Monday, January 14, 2019

Treating Lyme, 2019, a brief overview: The more things change the more things remain the same ( Plus ça change, plus c'est la même chose)

Things are changing slowly.

My paradigm for treating Lyme is in constant flux.  Lyme is in general, a systemic, multisystem disorder characterized by widespread inflammation. I try to understand the underlying cause of inflammation. Inflammation is due to an immune response which may be appropriate, inappropriate and/or autoimmune.  Mast cell activation (MCAS), for example, is an example of inappropriate immune response/inflammation which may be triggered by infection.  Germ persistence is a key factor. But related autoimmunity is important. For example, Lyme may trigger rheumatoid arthritis – or something that looks like it.  We know that other factors that incite systemic autoimmune responses, for example, gluten in susceptible patients may exacerbate symptoms of Lyme.. A variety of other autoimmune manifestations need be considered, for example, PANS (PANDAS) causing autoimmune encephalitis. Consider POTS, another multisystem disorder which can look like Lyme. Underlying genetic, somatic disorders may contribute to symptoms, for example, Ehlers Danlos syndrome, a connective tissue disorder. 
Following “Sutton’s Law” I try to go where the money is.  I treat symptoms, like disturbed sleep and fatigue. Increasing functionality is key to restoring quality of life. I focus on: Lyme, coinfections, inflammation, genetic disorders and symptoms. Nutritional issues are important.  I put aside: viral infection, heavy metal toxicity, mold toxins and other confounding issues that seem popular. (Antiviral meds can be very helpful). I put aside “adrenal fatigue.” Universally, chronically ill patients and Lyme patients develop adrenal dysfunction. This will usually fix itself when the underlying disease is treated, and treatment can backfire. Thyroid disease/dysfunction is another matter and must be treated. The role of epigenetics is unclear and not something I focus on early in treatment.  The notion that antibiotics alone will fix everything is incorrect. 
The antibiotics, antimicrobials mentioned are examples and not recommendations. Only a treating physician can decide what might be appropriate. Choice of antibiotics is driven by symptoms.  Lyme” coverage” is always present, if at a lower intensity.  If Lyme is the main driver of symptoms a cocktail of 3 drugs may be used.  Doxycycline, Rifampin and Tindamax is an example of a 3-drug cocktail – there are many others.  When rifampin is used Bartonella Herxheimer reactions may appear and may be severe.  If Bartonella is the primary target a cocktail of Zithromax or Biaxin, doxycycline and Rifampin may be used – and others.  If Babesia is the main issue a Cocktail of Zithromax, Mepron and doxycycline and others may be considered. Depending on the patient, one drug may be added, incrementally, every 3-4 days. The meds listed are exemplary.  Details including dosages and management of Herxheimer reactions is beyond the scope of this brief post. Transition from one therapy to another also not discussed here.  In some situations, for example, acute Lyme encephalopathy, IV Rocephin is used out of the gate. Rocephin remains the first line of intravenous therapy. I use continuous rather than pulse therapy. When a patient improves, I transition to pulse therapy and fewer antibiotics. Drugs like Dapsone may have a role impacted Babesia and Lyme. There are many other antibiotics and antibiotic combinations not mentioned here. 

Every patient is different and requires a unique treatment plan.  There are no "protocols."
Co-morbidities (other diseases, syndromes) are addressed.  Antibiotics don’t fix everything. 
Insomnia is treated with a variety of agents, e.g.: doxepin, Restoril, Seroquel, etc – whatever it takes. I routinely order sleep studies.  Sleep disorders including sleep apnea are common accompaniments of Lyme. I am frequently surprised to meet patients with 10 years or more of chronic fatigue who have never had a sleep study. 
Fatigue can frequently be effectively treated with drugs such as Nuvigil and others. 
Depression and pain must be treated.  I put the two together because some of the therapies dovetail.  Patients may tolerate various antidepressants in a way I cannot predict.  Some patients are on SSRI, e.g. Lexapro. The patient may not tolerate Cymbalta which is effective for pain. A very low dose of amitriptyline, e.g. 10 mg 1-3 daily can confer to the SSRI the pain modulating properties of Cymbalta without amitriptyline side effects. Gabapentin is indispensable. Muscle relaxers like Zanaflex or Flexeril, when dosed properly can be very effective.  Ketamine, effective for pain and depression is the drug of the future, already in use. There are numerous other approaches. 
Brain fog, cognitive impairment can be treated in part with supplements and prescription drugs like Namenda. 
Inflammation can be treated with supplements like curcumin e.g Theracurmin and Wobenzym, etc.  Rarely short courses of steroids and/or other immune modulators like Plaquenil and biologics may be considered. 
Adjunctive therapies may be very helpful, e.g. hyperbaric oxygen therapy, saunas, and perhaps EMF therapy. 
Ultimately, graded exercise is important. 
Treatment must be paced.  Herxheimer reactions must be heeded.   
We must exclude: immune deficiency disorders, e.g. low IgG and subclasses (IVIG may be very helpful); mast cell disorders; nutritional disorders; autoimmune disorders, e.g. thyroid disease and pernicious anemia and many other medical disorders.  A problem list is created for each symptom.  A differential diagnosis list is attached to each symptom to be revisited if needed.
When a therapy doesn’t work as expected the treatment and/or diagnosis must be reconsidered. 
To summarize:  Aggressive, frequently 3 agent therapy required. Treat other syndromes which may be present. Treat symptoms. Increase function and quality of life.  Address the most likely causes of illness. 

I do things differently from some of my colleagues.  I incorporate many mainstream medical therapies, practices (baby and bathwater).  This treatment approach has been very effective.

The approach is science based, allopathic but translational, incorporating new ideas, theories and clinical therapies. I try to keep things focused and simple (it is obviously quite complicated). 
The above represents opinions of the author, presented for educational purposes only and not intended for any clinical purposes, including the diagnosis or treatment of any patient.

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