What is the recommended treatment for chronic Lyme disease?

Treatment of Chronic Lyme Disease

There is no recommended antibiotic treatment for "chronic Lyme disease" as this is not a recognized clinical entity by major medical societies, and prolonged antibiotic therapy is strongly discouraged due to lack of benefit and potential harm. 1, 2

Understanding "Chronic Lyme Disease"

The term "chronic Lyme disease" is problematic and requires clarification:

• The Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) do not recognize "chronic Lyme disease" as a valid medical diagnosis 3, 1
• What is often called "chronic Lyme disease" may actually be one of several distinct conditions:
  • Post-treatment Lyme disease syndrome (PTLDS): persistent symptoms after appropriate treatment
  • Late manifestations of untreated Lyme disease (e.g., Lyme arthritis, acrodermatitis chronica atrophicans)
  • Alternative diagnoses unrelated to Borrelia burgdorferi infection

Management Approach

For True Late Manifestations of Lyme Disease

If a patient has objective evidence of active Lyme disease (not just symptoms), treatment should follow these guidelines:

• Lyme arthritis:

  • First-line: Oral doxycycline 100mg twice daily, amoxicillin 500mg three times daily, or cefuroxime axetil 500mg twice daily for 14-28 days 1
  • For persistent arthritis after initial treatment: Consider a second course of oral antibiotics for mild residual joint swelling
  • For moderate to severe persistent joint swelling: IV ceftriaxone 2g daily for 2-4 weeks 1

• Neurologic manifestations with CNS involvement:

  • IV ceftriaxone, cefotaxime, or penicillin G for 14-21 days 3

• Peripheral nervous system manifestations:

  • IV ceftriaxone, cefotaxime, penicillin G, or oral doxycycline for 14-21 days 3

For Post-Treatment Lyme Disease Syndrome

For patients with persistent symptoms following appropriate treatment without evidence of active infection:

• Non-antibiotic symptomatic management is recommended 1
• Approaches include:
  • NSAIDs for pain
  • Physical therapy
  • Cognitive behavioral therapy
  • Graded exercise programs
  • Pain management specialist referral if needed 1

Important Caveats and Pitfalls

• Extended antibiotic therapy beyond recommended durations provides no benefit and increases risk of adverse effects 1, 2

• Combination antimicrobial therapy is not recommended 1

• Antibiotic courses longer than 4 weeks are not supported by evidence 1, 2

• Patients with persistent symptoms should be evaluated for alternative diagnoses, including:

  • Fibromyalgia
  • Chronic fatigue syndrome
  • Autoimmune disorders
  • Neurological conditions
  • Psychiatric disorders 1, 4

• Diagnostic pitfalls:

  • Relying solely on Western blot without ELISA
  • Misinterpreting IgM antibodies without IgG in patients with long-standing symptoms
  • Failure to consider differential diagnoses 4

When to Refer

• Rheumatology: For persistent arthritis after appropriate antibiotic therapy
• Neurology: For persistent neurological symptoms
• Pain management: For chronic pain syndromes
• Psychiatry: For associated mood disorders or when psychological aspects of chronic pain are significant

Remember that symptoms attributed to "chronic Lyme disease" without objective evidence of infection should not be treated with prolonged antibiotics, as this approach has been shown to cause harm without providing benefit 1, 2.