs passed on during a tick bite. If someone has a co-infection, when possible I choose antibiotic combinations that simultaneously treat Lyme germs and the co-infection germs.
- The disulfiram is added here to treat persister Lyme. Note disulfiram does not appear to treat Bartonella.
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Touched By Lyme: When Lyme Disease Affects The Heart
Gone in a Heartbeat: A Physicians Search for True Healing, by Neil Spector, MD.
Neil Spector was a seemingly healthy physician living with his wife in Florida. One day, he experienced what appeared to be textbook symptoms of a heart attack. Erratic heartbeat, chest pressure, pain radiating from chest to neck and jaw. Except all the tests the emergency room gave him turned out normal. He wasnt having a heart attack, his doctors said. They chalked it all up to stress, suggested he learn how to relax, and sent him on his way.
Spector continued to have troubling symptoms. Often, his heart pounded too fast. Other times, way too slowly. Sometimes, without warning, hed fall to the ground. He had extended periods of bradycardia, when the heart doesnt pump enough oxygen-rich blood throughout the body. Yet, the answer from doctors was always the same: Nothing wrong at all. Just a little stress.
Gone in a Heartbeat: A Physicians Search for True Healing, Spectors gripping memoir, covers about two decades. It starts with those initial heart-related episodes. Then it progresses to stages where he needs a pacemaker, then an internal defibrillator, and eventually a heart transplant. Its a riveting account of how this affects him, his wife, and their family. Its also about Lyme disease.
Several weeks after receiving a pacemaker, Spector develops arthritis in his wrists. Coincidentally, he takes doxycycline for something unrelated. To his surprise, his wrist pain goes away.