What is the treatment for Lyme disease?

Treatment for Lyme Disease

The first-line treatments for Lyme disease are doxycycline (100 mg twice daily for 10 days), amoxicillin (500 mg three times daily for 14 days), or cefuroxime axetil (500 mg twice daily for 14 days), with appropriate dosage adjustments for children. 1

Treatment by Disease Stage

Early Lyme Disease (Erythema Migrans)

• Oral antibiotics for 10-14 days:
  • Adults:
    • Doxycycline: 100 mg twice daily for 10 days
    • Amoxicillin: 500 mg three times daily for 14 days
    • Cefuroxime axetil: 500 mg twice daily for 14 days 1, 2
  • Children:
    • Doxycycline: 4 mg/kg/day in 2 divided doses (maximum 100 mg per dose) for children ≥8 years
    • Amoxicillin: 50 mg/kg/day in 3 divided doses (maximum 500 mg per dose)
    • Cefuroxime axetil: 30 mg/kg/day in 2 divided doses (maximum 500 mg per dose) 1

Neurological Manifestations

• Meningitis or radiculopathy: IV ceftriaxone 2g daily for 14 days (range 10-28 days) 1
• Facial nerve palsy without CSF abnormalities: Oral regimen as for erythema migrans for 14 days 1
• Facial nerve palsy with CSF abnormalities: Treatment as for meningitis 1

Lyme Arthritis

• Initial treatment: Same oral regimens as for early disease
• For persistent arthritis:
  • Mild residual joint swelling: Second course of oral antibiotics for up to 1 month
  • Moderate to severe joint swelling with minimal response: IV ceftriaxone 2g daily for 2-4 weeks 1

Clinical Evidence and Efficacy

Clinical studies have demonstrated the effectiveness of these treatments. In FDA-approved studies, cefuroxime axetil showed comparable efficacy to doxycycline in treating early Lyme disease, with 91% of patients having satisfactory clinical outcomes at one month post-treatment with cefuroxime axetil compared to 93% with doxycycline 2.

The choice between doxycycline, amoxicillin, and cefuroxime axetil should consider:

• Patient age (doxycycline contraindicated in children <8 years)
• Pregnancy status (doxycycline contraindicated)
• Allergies to medication classes
• Side effect profiles (doxycycline has higher rates of photosensitivity reactions, while cefuroxime axetil has higher rates of diarrhea) 2

Post-Treatment Considerations

For patients with persistent symptoms following appropriate treatment:

• Approximately 10% of patients with Lyme arthritis may have persistent joint swelling after recommended antibiotic treatment 1
• Important: Additional antibiotic therapy has not shown benefit for persistent symptoms without objective evidence of active infection 1
• Symptomatic management should focus on:
  • NSAIDs for pain and inflammation
  • Physical therapy
  • Cognitive behavioral therapy for pain management
  • Graded exercise programs 1

Common Pitfalls to Avoid

1. Overtreatment with antibiotics: Extended antibiotic courses beyond recommended durations provide no additional benefit and increase risk of adverse effects 1

2. Misdiagnosis of post-Lyme disease syndrome: Persistent symptoms after appropriate treatment are not due to ongoing infection and do not respond to additional antibiotics 1, 3

3. Failure to consider alternative diagnoses: For persistent symptoms, consider alternative diagnoses such as fibromyalgia 1

4. Neglecting non-antibiotic approaches: For persistent symptoms, focus on symptomatic management rather than continued antibiotic therapy 1

5. Inappropriate prophylaxis: Prophylaxis is only recommended for high-risk tick bites meeting specific criteria (identified Ixodes tick, attached ≥36 hours, prophylaxis within 72 hours of removal, local infection rate ≥20%) 1

Early diagnosis and appropriate antibiotic treatment are crucial for preventing progression to later stages of disease, as all stages of Lyme disease are responsive to antibiotics, with treatment being most effective when initiated early 4.