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Treatment Principles

Understanding the nature of this spirochaete and its in vivo behaviour under attack is extremely important. It is actually a very clever bug. it is capable of intracellular activity shedding its cell wall. This structure is called the l-form. Withdraw the antibiotic and given a little time, the cell wall is remanufactured. Then there is the cyst form which is essentially a conglomeration of bacteria fused together. It is clinically inactive in this form.

Then there is the problem of delivery of treatment into the CNS - always difficult to cross the BBB isn't it?

So if in Australia we have a preponderance of neurological infection, any treatment regime will be aimed at all 3 forms of the Borrelia genus and also be capable of delivery into the CNS.

The Herxheimer Reaction

Every patient who has had Lyme disease treatment will talk to you about herxing. A patient needs to be warned of this reaction if you commence treatment. Please Google this for a full explanation but suffice it to say here that the breakdown products of the bacteria cause a nasty generalised reaction that is manifest with severe fatigue, headache, photophobia, muscle pains and much more. Wikipedia has an excellent, to the point, summary at http://en.wikipedia.org/wiki/Herxheimer_reaction

The Neurotoxin

The neurotoxin produced by this bacteria causes symptoms which at first can be very difficult to distinguish from CNS infection and can trick one into thinking there is muscle ligament or nerve infection. Primary symptoms of neurotoxicity are visual disturbance and muscle spasm / tetany. The former is best described as a loss of visual contrast sensitivity

A test for this can be done online at
 http://www.chronicneurotoxins.com/learnmore/lymedisease.cfm

For a video clip of an explanation of the test by the author http://video.google.com/videoplay?docid=1338318115845904191#

 

Treatment Options

Antibiotics

Oral, IM or IV? There are many choices to be made and combination therapy is needed. 
There is no one wonder drug, and treatments need to be cycled every 6-12 weeks depending on response

If a patient has had long standing symptoms and is debilitated orals will not work so well and possibly not at all. The same applies to any patient over 60 and also those who have ever had cortisone by oral or parenteral routes since the onset of Lyme disease. Indeed some proponents advocate this latter group must have parenteral antibiotics. Alcohol must be avoided.

Originally Lyme was treated with Penicillin - Bicillin however these are the advances we now know

All patients require intra and extra cellular antibiotics

Doxycycline and erythromycin work inside the cell whereas Ceftriaxone does not

The spirochaetal form is killed by Penicillin, Cephalosporins, Primaxin or Vancomycin. Abs level must be sustained

L form is killed by tetracycline and erythromycin. Spikes are required

Cyst form is killed by metronidazole tinidazole, rifampicin and plaquenil. Sustained levels are required

 

Oral

Clarithromycin is well tolerated and effective orally. Dosage 500mg bd. It is now known oral erythromycin is ineffective.
Doxycycline is likewise effective. Daily dose of 200mg for chronic Lyme has long been discarded. Did you know 400mg of doxycycline is bactericidal. This is the minimum effective dose. Some proponents recommend 600mg. 
Amoxycillin as the preferred choice of penicllin in EM or early Lyme disease is not considered effective now by itself for protracted Lyme disease.
Metronidazole at standard dosage kills the L-form and the cyst form. However watch out, as it can cause a very nasty but reversible peripheral neuropathy. Timidazole is equally effective but the dosage is relatively higher at 500mg bd for 14 days per month. Rifampicin and plaquenil may also be used.

Parenteral - the two standard choices here are

Ceftriaxone at a minimum of 2gm daily but 4gm is better. Some extremists are using 6gm. Biliary sludging and compaction is a severe worry with the higher doses and can be prevented by simultaneous use of Ursodeoxycholic acid. Treatment with ceftriaxone is given over 4 days with 3 days off per week. The rationale of this is the bug is stunned and takes time to commence the growth phase again.
Bicillin injections - I wont put forward a suggested regime here, but essentially this can also be pulsed
Benzyl penicillin IVI q 4h
Tigercycline twice a day for 4 days per week
Azithromycin twice per week

As well as the Ilads recommendations, here is a US Government treatment guidelines document which is basically in agreement with the above http://www.guidelines.gov/content.aspx?id=9537&search=lyme+disease

Here is a Dutch paper emphasisizing the problem with the cyst form. It also proposes that penicillin and ceftriaxone drive the germ into the cyst form thus emphasisng again teh need to treat all forms http://www.lymemed.nl/wetenschap/312-Margulis-final.pdf

 

Combating the Neurotoxin

Hepatic clearance of the toxin is very high, as the raw toxin in bile. it is then reabsorbed 100% in small intestine. What a clever liver, what a clever toxin. However it can be sequestrated by cholestyramine very effectively. It is said that the toxin load can be virtually eradicated in 2 to 3 months at a dosage of 1 sachet bd. this however has not been my clinical experience with patients still having some symptomatology at 6 months

Nutritional supplements

Expert opinion reinforces the need for adequate dietary supplementation

I am going to refer you to page 27 of the 2008 Burruscano document for a full listing

I find many of my patients just simply cant afford these. For these people I give the following advice.

Proper nutrition is gained by sourcing food fresh and in a large variety. This is not gained on the supermarket restaurant and take away food merry go round because the food is highly processed, pre prepared and packaged and people tend to buy and eat the same things all the time, over and over again.

Best nutritional advice is selecting 30 or more food substances in a day. Some will be in trace quantity in the meal. Then if you can be selecting a large range and differing 30's as much as possible each day you are getting the right variety. 

There is a fuller treatise on nutrition the patient pages

Hyperbarics

Please Google this in association with Lyme for several treatises on the subject

Alternative medicine

My understanding is that any well versed practitioner in this field will advise that antibiotics are essential.