Lyme antibiotic treatment

Antibiotics are a mainstay of treatment in chronic lyme disease. There are two standards of care for lyme disease, one which involves the conventional, more restrictive guidelines set out by the Infectious Disease Society of America, and one which involves the more liberal, progressive guidelines set by the International Lyme and Associated Diseases Society. It is the latter that I follow for diagnosis and treatment.

As a naturopathic doctor treating chronic lyme disease, antibiotics are not the sole therapy that I use. It is vital that the non-antibiotic components of chronic lyme treatment are followed, as well as basic naturopathic therapies that will help support nutrition, detoxification, and especially regulating the immune system. Having said that, antibiotics still have a major role to play in most cases of chronic lyme treatment.

Conventional treatment guidelines

Most conventional guidelines use oral doxycycline 100 mg twice a day for 2-4 weeks, or intravenous ceftriaxone for 2-4 weeks if neurological involvement is suspected. Further, such treatment is usually restricted to recent diagnosis, ELISA and western blot confirmed or bull's eye rash (erythema migrans) confirmed cases. I've written about these diagnostic limitations the chronic lyme overview page.

Most doctors treating chronic lyme according to the more progressive ILADS guidelines would agree that often the above is not sufficient, especially in cases which did not have immediate treatment at first onset of infection.  For one thing, it is well known that Borrelia burgderfori, the spirochete that causes lyme, has a slow growth phase, usually cycling every 4 weeks. Given that most antibiotics are not aimed at directly killing the germ, but rather inhibiting its growth, it is usually necessary to treat through multiple growth phases.

My approach with antibiotics

This is a simplified summary, as every single lyme patient that I have treated has been quite complex, with some patients having additional problems with biofilm protecting the lyme in the blood, and most patients having co-infections that need to be addressed separately as well.

When treating chronic lyme, we have to be cognisant of the 4 week growth cycle, and thus need to treat through a few cycles until the patient is relieved of their symptoms for a few of these cycles. Further, we can expect Herxheimer or die off reactions usually every 4 weeks during treatment. Duration is often shortened when we take the holistic, naturopathic approach and focus on nutrition, detoxification, and immune support as well.

Borrelia also has a cyst form (in vitro, or in a test tube, though most clinical experience indicates this happens in the body as well). Thus drugs or herbs may have to be used that address this cyst form as well.  Grapefruit seed extract can be used, and some times metronidazole (though much more toxic) can be used as well.

Chronic lyme treatment requires that we address tissue location of the spirochete Borreliaas well. Thus we need antibiotics that give good blood spikes, such as higher doses of doxycyline or high doses of amoxicillin with probenecid to increase blood levels. Since Borrelia is also in the tissues, getting medicines that penetrate the tissues well, such as the macrolide antibiotics (azithromycin, clarithromycin) can be useful.  This is the rationale behind combination therapy with different antibiotics.

If the tissue location is in the central nervous system, there was a good study on oralcefixime with probenecid vs intravenous ceftriaxone, described here.

Finally, there is a life cycle of the Borrelia that does not involve a cell wall. Thus, if a patient is not responding to a cell wall type agent, such as the penicillin class, or the cephalosporin class (eg cefuroxime, cefixime, ceftriaxone) then other agents such as the protein synthesis inhibitors (eg doxycyline, azithromycin) can be used. Again, the rationale for combination therapy.

Naturopathic support

Before any antibiotic therapy is given, I have followed Dr Burrascano's guideline of "resuscitating" the patient first. This involves largely the non-antibiotic approach to chronic lyme while we wait for labs to be back over 2 weeks.

We have to be aware of the side effects of antibiotic therapy as well, including allergies and drug interactions. Aside from the very important latter two, yeast overgrowth and gastrointestinal disturbances are common. I use natural anti yeast medications prophylactically, as well as good therapeutic doses of probiotics. Liver support and detoxification support (beyond what is described in the non-antibiotic approach to chronic lyme) is also used.  

Therapies to stimulate the immune system, such as ultraviolet blood irradiation therapy,are vital as well given that the immune system needs to be operating at full capacity to speed recovery and prevent recurrence. I have seen patients who have been on long term antibiotics with some benefit, improve rapidly when we stimulate the immune system this way.

There is test tube type of evidence that certain antibiotics impair energy generation by mitochondra within cells. This is important to keep in mind as the immune system can be affected, and of course most lyme patients are profoundly fatigued.  Nutrients such as methyl B 12 injections, Myers infusions, ribose powder, andrographis herb, Eleuthero herb, are used in some cases to support this.

Herxheimer reactions, or worsening of symptoms due to die-off of the lyme spirochete, are common and usually managed well with detoxification support such as glutathione infusions or IV vitamin C.

General information on what to expect

A patient with concerns, or previous diagnosis, of chronic lyme, would call the office to set up an initial visit. It is important to tell the receptionist that the visit involves possibly lyme disease, so adequate time is booked. Further, if labs are sent to Igenex, usually we collect blood on certain days only and it is most convenient to schedule the visit on one of those days.

After an initial consultation and exam, usually we start on naturopathic support as well as order applicable labs. The labs definitely include CBC, liver enzymes, kidney function, and usually involve the lyme western blot from Igenex a well (a better lyme disease test). A lyme Elispot can be useful also.  Coinfections may be tested for, depending on the symptoms and history.

During antibiotic treatment, I assess tolerance and blood tests (liver, kidney, blood counts) usually every 4-6 weeks. Of course antibiotic drug treatment changes depending on how the patient is responding as well. Patients can expect to be on immune support treatments during this time as well, which may involve ultraviolet blood irradiation or ozone therapy every 1-2 weeks.

 

Costs:

The initial visit is $300. Follow up consultations are usually 30 minutes and cost $150.

Lab charges to monitor antibiotic therapy average $50-100, and Igenex lab testing varies according to what is ordered, but the usual western blots for IgG and IgM cost $100 USD each.

UV and ozone therapy is $120.

Oral naturopathic support varies according to the patient, though most patients nutrients cost between $100-300 per month, most of which are available at Kripp's Pharmacy or Finlandia Pharmacy. Nutrients not readily available at those pharmacies can be ordered or are available at the office.

Antibiotic therapy varies in cost, though the older agents, amoxicillin, doxycycline, etc are quite inexpensive. Some of the newer agents, may cost upwards of $100 per month.