Antibiotics are the primary treatment for Lyme disease, but the most appropriate antibiotic treatment depends upon the patient and the stage of the disease. The antibiotics of choice are doxycycline (in adults), amoxicillin (in children), and ceftriaxone. Alternative choices are cefuroxime and cefotaxime. Macrolide antibiotics have limited efficacy when used alone. Many physicians who treat chronic Lyme disease have noted that combining a macrolide antibiotic such as clarithromycin (biaxin) with hydroxychloroquine (plaquenil) is especially effective in treatment of chronic Lyme disease. It is thought that the hydroxychloroquine raises the pH of intracellular acidic vacuoles in which B. burgdorferi may reside; raising the pH is thought to activate the macrolide antibiotic, allowing it to inhibit protein synthesis by the spirochete.
Results of a recent double blind, randomized, placebo-controlled multicenter clinical study, done in Finland, indicated that oral adjunct antibiotics were not justified in the treatment of patients with disseminated Lyme borreliosis who initially received intravenous antibiotics for 3 weeks. The researchers noted the clinical outcome of said patients should not be evaluated at the completion of intravenous antibiotic treatment but rather 6-12 months afterwards. In patients with chronic post-treatment symptoms, persistent positive levels of antibodies did not seem to provide any useful information for further care of the patient. However, this study has been criticized by the International Lyme and Associated Diseases Society (ILADS), on the grounds that
1) treatment over years is often necessary to produce noticeable improvement in chronic Lyme patients and
2) the antibiotics used were cell wall antibiotics which may act relatively slowly against Lyme disease.
In later stages, the bacteria disseminate throughout the body and may cross the blood-brain barrier, making the infection more difficult to treat. Late diagnosed Lyme is treated with oral or IV antibiotics, frequently ceftriaxone, 2 grams per day, for a minimum of four weeks. Minocycline is also indicated for neuroborreliosis for its ability to cross the blood-brain barrier.
Therapies for “post-Lyme syndrome”/”chronic Lyme disease”
- Further information: Lyme disease controversy
Some Lyme disease patients who have completed a course of antibiotic treatment continue to have symptoms such as severe fatigue, sleep disturbance, and cognitive difficulties. It is currently unclear whether persisting symptoms following antibiotic treatment result from continuing low-level B. burgdorferi infection or from residual effects of the infection prior to treatment. Currently there are two sets of peer-reviewed published guidelines in the United States. The International Lyme and Associated Diseases Society advocates extended courses of antibiotics for chronic Lyme patients in light of evidence of persistent infection following “standard” antibiotic treatment of some Lyme disease patients. In contrast, the Infectious Diseases Society of America, which favors the term “post-Lyme syndrome” to describe the condition in these patients, does not believe persisting symptoms following standard antibiotic treatment results from chronic infection and does not recommend additional antibiotic treatment.
Three double-blind, placebo-controlled trials of long-term antibiotics for chronic Lyme have produced mixed results. In all three studies, the subjects had persisting symptoms despite being treated with a standard course of antibiotics for Lyme disease.
The first published study failed to detect any benefit of a 90-day course of antibiotics. However, the patients enrolled in the study may have been unusually difficult to treat as suggested by their previous multiple antibiotic treatment failures and their lengthy illness prior to the study; hence the results may not be generalizable to others with post-Lyme syndrome. Further, the study has been criticized for failing to run the antibiotic treatment over a long enough period to take into account the very gradual improvement of chronic Lyme patients seen over many months or even years on antibiotics.
The second clinical trial, which used slightly different enrollment criteria and outcome measures, noted improvement in disabling fatigue that was sustained for six months following antibiotic therapy. The most recent trial was published by a group known to favor prolonged treatment with antibiotics. They found that subjects with post-treatment cognitive impairment exhibited some improvement following intravenous cefriaxone treatment for 10 weeks. However, the cognitive gains were lost when the subjects were examined 14 weeks following treatment. There is disagreement with the interpretation of the data. ILADS believes that the relapse observed following the termination of antibiotic therapy is consistent with persistent infection with B. burgdorferi, whereas the lack of lasting improvement is cited in the editorial accompanying the article as evidence that prolonged antibiotic treatment is not helpful.
A controversial new guideline developed by the American Academy of Neurology, finds conventionally recommended courses of antibiotics are highly effective for treating nervous system Lyme disease. They find no compelling evidence that prolonged treatment with antibiotics has any benefit in treating symptoms that persist following previous standard antibiotic therapy. The new guideline was touted as independent corroboration of the IDSA guideline and was quickly endorsed by the IDSA. However ILADS has accused AAN of simply repackaging the IDSA guidelines as three coauthors of the new guideline, including the lead author, were also coauthors of the IDSA Lyme guideline. There is significant disagreement with this guideline.
Antibiotic-resistant therapies
Antibiotic treatment is the central pillar in the management of Lyme disease. In the late stages of borreliosis, symptoms may persist despite extensive and repeated antibiotic treatment. Lyme arthritis which is antibiotic resistant may be treated with hydroxychloroquine or methotrexate. Experimental data are consensual on the deleterious consequences of systemic corticosteroid therapy. Corticosteroids are not indicated in Lyme disease.
Antibiotic refractory patients with neuropathic pain responded well to gabapentin monotherapy with residual pain after intravenous ceftriaxone treatment in a pilot study. The immunomodulating, neuroprotective and anti-inflammatory potential of minocycline may be helpful in late/chronic Lyme disease with neurological or other inflammatory manifestations. Minocycline is used in other neurodegenerative and inflammatory disorders such as multiple sclerosis, Parkinsons, Huntington’s disease, rheumatoid arthritis (RA) and ALS.
Alternative therapies
A number of other alternative therapies have been suggested, though clinical trials have not been conducted. For example, the use of hyperbaric oxygen therapy (which is used conventionally to treat a number of other conditions), as an adjunct to antibiotics for Lyme has been discussed. Though there are no published data from clinical trials to support its use, preliminary results using a mouse model suggest its effectiveness against B. burgdorferi both in vitro and in vivo. Anecdotal clinical research has shown potential for the antifungal azole medications such as diflucan in the treatment of Lyme, but has yet to be repeated in a controlled study or postulated a developed hypothetical model for its use.
Alternative medicine approaches include bee venom because it contains the peptide melittin, which has been shown to exert inhibitory effects on Lyme bacteria in vitro; no clinical trials of this treatment have been carried out, however.
