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Lähettäjä: Soijuv Lähetetty: 4.10.2004 13:21

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New Lyme disease guidelines advocate extended treatment

Lyme disease is considered the fastest-growing vector-borne disease in the United States by the Centers for Disease Control & Prevention. The number of new Lyme disease infections per year may be 10 times higher than the 17,730 cases reported to the CDC during 2000.

The International Lyme and Associated Diseases Society (ILADS) recently published Evidence-based guidelines for the management of Lyme disease as a supplement to the January/February 2004 issue of Expert Review of Anti-infective Therapy.

A need for new guidelines exists, said Andrea Gaito, M.D., a rheumatologist in private practice in Basking Ridge, N.J., and a member of the ILADS Working Group that developed the guidelines. This is because so much new research has been done since the Infectious Diseases Society of America guidelines were published in 2000 in Clinical Infectious Diseases: an official publication of the Infectious Diseases Society of America. She pointed out that because Lyme disease was first recognized fairly recently, until now a void has existed in terms of a standard of care for patient management.

The ILADS guidelines are more broad-based than previous guidelines, said Robert Bransfield, M.D., a psychiatrist in private practice in Red Bank, N.J., who was a member of the team that reviewed the guidelines prior to final submission and is also a member of the ILADS Board of Directors.

The ILADS Working Group broke down Lyme disease into different stages and recommended that treatment correspond to the stage of the illness and the problems that the patient presents with, Gaito said. Bransfield noted that the ILADS guidelines incorporate psychiatric considerations, which previous guidelines did not.

The medications used to treat Lyme disease today are chosen based on a number of criteria, including clinical relevance and patient ease of use, explained Jim Hennig, R.Ph., the director of clinical services for Homecare Services, in Metuchen, N.J.

For many patients with Lyme disease, oral antibiotics are preferred to parenteral therapy, since the former approach is less expensive and invasive. Oral agents that are considered by the guidelines to be "first-line" therapy include amoxicillin, azithromycin (Zithromax, Pfizer), cefuroxime, clarithromycin (Biaxin, Abbott), doxycycline, and tetracycline.

Since data supporting oral therapy in persistent, recurrent, and refractory Lyme disease are limited, IV antibiotics are considered to be the treatment of choice. Patients are usually treated with home infusion therapy, Hennig said, if they do not respond to oral therapy or if they are diagnosed with Lyme disease only after they have significant progression of their disease. Patients with advanced disease require intensive infusion therapy, Hennig went on.

In addition, Lyme disease can be associated with physiological and musculoskeletal issues that prohibit those with advanced disease from self-administering complex and extensive therapies, and necessitate assistance with their care, Hennig said. Most patients are treated with a once-daily infusion of ceftriaxone, unless they are allergic to penicillin or cephalosporins. They may also be treated with once-daily or twice-daily infusions of doxycycline, he said, adding that cefotaxime is a third therapeutic option.

In patients who are intolerant of, or who do not respond to, oral or IV antibiotics, intramuscular benzathine penicillin (1.2 to 2.4 million units weekly) is sometimes effective. IM penicillin produces low-serum drug levels and, although the causative organism (B.burgdorferi) succumbs to relatively small concentrations of antibiotics, it's killed slowly. As a result, long-term therapy may be necessary in order to ensure a cure.

Those with Lyme disease present with a plethora of problems, and so require multiple medications (including combination antibiotic therapy in certain refractory cases), Hennig said. Although antibiotics are the primary therapeutic weapons used against Lyme disease, a host of other ancillary medications are also given, he said.

The severity of the disease should determine the duration of therapy, Gaito advises. The main difference between these guidelines and earlier publications is that the ILADS Working Group recommends longer courses of treatment, noted Bransfield.

Pharmacists should understand the importance of routinely monitoring the patient's medication profile, Hennig stressed. They should check for drug-drug interactions and evaluate the impact of the multi-drug regimen on the patient's hematologic profile.

Pharmacists can also act as patient advocates, and obtain authorization for extended courses of treatment, Hennig concluded. The R.Ph. must work on a round-the-clock basis to ensure that patients with Lyme disease get the therapy they need for the length of time that they need it in order to restore a sense of normalcy to their lives.
Charlotte LoBuono

Charlotte LoBuono. New Lyme disease guidelines advocate extended treatment. Drug Topics May 3, 2004;148:22.

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