What is the treatment for Lyme-associated erythema migrans?

From the Guidelines

The treatment for Lyme-associated erythema migrans is oral doxycycline 100 mg twice daily for 10-14 days, as recommended by the most recent guidelines 1. This recommendation is based on the strong recommendation and moderate-quality evidence from the 2020 guidelines for the prevention, diagnosis, and treatment of Lyme disease by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) 1. Alternative options include:

• amoxicillin 500 mg three times daily for 14-21 days
• cefuroxime axetil 500 mg twice daily for 14-21 days. Doxycycline is preferred in most adults because it is effective against other tick-borne diseases that may coexist with Lyme disease, as noted in the clinical practice guidelines by the IDSA 1. However, doxycycline should be avoided in pregnant women and children under 8 years old, for whom amoxicillin is the preferred treatment, according to the guidelines 1. For patients allergic to both doxycycline and beta-lactams, azithromycin 500 mg daily for 7-10 days can be used, though it is slightly less effective, as mentioned in the 2020 guidelines 1. Early treatment is important to prevent progression to later stages of Lyme disease, and patients should complete the full course of antibiotics even if symptoms resolve quickly, and they should be monitored for resolution of the rash and other symptoms. These antibiotics work by inhibiting bacterial protein synthesis or cell wall formation, effectively eliminating the causative organism Borrelia burgdorferi. It's worth noting that the 2021 guidelines 1 provide more recent and higher-quality evidence compared to the 2006 guidelines 1, and therefore, its recommendations should be prioritized in clinical practice.

From the FDA Drug Label

Two adequate and well-controlled studies were performed in patients with early Lyme disease. In these studies all patients had to present with physician-documented erythema migrans, with or without systemic manifestations of infection Patients were randomized in a 1:1 ratio to a 20-day course of treatment with cefuroxime axetil 500 mg twice daily or doxycycline 100 mg 3 times daily.

The efficacy data summarized below are specific to this “validated” patient subset, while the safety data summarized below reflect the entire patient population for the 2 studies

Analysis of the submitted clinical data for evaluable patients in the “validated” patient subset yielded the following results:

Table 7: Clinical Effectiveness of Cefuroxime Axetil Tablets Compared to Doxycycline in the Treatment of Early Lyme Disease

Part I (1 Month Posttreatment)*

Part II (1 Year Posttreatment)†

Cefuroxime Axetil Doxycycline

Cefuroxime Axetil Doxycycline

(n = 125) (n = 108) (n = 105‡) (n = 83‡)

Satisfactory clinical outcome§ 91% 93% 84% 87%

Clinical cure/success 72% 73% 73% 73%

Clinical improvement 19% 19% 10% 13%

The treatment for Lyme-associated erythema migrans is cefuroxime axetil 500 mg twice daily for 20 days or doxycycline 100 mg 3 times daily for 20 days 2.

• Key points:
  • Cefuroxime axetil and doxycycline were effective in treating early Lyme disease.
  • Cefuroxime axetil and doxycycline were effective in prevention of the development of sequelae of late Lyme disease.
  • The incidence of drug-related adverse events was similar in the 2 treatment groups.

From the Research

Treatment for Lyme-Associated Erythema Migrans

The treatment for Lyme-associated erythema migrans typically involves the use of antibiotics. The following are some of the commonly used antibiotics:

• Amoxicillin: This is often prescribed for children and adults who are not pregnant or breastfeeding 3, 4, 5, 6.
• Doxycycline: This is commonly used in adults, but it should be avoided in pregnant or breastfeeding women, as well as children under 8 years old due to the risk of tooth and bone disorders 3, 4, 5, 6.
• Cefuroxime axetil: This has been shown to be effective in treating erythema migrans, especially in children who are unable to tolerate amoxicillin 3, 4.
• Ceftriaxone: This is sometimes used, especially in severe cases or when oral antibiotics are not effective 4, 7.

Duration of Treatment

The duration of treatment for erythema migrans typically ranges from 14 to 28 days, depending on the antibiotic used and the severity of the infection:

• Amoxicillin and doxycycline are usually prescribed for 20-28 days 4, 5.
• Cefuroxime axetil is typically prescribed for 20 days 3.
• Phenoxymethylpenicillin, amoxicillin, and doxycycline have been compared in a randomized controlled trial, with no significant difference in effectiveness or safety found between the three antibiotic groups 6.

Effectiveness of Treatment

The effectiveness of treatment for erythema migrans is generally high, with most patients experiencing complete resolution of symptoms:

• Amoxicillin, doxycycline, cefuroxime, and ceftriaxone have been shown to have similar efficacy, clearing signs and symptoms in about 90% of patients, with a relapse rate of less than 5% at 6 months 5.
• Azithromycin, clarithromycin, and erythromycin appear to have lower efficacy 5, 7.