New lyme
disease guidelines advocate extended treatment
Drug Topics
Montvale, NJ
by Charlotte LouBono
3 May 2004
Lyme disease is
considered the fastest growing vector-borne disease in the US by the Centers
for Disease Control and Prevention (CDC). 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, and this is considered a conservative estimate.
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, MD, a rheumatologist in private practice in
Basking Ridge, NJ, and a member of the ILADS Working Group that developed
the guidelines, because so much new research has been done since the Infectious
Diseases Society of America guidelines were published in 2000 in the 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, clinicians can be unsure regarding what medications
to use and tests to order, and a void exists in terms of a standard of
care for patient management.
The ILADS guidelines
are more broad-based than previous guidelines, said Robert Bransfield,
MD, a psychiatrist in private practice in Red Bank, NJ, who was a member
of the team that reviewed the guidelines prior to final submission. Lyme
disease is a multi-systemic illness with many manifestations, added Bransfield,
who 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 be commensurate with the stage of the illness and the problems
that the patient presents with, Gaito said. Bransfield mentioned that
the ILADS guidelines incorporate psychiatric considerations, which previous
guidelines failed to do.
The kind of medications
used to treat Lyme disease today are chosen based 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, Inc, in
Metuchen, NJ. Patients are usually treated with home infusion therapy,
he 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 receiving complex
and extensive therapies, he said.
Most patients are
treated with a once-daily infusion of ceftriaxone (Rocephin, Hoffman-LaRoche),
unless they are allergic to penicillin or cephalosporins, said Hennig.
They may also be treated with once-daily or twice-daily infusions of doxycycline,
he said, adding that cefotaxime (Claforan, Aventis Pharmaceuticals) is
a third therapeutic option.
Those with Lyme disease
present with a plethora of problems, and so require multiple medications,
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 said. The main
difference between these guidelines and earlier publications is that the
ILADS Working Group recommends longer courses of treatment, concurred
Bransfield. Compared to earlier guidelines, the ILADS document gives greater
recognition to the fact that the risk of untreated Lyme disease outweighs
the risk of long-term therapy. According to Hennig, therapy can last for
4 to 6 weeks or often longer.
R.Phs must understand
the importance of routinely monitoring the patient’s medication profile,
Hennig said. They should check for drug-drug interactions and evaluate
the impact of the multi-drug regimen on the patient’s hematologic
profile. Hennig said that his patients have blood work done on a weekly
basis.
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 need it, in order to restore a sense of normalcy
to their lives.
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