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Tuesday, June 24, 2008

Treatment Plans

For the average patients with chronic Lyme disease I start treatment with two antibiotics. I pick one from column A and one from column B. In the first group are Amoxicillin and Ceftin. Amoxicillin is dosed at one gram twice daily or more. Ceftin is dosed at 500 mg twice daily. In the second group are Doxycyline, Biaxin and Zithromax. The dose for Doxy is 200 mg twice daily, the Biaxin is dosed 500 mg twice daily and the Zithromax is dosed 500 mg daily. In the warmer months Doxy is avoided due to photosensitivity. When Biaxin or Zithromax is chosen I add Plaquenil 200 mg twice daily to the regimen to optimize the effectiveness of these medicines.
Patients are instructed to take probiotics with the regimens. I typically recommend a probiotic complex with Acidophilus, such as that found at Whole Foods, one or two tablets twice daily. Initially I like to see patients back in one month. A Herxheimer reaction is expected and this is explained to the patient. If diarrhea is an issue further probiotic coverage with Sachromyes is useful. If muscle pain is prominent enzyme therapy with Wobenzym-N may be helpful. If cognitive issues are prominent a bile acid resin such as Questran one pack twice daily or Welchol three tablets twice daily may be added. If Vitamin D toxicity is a major issue avoidance of the sun and dairy products is recommended and Benicar 20 to 40 mg may be added. Patients are followed at various intervals to assess progress. When the patient is much improved Flagyl is added for cyst coverage. I typically prescribe 250 to 500 mg once daily and may increase the dose to twice daily. Patients are treated until symptoms resolve 100% and then continued for two additional months. If Babesia is strongly suspected by serology or clinical symptoms which sound malaria like, or when the patient fails to respond to treatment as outlined above then treatment is switched to focus on this co-infection. The best regiment is Mepron 750 mg twice daily with Zithromax 600 mg daily. This is continued for at least 3 weeks and for no longer than 4 months. Yeast infections which occur secondary to antibiotics are treated with Diflucan 100 or 200 mg daily for several weeks. Ehylichia infections are treated with Doxycyline as outlined above for two months. If it does not respond well Rifampin 300 mg daily is added. If Bartonella is clearly present I treat with Cipro 250 mg to 500 mg twice daily for two months. Bartonella should also respond to other drugs including Zithromax and Rifampin. At times adding Rifampin to Lyme regiments as described above may be helpful. When high titers for Chlamydia pneumonia are present I combine Amoxicillin with Doxy or Zithro with Flagyl and frequently Rifampin. If patients have severe disease with significant brain involvement I use intravenous antibiotics. Intravenous antibiotics may also be considered when patients respond poorly to 4 to 6 months of oral antibiotics. Typically I prescribe Rocephin 2 gm daily for at least 3 months if possible. I will continue Zithro, Doxy and Flagyl orally if the patient is taking these antibiotics. When patients are allergic to Rocephin I sometimes use intravenous Zithromax 500 mg daily. Another treatment is intravenous Primaxin. I have not used it since is requires multiple daily dosing. Another drug which may have good activity for Lyme is Cleocin, Clindamycin. Some physicians have used it intravenously and orally. It also has some activity against Babesia. So far I have not used this drug either. It is associated with severe diarrhea, Clostridia difficile. This outlines the general process of treatment. It corresponds roughly with ILADS guidelines and methods used by many ILADS affiliated physicians. I have found that overall the treatments above are effective in the vast majority of patients. The duration of treatment varies tremendously. Some patients may improve after 6 month; most need treatment for between 18 months to many years. The best metric for deciding when to stop therapy is patient symptoms.


TickTock said...

What would make you suspect bartenello?

Unknown said...

What type of herxheimer reactions would one expect to experience during treatment with IV rocephin? I've just started my course of therapy (although my insurance carrier has only given leeway for one month of treatment - we'll have to appeal with justification for further treatment) and on the first three days I felt great - Monday night I went home and worked out (cardio for 30 minutes)and then I was just exhausted - Tuesday remained that way and today I had a headache which was relieved with Excedrin and an extra hour of nappage in the bed prior to my going into work.

Does this sound normal?

Lyme report: Montgomery County, MD said...

Some doctors think all Lyme patients have Bartonella. Some physicians use Frye labs which does a blood smear, but I am not sure this is accurate. Bartonella is transmitted by the bites of many insects and has been found in homeless individuals. I think it may only be significant when there is a lot of immune suppression. A psychiatrist who treats a lot of Lyme patients believes it causes a lot of mental issues. Most Lyme drugs cover it. If patients do not get better with typical Lyme therapy then drugs which target this specifically can be tried. My sense is that Bartonella is not that significant. I recently spoke with Dr. Jemsek, a leading Lyme doc in the US. He calls Lyme a Lyme complex disorder and feels all patients should be treated for Lyme, Babesia and Bartonella. There are different opinions. There are not specific symptoms that I am aware of that make one think of Bartonella for the most part.

Lyme report: Montgomery County, MD said...

Herxheimer reactions mean the treatment is working. If a prior Herx with oral antibiotics has resolved and a new one develops with intravenous antibiotics it tells us that the IV is killing a lot of Bb germs that were not being treated with the prior therapy. Usually Herx reactions kick in several days into therapy and last for 2 to 3 weeks. A Herx in someone who has already been treated may be less severe. Herx reactions occur when there is a large kill off of spirochetes with a big surge in cytokine release, chemical mediators of an immune response.

MJ said...

This treatment plan might sound as too many pills or antibiotics, but as a sick person I can say this might be the difference between having a decent life or being prostrated in a bed for the rest of our days suffering innumerable pains and problems...
Doctor, I have no enough words to thank you for sharing your findings, your methods, your plans and concerns.
You are part of the ones that help us see that light out of the tunnel; your dedication is outstanding and I specially admire your honesty and that you are humble, maybe that is what makes you so be better every day! Never stop listening to the patients and please keep on being so compassionate!!!
you don't know how much you have helped me with your blog!!!!!! I just can say, as the people from my country say: "May God pay you"!!
Thank you, thank you!!!!