What is the treatment approach for patients with persisting Lyme disease symptoms after a course of doxycycline (antibiotic)?

From the Guidelines

For patients with persisting symptoms after initial doxycycline treatment for Lyme disease, the recommended approach is individualized symptom management rather than additional antibiotics. This approach is based on the latest guidelines from the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) 1. The guidelines strongly recommend against additional antibiotic therapy for patients with persistent or recurring nonspecific symptoms such as fatigue, pain, or cognitive impairment following recommended treatment for Lyme disease, but who lack objective evidence of reinfection or treatment failure.

The treatment should focus on addressing specific symptoms such as:

• Joint pain: Non-steroidal anti-inflammatory drugs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) may help with arthralgia and myalgia.
• Fatigue: Gradual exercise programs and sleep hygiene improvements are recommended.
• Neurological or cognitive symptoms: Might benefit from consultation with appropriate specialists. Some patients may require pain management specialists or cognitive behavioral therapy. This approach recognizes that post-treatment Lyme disease syndrome likely involves immune-mediated mechanisms rather than ongoing infection, explaining why additional antibiotics typically don't resolve symptoms 1.

It's essential to note that extended antibiotic therapy (beyond the standard 2-4 weeks) has not shown benefit in controlled studies and may increase risks of adverse effects. Regular follow-up is important to monitor symptom progression and adjust management strategies as needed. In patients with Lyme arthritis, consideration should be given to exclusion of other causes of joint swelling, medication adherence, duration of arthritis prior to initial treatment, degree of synovial proliferation versus joint swelling, patient preferences, and cost 1.

From the Research

Treatment Approach for Persisting Lyme Disease Symptoms

• The treatment approach for patients with persisting Lyme disease symptoms after a course of doxycycline is a topic of ongoing research and debate 2, 3, 4, 5, 6.
• According to a 1992 study, there is no evidence that longer duration therapy is indicated or more efficacious for patients with persisting symptoms, and special care is needed to avoid prescribing prolonged or unending courses of antibiotics for noninfectious problems 2.
• A 2016 study suggests that pulse dosing with ceftriaxone may not be effective in eradicating biofilm-like microcolony B. burgdorferi persisters, and that a combination of daptomycin, doxycycline, and cefuroxime without pulse dosing may be more effective 3.
• Clinical trials have shown that extending treatment with doxycycline from 10 to 20 days or adding one dose of ceftriaxone to the beginning of a 10-day course of doxycycline did not enhance therapeutic efficacy in patients with erythema migrans 4.
• Other studies have compared the effectiveness of ceftriaxone and doxycycline in treating acute disseminated Lyme disease, and found that both treatments were highly effective, with similar rates of clinical cure and residual symptoms 5.
• A retrospective study of patients treated with oral doxycycline for Lyme neuroborreliosis found that all patients improved during and after treatment, with a complete recovery seen in 56 patients, and 13 patients still having persistent sequelae 1 year after antibiotic treatment 6.

Considerations for Treatment

• The choice of treatment for persisting Lyme disease symptoms should be based on individual patient needs and circumstances, and should take into account the potential risks and benefits of different treatment approaches 2, 3, 4, 5, 6.
• Patients with persisting symptoms should be carefully evaluated to determine the cause of their symptoms, and to rule out other potential causes of their symptoms 2.
• Treatment should be tailored to the individual patient, and should take into account the severity of their symptoms, their medical history, and their response to previous treatment 4, 5, 6.