Tuesday, February 4, 2020

Lyme update 2020: Key points



Eradication

We go back to the three legged monster I described so many years ago. The tickborne monster has legs of Lyme, Babesia and Bartonella.

For the first time Lyme has been eradicated in an animal model (murine/mice).  Dr. Zang of Hopkins was successful with a daptomycin based 3 drug cocktail: daptomycin, ceftriaxone and doxycycline. These 3 FDA approved drugs are well known and well used. Short of human studies, considered repurposing of vetted drugs may be considered. 

IV therapy is preferred and/or the standard of care in specific cases: sometimes indications are gray.  The risks of IV therapy include infection and venous access line and possible sepsis, thrombosis/blood clots and pulmonary embolism.  The use of intravenous antibiotic does not decrease the likelihood of C. difficile infection. The mainstay of intravenous antibiotic therapy has been Rocephin for many years.  Other antibiotics frequently employed include Flagyl, azithromycin and doxycycline.  Treatment incorporating daptomycin is new and has been well tolerated.  The drug itself is actually quite old.  It has been reserved for serious, resistant infections in many institutions and infectious disease experts have cautioned against first line therapy or other inappropriate use.

The primary indications for intravenous therapy include: Acute/subacute neurological disease ranging from encephalitis, meningitis to peripheral neuropathies including Bell’s palsy and others; acute inflammatory arthritis nonresponsive to oral therapy; Lyme carditis.  Patients with chronic Lyme encephalitis, /neuroborreliosis with cognitive problems are frequent candidates.  Patients who fail aggressive oral therapy, suffering with a multisystem disorder and poor quality of life are candidates.  The choices available for oral therapy are evolving.  As a general rule, IV antibiotics and oral antibiotics should be started and added one ag a time. The anticipated duration of therapy is always completely unknown. Every case is different.

Antabuse

Antabuse/disulfiram may be a game changer. In Vitro studies (Stanford University) demonstrated efficacy against Lyme spirochetes, round forms and biofilm forms. Antabuse has been used for more than a century as an antiparasitic, a commercial agent used for rubber manufacturing and for treating alcoholism.  Antabuse inhibits degradation of acetaldehyde, a toxic intermediary of alcohol metabolism.  Alcohol with disulfiram is a miserable experience one will never forget.  There are better ways to treat alcohol abuse. Antabuse has new life as a Lyme killer.  Antabuse has been effective against resistant forms of bacteria, including Staphylococcus (including biofilms) in-vitro. It seems to have a narrow spectrum against gram positive bacteria and should be easier on the gut. 

Side effects and tolerability described in older literature regarding aplicability for alcoholism does not to apply to our experience with Lyme patients.  For example, rare neuropathy described in alcoholics is not rare for Lyme patients. Herxheimer reactions are common and frequently severe; lower doses of the drug is required.

One option is to cut a 250 mg tabs into quarters enabling initial treatment with 62.5 mg. Compounding allows for more flexibility. Disulfiram can be compounded to any dose you like, for example, 10 mg or 25 mg. A target dose of 250 mg is frequently effective. Some patients claim that the 500 mg dose is more effective. I still combine disulfiram with traditional antibiotics for an optimal response. 

In my experience disulfiram does not eradicate Babesia. In many cases Lyme and Babesia are mysteriously linked. When Lyme clears and remits Babesia too may recede into remission. This may give the appearance the drug kills Babesia. 

Babesia

The malaria like red blood cell parasite is very problematic.   B. duncani and other unidentified organisms are very troublesome. Full eradication should be the goal.  Recurrences can be very difficult since the parasite often returns resistant to an arsenal of anti-Babesia drugs. Most “virgin” Babesia cases respond to Mepron. It is important to start with 10 cc or 2 tsp twice daily with fat. The 5 cc dose frequently recommend is inadequate. Mepron must be used with Zithromax.  Zithromax has the unique ability to concentrate inside cells at an incredibly high level. Other drugs like Biaxin, doxycycline, Bactrim and clindamycin are not effective.   I recommend more than one anti-Babesia drug even when Mepron appears effective. Bellwether symptoms:  night sweats, air hunger, random tearfulness are important but Babesia may cause many other symptoms as well. Coartem is my next favorite agent. It includes a much more bioavailable and effective artemisinin derived component, artemether. 

My third preferred agent is tafenoquine (well tolerated excluding G6PD deficiency). It comes in 2 forms.  Krintafel comes in 150 mg tabs and is used as a single dose for Malaria, repeated at intervals, e.g. weekly and  Arakoda, approved for malaria prevention.  The 100 mg tab is approved for daily use for malaria prevention. 

How long is Babesia treated? We say until symptoms are gone.  I have seen many cases of hoped for cure relapsee. I currently treat for 4 months beyond the point of complete remission if possible.  . 

Bartonella

This small bacteria lives in the cells that cover the inside of blood vessels. The bacteria may occupy red blood cells after infection until they "Uber" into blood vessel lining cells (endothelial cells).  Bartonella persistern forms have been observed.  Complex antibiotic cocktails with multiple bacteriostatic antibiotic, including tetracyclines, macrolides, rifamycins and sulfa drugs do not eliminate the bacteria. Bactericidal drugs, including gentamicin and daptomycin have proved effective. (only by injection, IV or IM). Quinolones should be avoided for safety reasons. 





1 comment:

Lyme report: Montgomery County, MD said...

There is no reason to routinely remove gallbladder because you have Lyme. You cannot go around removing all the organs infected with Lyme in your body.

You need to eradicate the Lyme, everywhere.