There are two "side bars" that are worthwhile in this article:
First by Dr. Fallon:
Another point of view
This sidebar, expressing a divergent viewpoint, was prepared with assistance
from Brian Fallon, MD, Associate Professor of Clinical Psychiatry, Columbia
University College of Physicians and Surgeons, New York, NY; and Director, Lyme
Disease Research Program, New York State Psychiatric Institute, NY.
An unusually bitter debate has centered on the diagnosis of seronegative
Lyme disease and the treatment of patientswho often do not have serologic
evidence of infectionwith persisting symptoms after antibiotic treatment for
Lyme disease. The lack of a definitive marker of active Lyme disease clearly
fuels the conflict, allowing for heated argument over whether patients with
lingering symptoms could still have Lyme infection. Some refer to the
persistence of symptoms as the post-Lyme disease syndrome, reflecting the
belief that the cause is not continuing infection but one of a variety of
mechanisms, including permanent damage and immunologic phenomena, triggered by
previous Lyme disease.
Everyone agrees that long-term antibiotics, especially IV antibiotics, are
inappropriate in the absence of persisting infection, but the mainstream
viewpoint is that persisting infection is extremely rare. It is difficult
to believe that the causative spirochete can survive in humans after aggressive
antibiotic treatment. Those who diverge from this viewpoint cite case reports
of the organism's having been cultured in such circumstances.1 The spirochete
is believed to embed itself deep within tissues, eluding normal courses of
antibiotic therapy.
It has been suggested that shorter courses of therapy may at times
suppress rather than eradicate the organism.1 Seronegativity in the presence of
persisting infection is said to occur because antibody responses may wax and
wane over time or be undetectable because of the formation of immune
complexes.1 It has further been suggested that Borrelia burgdorferi can remain
quiescent for months to years before symptoms appear.2 Some physicians thus
believe that 6 weeks should be the minimum treatment duration to ensure that
the antibiotic hits the growth phase of the organism and that late disseminated
infections need to be treated for many months to be successful.
Mainstream physicians point to the lack of data from controlled studies to
back this point of view. Those with divergent views point to data from
uncontrolled trials showing benefit from longer term therapy. In a pilot study,
patients with chronic memory deficits despite treatment for Lyme disease were
tested before and after receiving additional treatment from their personal
physicians. Patients given additional IV antibiotic therapy scored better than
others on standardized measures of cognition after control for baseline
differences, with seronegative patients as likely to improve as seropositive
patients.3 In another study, patients treated with tetracycline for 1 to 11
months showed greater improvement with a longer duration of therapy. Outcomes
were similar for seronegative and seropositive patients.4
Findings such as these require confirmation in randomized,
placebo-controlled studies. Brian Fallon, MD, is presently the principal
investigator of a National Institutes of Health-funded, double-blind,
controlled study of the treatment of chronic Lyme disease that aims to
determine whether 10 weeks of IV antibiotics will result in further improvement
in patients with persistent memory problems who have already received more than
the standard amount of treatment. Outcome will be based on neuropsychological
testing and brain imaging (MRI and positron emission tomography scans).
A recently terminated study sponsored by the National Institute of Allergy
and Infectious Diseases showed no difference between antibiotic-treated and
placebo-treated patients with persisting symptoms, appearing to confirm the
mainstream point of view.
Dr Fallon points to three possible explanations for these results: that
they are correct and there is no benefit to retreating; that aspects of the
study design may have limited the ability to detect differences between groups;
or that the length of time that IV antibiotics were given30 dayswas too
short to properly treat entrenched illness.
1. Liegner KB. Lyme disease: the sensible pursuit of answers. J Clin Microbiol.
1993;31:1961-1963.
2. Logigian EL, Kaplan RF, Steere AC. Chronic neurologic manifestations of Lyme
disease. N Engl J Med. 1990;323:1438-1444.
3. Fallon BA, Tager F, Fein L, et al. Repeated antibiotic treatment in chronic
Lyme disease. Journal of Spirochetal and Tick-borne Diseases. 1999;
6(4):94-102.
4. Donta ST. Tetracycline therapy for chronic Lyme disease. Clin Infect Dis.
1997;25(suppl 1):S52-S56.
Then by Dr.GEOFFREY T. ANDERS, with a interesting approach to treat a patient
and protect the doctor and the patient:
Persistent symptoms of Lyme disease: To treat or not to treat?
A patient demands long-term antibiotic treatment to resolve lingering Lyme
disease symptoms. Must you provide treatment? No. Since the available
controlled studies do not support this therapy, you are at little risk from a
patient's claim of malpractice or inappropriate failure to treat.
Furthermore, since both the American College of Rheumatology (ACR) and the
Infectious Diseases Society of America (IDSA) have weighed in against this
treatment, a decision not to treat would certainly seem in line with mainstream
thinking.
Still, if the patient understands the potential downside of long-term
antibiotic treatment and wants to proceed anyway, why not treat? Patients today
are better informed and want to take an active role in their personal health
choices. It is hard to resist a patient's choice of treatment if there is a
rational basis for it and you believe it will do no harm. There may be a
reasonable basis to treat here since dissension among practitioners persists,
despite organized medicine's positions.
If you decide to treat in accord with the patient's wishes, fashioning and
delivering a clear statement of informed consent are key for your protection.
Probably best, in addition to your {*filter*}and written explanations, is to
require the patient to read selected articles describing the benefits and
possible adverse effects of the desired course of treatment, including the ACR
and IDSA opinions. The written consent should acknowledge that the patient has
read and understood the articles in addition to your advice, warnings, and
recommendations.
This PracticePoint was contributed by practice management consultant
GEOFFREY T. ANDERS, The Health Care Group, Plymouth Meeting, Pa.
From:
Quote:
>Lyme disease: The debate continues,
>>Patient Care 2001;11:60-75, 15 Jun 01
>> http://www.***.com/
15/06a01lymediseas.html
Quote:
Lyme disease: The debate continues, Patient Care 2001;11:60-75, 15 Jun 01