Thursday, August 28, 2008

Burrascano: Dosing the drugs

Before the IDSA, a young doctor found himself in the midst of an epidemic. It was 1983, two years after Willie Burdorferi saw this new spirochete undulating under the lens of his microscope. Little was known about this new tick borne zoonosis. At first it was considered a cause of inflammatory arthritis in children. But it was much more. It was a multi-system disorder with wide ranging ramifications. Joe Burrascano tackled this mysterious illness head on. He was a pioneer in the field of chronic Lyme disease, his cause later taken up by ILADS. Joe developed diagnostic clues and guidelines for the diagnosis and treatment of Lyme disease. For 20 years he wrote down these guidelines and made them available to other practitioners. These 40 pages, last updated in 2005, which anyone can print of the Internet, appear unassuming. Yet these simple, unadorned pages contain profound insights and distilled clinical pearls which have become the basis for a new paradigm in medical practice. The definition of Lyme literate is unclear, but a prerequisite is the work of Dr. Burrascano. However, some differences exist between the Burrascano guidelines and the medication doses used by myself and other Lyme docs I am familiar with. The doses of oral medications seem exceptionally high. The doses exceed published recommendations of the maximal tested doses of the medications. Long term and combination therapy is the rule, not the exception. Even recent studies with IV Rocephin show that the benefits wane quickly when the medicine is stopped after three months. Treating chronic Lyme appears more a marathon than a sprint. The duration of therapy may be more important than the dose of antibiotic. There is a clinical sense that Lyme can only be cured at a particular pace. As the organisms are killed, the immune system has to make adjustments which allow the host to recover. Causing severe Herx reactions does not appear to shorten the duration of therapy. And in some cases, severe Herx reactions can have adverse clinical effects. Any dose of antibiotic sufficient to cause a Herx is killing Lyme. Dr. Burrascano recommends doses of Amoxicillin of 3 to 6 grams plus Benemid which increases drug levels by inhibiting urinary excretion. In my experience, doses of 2 to 3 grams per day, without Benemid are effective. He recommends Ceftin 2 grams per day. The maximum recommended dose is 1 gram per day. I am hesitant to exceed this dose. He recommends Zithromax up to 1200 mg per day. I am not comfortable exceeding 600 mg per day. Zithromax has a long half life and accumulates high blood and tissue levels over time. He recommends Biaxin, 2 grams per day. The maximal recommended dose is one gram. I have not exceeded this dose. He recommends Doxycyline doses up to 600 mg per day. The standard dose is 200 mg per day. I generally use 400 mg per day, but am hesitant to exceed this dose. He omits Minocin as an option. This drug is favored by many Lyme docs. It is reported to have better blood brain penetration and reported to have other positive neurological and immunological affects. The maximum recommended dose is 200 mg. Like other Lyme docs, I am comfortable pushing the dose for this drug to 300 mg. The higher doses of oral antibiotics are difficult to tolerate. Probiotics can only be pushed so far. GI intolerance, diarrhea and the risk of C. diff infection must be considered when pushing oral medicines to the higher doses. On the other side of the coin, some of my colleagues use doses of antibiotics which I consider "homeopathic." Doses of Minocin 50 mg per day with Zithromax 250 mg every other day are not effective. I recently saw a chronic Lyme patient who had been under the care of another LLMD for one year without any improvement. This patient had been on low dose antibiotic therapy. After only one month of antibiotics prescribed at the doses discussed above, the patient stated that she was finally improving. The Burrascano regimens for treating: Ehrlychia, Babesia and Bartonella are with lower doses of antibiotics, consonant with approaches agreed upon by most LLMDS (and even many IDSA MDs). None of this is meant to diminish the contributions of Dr. Burrascano. The lower doses I recommend may be based on the uses of combinations from the starting gate and an understanding that treatment is long term. Perhaps it also reflects some fear on my part to push the envelope too far. When higher doses of antibiotics are needed I reach for intravenous therapy which is more effective and better able to traverse the blood brain barrier. Of course I probably wouldn't be having this discussion without the seminal work of Dr. Joseph Burrascano. I have recently read about pulse therapy using very high doses. I have not found pulse dosing to be effective in my patients. but perhaps I need to reconsider this approach. Its a work in progess. Thank you Joe.

8 comments:

Leslie said...

Very informative. I've started reading your blog regularly, your approach is very balanced. Thanks!

Frosch said...

Back when the wikipedia page still mentioned ILADS I found those guidelines. It's funny because I was just looking at them again this morning, before I visited the blog. It's a pity they have not been updated since '05. Maybe he should pass on the torch. The general ILADS guidelines are not very specific. For example he is very supportive of telithromycin, which has fallen out of favor due to its risks.

It was nice for me to have them to get a sense of the model that LLMDs were operating on, even if there was individual variation from doctor to doctor.

AllClearInVirginia said...

With Lyme , apparently flexibility can yield results.

Wendy said...

What would you recommend for treatment when an embedded nymph has been pulled off, and there is a rash? Doxy as a "caution?"

Wendy said...

What would you recommend for treatment after an embedded nymph tick has been pulled off, not sure how long it was attached, and there is a rash? Doxy as a "caution" or wait and see if there are symptoms?

Wendy said...

What would you recommend for treatment after an embedded nymph tick has been pulled off (not sure how long it was attached) and there is a bull's eye rash at the site? Doxy as a caution, or wait and see if symptoms develop?

Wendy said...

What would you recommend for treatment after an embedded nymph tick has been pulled off (not sure how long it was attached) and there is a bull's eye rash at the site? Doxy as a caution, or wait and see if symptoms develop?

Wendy said...

What would you recommend for treatment after an embedded nymph tick has been pulled off (not sure how long it was attached) and there is a bull's eye rash at the site? Doxy as a caution, or wait and see if symptoms develop?