From the Guidelines
More doxycycline is not recommended for patients with persistent symptoms of Lyme arthritis without response to initial treatment. According to 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, patients with Lyme arthritis who have no or minimal response to an initial course of oral antibiotic may benefit from a 2–4-week course of IV ceftriaxone.
Key Considerations
- The guidelines suggest that additional antibiotic therapy is not recommended for patients with persistent nonspecific symptoms following standard treatment for Lyme disease, but who lack objective evidence of reinfection or treatment failure 1.
- For patients with Lyme arthritis with partial response to initial treatment, 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.
- A second course of oral antibiotics for up to 1 month may be a reasonable alternative for patients in whom synovial proliferation is modest compared to joint swelling and for those who prefer repeating a course of oral antibiotics before considering IV therapy 1.
Next Steps
- Evaluation for alternative treatments, such as switching to a different antibiotic regimen, should be considered for patients with persistent symptoms of Lyme arthritis without response to initial treatment.
- A rheumatology consultation would be beneficial to determine the most appropriate next steps in management, including the possibility of post-infectious inflammatory arthritis that persists after the infection has been cleared.
From the FDA Drug Label
Patients taking doxycycline for ... bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by doxycycline hyclate or other antibacterial drugs in the future.
The patient has already been prescribed two treatment regimens of doxycycline and is still experiencing persistent symptoms. The FDA drug label does not provide guidance on extending or modifying treatment in this scenario. Given the lack of direct information, no conclusion can be drawn about the need for more doxycycline. 2
From the Research
Persistent Symptoms in Lyme Arthritis
- Patients with Lyme arthritis may experience persistent symptoms despite treatment with doxycycline, as seen in studies 3, 4, 5.
- The efficacy of different therapeutic regimens for Lyme arthritis has been reviewed, with oral doxycycline or amoxicillin in association with probenecid showing similar success rates 4.
- However, some patients may not respond to antibiotic treatment, and additional interventions such as disease-modifying drugs or intraarticular injections of steroids may be considered 4, 5.
Treatment Outcomes and Response
- Studies have shown that patients with Lyme arthritis can usually be treated successfully with oral antibiotics, but some may still develop neuroborreliosis or have persistent arthritis despite treatment 5, 6.
- The use of long-term antibiotic therapy may be useful for eradicating the sanctuaries of Borrelia burgdorferi, but there is no evidence that additional or prolonged courses of antimicrobial therapy benefit patients with a chronic fatigue-like state after appropriately treated Lyme disease 4, 6.
Considerations for Treatment
- The diagnosis of Lyme arthritis is typically made through serologic testing and clinical presentation, and the mainstay of initial treatment is a prolonged course of oral antibiotics 3, 7.
- Patients with persistent symptoms despite treatment with doxycycline may require further evaluation and consideration of alternative treatment options, but there is no evidence to suggest that more doxycycline is needed in these cases 6.