From the Guidelines
Late-stage Lyme disease treatment is indicated for patients with persistent or recurrent symptoms, such as arthritis, neurological issues, or skin lesions, after a recommended course of oral antibiotic therapy, and is typically considered positive if the patient shows significant improvement in symptoms after a 4-6 week course of antibiotics, such as doxycycline 100mg twice daily or amoxicillin 500mg three times daily, with or without the addition of probenecid 500mg four times daily 1.
Key Indications for Late-Stage Lyme Disease Treatment
- Arthritis without neurologic disease: Oral regimen for 28 days, with options including doxycycline, amoxicillin, or cefuroxime axetil 1
- Recurrent arthritis after oral regimen: Oral regimen or parenteral regimen for 14-28 days, with options including doxycycline, amoxicillin, cefuroxime axetil, or ceftriaxone 1
- Central or peripheral nervous system disease: Parenteral regimen for 14-28 days, with options including ceftriaxone, cefotaxime, or penicillin G 1
- Antibiotic-refractory arthritis: Symptomatic therapy, such as nonsteroidal anti-inflammatory agents, intra-articular injections of corticosteroids, or other medications, with expert consultation with a rheumatologist 1 For patients with neurological involvement, ceftriaxone 2g intravenously daily for 2-4 weeks may be recommended 1. Treatment is usually considered effective if the patient's symptoms resolve or significantly improve within 6-12 months after completion of antibiotic therapy.
Important Considerations
- Patients with persistent or recurrent symptoms after a recommended course of oral antibiotic therapy may require re-treatment with another 4-week course of oral antibiotics or with a 2–4-week course of intravenous ceftriaxone 1
- Clinicians should consider waiting several months before initiating re-treatment with antimicrobial agents because of the anticipated slow resolution of inflammation after treatment 1
- Symptomatic therapy may be necessary for patients with antibiotic-refractory arthritis, and expert consultation with a rheumatologist is recommended 1
From the Research
Indications for Late-Stage Lyme Disease Treatment
The following are indications for late-stage Lyme disease treatment if the result is positive:
- Central nervous system involvement, such as meningoradiculoneuritis in adults or meningitis in children 2
- Lyme arthritis, characterized as a monoarthritis or oligoarthritis, typically involving the knees 3
- Positive serum borrelial antibody titers and/or erythema migrans prior to the onset of symptoms 4
- Persistent symptoms attributed to Lyme disease, such as migratory polyarthralgia, cardiac, and/or neurologic sequelae 5, 3
Treatment Options
Treatment options for late-stage Lyme disease include:
- Doxycycline, which is recommended for late Lyme arthritis 3 and is as effective as ceftriaxone in patients with symptoms suggesting central nervous system involvement 4
- Ceftriaxone, which is recommended for patients with inadequate response to doxycycline or amoxicillin 3
- Amoxicillin, which may be considered for late Lyme arthritis 3
- Intravenous penicillin, which has been used to treat neurologic abnormalities and established arthritis in Lyme disease 6
Considerations
When treating late-stage Lyme disease, consider the following:
- Pre-treatment expectancies regarding symptom improvement are consistently associated with stronger physical and mental health-related quality of life improvements 5
- Post-treatment expectancies regarding having received antibiotics vs. placebo may be associated with more health-related quality of life improvement at end-of-treatment, but not at follow-up 5
- Approximately 10% of patients may have persistent arthritis despite antimicrobial therapy, termed postinfectious Lyme arthritis, which requires immunosuppression and/or synovectomy 3