Amoxicillin 200 mg

Doxycycline absorption is decreased by food and milk and especially decreased by antacids or laxatives that contain calcium, magnesium, or aluminum or vitamins that contain iron. The latter medications or vitamins should be taken 6 hours before or 2 hours after the doxcycline. Note 1: Doxycycline raises the risk of sunburns due to increased skin sensitivity to sunlight.

Doxycycline side effects include moderate to severe gastric symptoms (nausea, vomiting, diarrhea), vaginal yeast infections, decreased effectiveness of birth control pills, and rarely liver damage or esophagitis. Doxycycline should not be combined with the acne drug isotretinoin as that will increase the risk of elevated intracranial pressure (and the potential for vision loss).

Note 2: Use of any tetracycline-class agent (like doxycycline) with alcohol may lead to a bad reaction with symptoms such as headaches, nausea, vomiting, confusion, and flushing. Note 3: Doxycycline is contra-indicated in pregnancy.

Previously its use was discouraged in children under age 8, but the American Academy of Pediatrics has recently revised their guidelines to allow use.

Note 4: Patients on blood thinners (anti-coagulants) should be aware that doxycycline can lead to an enhancement of the anti-coagulant effect, possibly increasing the risk of bleeding.

The impact of anti-coagulants while on doxycycline should be monitored by the health care provider.

Ceftriaxone (Rocephin) Ceftriaxone is a third generation cephalosporin and, like other cephalosporins, is bacteriocidal.

Individuals with neurologic Lyme disease, cardiac Lyme disease, or Lyme arthritis that hasn’t responded well to oral antibiotic treatment will often be given intravenous ceftriaxone.

Ceftriaxone has excellent penetration of the blood-brain barrier and is one of the most effective drugs for Lyme disease. Ceftriaxone is typically given once a day intravenously, typically in 45 minutes. While this can be administered in the doctor’s office on a daily basis through a

peripheral

Note 1: Ceftriaxone can result in biliary sludging that in some patients leads to biliary stones and need for gall bladder removal; in our research study, one patient of 37 developed

biliary

Therefore, patients need to remember to flush their PICC or Mid-line daily, to keep the PICC line site clean, and to not engage in “jerky” arm movements, such as might occur when washing windows or playing tennis or golf. IN the evaluation of the patient prior to insertion of a PICC line or a Mid-Line, the clinician order blood tests to determine if the patient is at higher risk of forming blood clots or inquire about one’s family history of blood clotting. Note 3: Rarely ceftriaxone can trigger hemolytic anemia and pancreatitis. Note 4: Cefotaxime (Clarforan) is also a 3rd generation intravenous antibiotic. While Cefotaxime is less likely to cause gallstones, it requires 3x daily dosing which for most patients is too difficult to maintain. Given that it is essential for efficacy that the drug be administered every 8 hours, cefotaxmine is less commonly used than ceftriaxone. Benzathine Penicillin (Bicillin-LA) Benzathine Penicillin is an intramuscular form of penicillin that has the advantage of being long-acting and allowing for consistently high blood and tissue levels of penicillin.

Early studies indicated that it was helpful for neurologic Lyme disease, but not nearly as effective as intravenous ceftriaxone (Rocephin). The blood levels after benzathine penicillin are almost as high as after IV ceftriaxone.

Because of the intramuscular administration, the risk of gastrointestinal side effects and yeast infections are lower than with oral antibiotics. Note: In most individuals Bicillin is self-administered, often in the muscle of the buttocks.

A lidocaine-like anesthetic cream can be applied topoically30-60 minutes before to reduce the injection site pain. The downside to benzathine penicillin is that many people do not want to inject themselves.

Because once injected, it can’t be removed, it is important to make sure the individual is not allergic to this medication before initiating treatment.

Azithromycin and clarithromycin are macrolide

antibiotics

Both azithromycin and clarithromycin are considered second-line agents for Lyme disease among individuals who cannot tolerate doxycycline, amoxicillin, or cefuroxime. (Erythromycin is considered inferior to the other first line agents such as doxycycline or amoxicillin and is therefore not recommended as a primary agent for Lyme disease.) In addition to their

benefits

There are study design problems with the research studies of azithromycin and clarithromycin; therefore, it is hard to know whether they are truly less efficacious than the first-line agents for early Lyme disease. Macrolides however should be used with caution given the risk of interaction with other medications. The key to consider is that these antibiotics impact the liver enzymes that help to metabolize other medications; specifically they can affect the cytochrome P450 1A2 and 3A4 isoenyzmes. For example, erythromycin or clarithromycin can lead to dangerously increased blood levels of the anticonvulsant drug carbamazepine (Tegretol) as well as increases in the anti-anxiety drug alprazolam (Xanax). Erythromycin and clarithromycin can also lead to an increase in the blood levels of the anti-asthmatic drug, theophylline, which can put the patient at risk for seizures or arrhythmias.

When macrolides are used with paroxetine (Paxil) – an anti-depressant drug, there may be an unexpected increase in the blood level of the parosetine due to the macrolide-inducted inhibition of the liver enzyme metabolism; this could lead to mania or serotonin syndrome. These approaches are considered for those patients who have persistent symptoms that have not abated or resolved after antibiotic therapy.

When symptoms persist, it is very important to take a fresh look at the patient and determine whether other problems have emerged (possibly unrelated to Lyme disease) that may be causing the symptoms.

For example, fatigue may be due to anemia or thyroid deficiencies.

Numbness and tingling may be due to vitamin deficiency (B1, B6, B12), diabetes, carpal tunnel sydnrome, or autoimmune causes. While infection with Borrelia burgdorferi

itself

None of these treatments have been FDA-approved for the treatment of Lyme disease-related symptoms.

Neuropathic pain (numbness, tingling, burning, shooting) and central "brain" pain syndromes can often be helped with agents such as gabapentin ("Neurontin") or pregabalin ("Lyrica").

There was a small open label trial that showed that gabapentin was quite helpful in reducing neuropathic pain for a group of Lyme patients complaining of persistent fatigue (Weissenbacher 2005).

Neuropathic, muscular, and arthritic pain can often be helped with agents such as amitriptyline, cyclobenzaprine, or SNRIs (e.g., duloxetine (Cymbalta), milnacipran (Savella), venlafaxine (Effexor)).

The SNRIs are particularly useful for patients with persistent LYme-related symptoms as they are quite effective for reducing pain as well as for improving mood and decreasing anxiety. It should be noted however that to obtain the pain relief from a medication such as venlafaxine, in most patients the dose needs to be increased to 225-300 mg/day in order to obtain the benefits for pain and mood. Neuropathic pain that has an autoimmune etiology (possibly triggered by the prior infection with B.burgdorferi) may benefit from treatment with intravenous gammaglobulin therapy .

Musculoskeletal pain may be helped by low-dose naltrexone, as 2 published trials

have

Beware however that long-term use of NSAIDS increases the risk of gastric ulcers and kidney damage. For patients whose arthritis is not helped by NSAIDS, published reports indicate that methotrexate or hydroxychloroquine can be helpful; these are called disease-modifying anti-rheumatic drugs. Mindfulness meditation and Yoga can reduce stress and pain and enhance energy.

We have a research study that examines the use of meditation and Yoga for patients with persistent fatigue and pain after antibiotic treatment for Lyme disease. Qigong is a mind-body-spirit practice that integrates posture, movement, breathing technique, self-massage, sound, and focused attention.

In one randomized controlled trial, fatigue and mental functioning were significantly improved in the experimental group compared to the wait-list controls. Ensure quality sleep of seven to eight hours per night. Undiagnosed sleep disorders need to be ruled-out (e.g, sleep apnea). Because fatigue can be a prominent symptom of depression, it is important to ensure a low-grade depression hasn't gone untreated. Bupropion is an anti-depressant agent that boosts norepinephrine and dopamine and tends to improve mood, energy, and cognitive focus.

Onset of improvement is usually seen after two to four weeks of daily treatment. Modafinil (Provigil) or Armodafinil (Nuvigil) are both wakefulness promoting agents that have been reported to help fatigue in other diseases. Amantidine Acupuncture has been studied as a treatment for fatigue, primarily in China. In a randomized, sham-controlled trial of acupuncture of 127 individuals diagnosed with "chronic fatigue syndrome" (two sessions per week for four weeks), the acupuncture group showed moderately large reductions in physical and mental fatigue.

Mindfulness meditation and Yoga can reduce stress and pain and enhance energy.

We have a research study that examines the use of meditation and Yoga for patients with persistent fatigue and pain after antibiotic treatment for Lyme disease. Qigong is a mind-body-spirit practice that integrates posture, movement, breathing technique, self-massage, sound, and focused attention. In one randomized controlled trial, fatigue and mental functioning were significantly improved in the experimental group compared to the wait-list controls. Poor sleep can lead to daytime fatigue, impaired cognition, and musculoskeletal pain. Clinicians should ask the patient about sleep behaviors, as poor sleep hygiene can induce insomnia.

Undiagnosed sleep disorders should be ruled out, including restless leg syndrome,

narcolepsy

Avoid substances that would impair sleep (e.g., alcohol, appetite suppressants, caffeine).