Dissension continues on how to treat Lyme disease

According to guideline author John J. Halperin, M.D., from Atlantic Health and Overlook Hospital in Summit, N.J., previously existing documents help diagnose and treat general Lyme disease, but there is uncertainty about how to treat neuroborreliosis, in which the Lyme disease-causing bacteria Borrelia burgdorferi affect the nervous system. It occurs in 10% to 15% of cases.

In adults and children, the guidelines state that Lyme disease involving the nervous system responds well to penicillin, ceftriaxone, cefotaxime, and oral doxycycline.

Raasch also noted that some experts' experience with doxycycline for treatment of late neurological Lyme disease is not so positive, but the AAN statement derives its conclusions from an adequate strategy of identifying well-done studies to address the use of the drug.

For parenchymal involvement, severe neurologic symptoms, or failure to respond to oral therapy, parenteral antibiotic regimens may be associated with better outcomes.

The new practice parameter also addresses the issue of post-Lyme syndrome, defined as a combination of chronic symptoms of fatigue, musculoskeletal pain, and neuropsychiatric symptoms in the absence of laboratory or clinical evidence of focal or inflammatory nervous system involvement.

While review of the literature found that the etiology of post-Lyme syndrome is uncertain, the AAN guideline states that the syndrome does not respond to prolonged courses of antibiotics and such treatment could be associated with adverse effects, such as diarrhea, bloodstream infections, and blood clots. Not all agree. In fact, the recommendation against long-term use of antibiotics to treat Lyme disease has been a bone of contention among infectious-disease associations since the Infectious Diseases Society of America (IDSA) came out with it in its 2006 guidelines.

Chief author of the International Lyme and Associated Diseases Society (ILADS) guidelines Daniel Cameron, M.D., MPH,, told Drug Topics, "ILADS does not agree with the IDSA nor the AAN guideline recommendations for the treatment of Lyme disease beyond 30 days." Cameron claims the ILADS review of the same published evidence concluded that prolonged antibiotic use is effective for chronic Lyme disease, and that AAN based its recommendation on only three trials (184 patients) with questionable methodology.

Pat Smith, president of the Lyme Disease Association (LDA), questioned the authors chosen to write the AAN guide. "The AAN guideline authors claim that the panel was 'selected to represent a broad range of relevant expertise and opinion,' yet physicians who treat chronic patients are not even represented on the panel," she noted. She added that members of the IDSA guideline panel, on the other hand, are also on the AAN panel, despite the fact that the IDSA guidelines are currently under investigation by the Attorney General in Connecticut for possible antitrust violations, including exclusionary conduct. Both sets of guidelines have three authors in common.

"So while politically powerful medical societies rubber-stamp each other's dogma and deny treatment to patients, thousands of abandoned chronic Lyme patients struggle to find the few courageous physicians who exercise proper clinical judgment and treat those who need it with antibiotics long-term-antibiotics not even denied to those with acne," Smith charged.

The new practice parameter was published in the July 3 issue of Neurology and is available on-line at http:// http://www.neurology.org/cgi/content/full/69/1/91/.