A
Medical Conference Would Help Close The Rift
Steven
Phillips, MD, Wilton
Immediate Past-President, ILADS
HARTFORD
COURANT
September
24th, 2006
I am writing to praise
your evenhanded coverage of the disparate viewpoints on chronic
Lyme disease and the issues that currently face Dr. [Charles
Ray] Jones. I'd also like to take this opportunity to present
some of the science behind these issues.
There are in excess
of 20 published articles in some of the most well respected
medical journals which document unequivocally the persistence
of Lyme bacteria in patients with chronic symptoms who have
failed the IDSA's recommended antibiotic treatment protocols.
Curiously, some of this very same published data to which I
refer has been authored by some of those who penned the IDSA's
Practice Guidelines for the Treatment of Lyme Disease. Despite
this, these guidelines support only short-term antibiotic therapy.
Directly from these
guidelines, it is unambiguously stated that in a study of 123
patients with early Lyme disease who were treated with 20 days
of either of two different antibiotics commonly prescribed,
"19 percent and 16 percent of patients, respectively had
persistent subjective complaints." Failure rates of 19
percent and 16 percent are hardly inconsequential. More worrisome
still, several studies document that antibiotic therapy in accordance
with IDSA's guidelines for patients with later stage Lyme disease
results in chronic symptoms in 25-50 percent. The IDSA is aware
of this because one of the authors of the guidelines was an
author of one of the aforementioned studies.
[Dr. Henry M.] Feder,
who states, "the great, great majority of Lyme patients
fit a very straightforward kind of pattern" and [Dr. Eugene]
Shapiro, who states, "If a patient has only non-specific
symptoms, it's unlikely due to Lyme" may argue that these
patients with chronic symptoms after Lyme disease no longer
have the illness due to the presence of only subjective complaints.
For your readership's clarification, objective clinical signs
such as joint swelling and Bell's palsy can be seen by the physician,
whereas subjective complaints such as headache, fatigue, and
muscle pain are not visible to the physician.
As doctors, we are
all taught in medical school that over 90 percent of the critical
information required in clinical decision-making comes from
talking to the patient. Somehow, this has been overlooked and
been supplanted with an obsession for objective findings in
an illness that is subjective rich and objective poor. In fact,
in a published study that was co-authored by the former head
of the CDC's division in charge of Lyme disease, they found
that in patients with early Lyme disease documented by the initial
prototypical rash, apart from the rash, only 10 percent had
objective signs. In the other 90 percent, only subjective complaints
such as fatigue, muscle pain and headaches were present.
Feder and Shapiro
may argue that these patients had the rash, so therefore they
had an objective finding. This is true. However data from the
CDC document that only 68 percent of patients with Lyme disease
have a history of the rash. This figure is likely over-inflated
due to the selection bias inherent to the fact that the rash
is part of the reporting criteria. In another study by physicians
of the camp that agrees with the IDSA, they found that in late
Lyme disease, only 22 percent had a history of the rash. This
figure is likely under-inflated due to selection bias in the
opposite direction, for patients with Lyme disease who have
the initial rash are more likely to receive early treatment
and less likely to develop late Lyme disease. In yet another
study of chronic Lyme disease despite antibiotic therapy, where
the persistence of the organism was well documented, a full
50 percent of the patients had subjective symptoms only.
Shapiro states that
prolonged antibiotics can cause gallstones and heart infections.
This is half-true. Prudence requires clarification of this statement.
These risks occur with Rocephin, an intravenous antibiotic which
can be used for Lyme. They do not occur with oral antibiotics.
Everything boils down to a risk/benefit analysis. I personally
was treated with over two years of doxycycline and tetracycline
for acne as a teenager. It's a curious double standard that
treating zits with long term antibiotics is OK, but treating
similarly with antibiotics for Lyme disease, an illness which
can cause significant disability, is frowned upon by the IDSA.
Given that the NIH has only funded essentially three large prospective
blinded placebo controlled studies on the antibiotic treatment
of patients with chronic Lyme disease and that two of the three
found statistically significant benefits to treatment, it may
be worthwhile for the IDSA to re-assess a risk-benefit analysis
on this issue.
The ILADS Evidence-Based
Guidelines for the Management of Lyme Disease are currently
the only Lyme treatment guidelines listed on the National Guidelines
Clearinghouse under the auspices of the Department of Health
and Human Services. Despite the fact that these guidelines were
forged from the evidence-based medical literature and published
in a peer reviewed infectious disease journal, Feder states
that "The bias of ILADS is to make everything fit Lyme
disease." His statement is not only unsupported, in my
opinion it betrays a prejudice against doctors that treat Lyme
disease. I think it underscores the absolute necessity of establishing
a dialogue across the medical divide.
A medical conference
where the two sides of Lyme disease can present their data would
be a great first step toward this goal.
Steven
Phillips, MD, Wilton
Immediate Past-President, ILADS
Copyright 2006, Hartford
Courant
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