Treatment for Lyme Arthritis
For patients with Lyme arthritis, initiate oral antibiotic therapy with doxycycline 100 mg twice daily or amoxicillin 500 mg three times daily for 28 days as first-line treatment. 1, 2
Initial Oral Antibiotic Therapy
- Doxycycline 100 mg twice daily for 28 days is the preferred regimen for adults and children ≥8 years old 2
- Amoxicillin 500 mg three times daily for 28 days is the alternative for children <8 years, pregnant women, or those intolerant to doxycycline 2
- Cefuroxime axetil 500 mg twice daily for 28 days is another effective oral option 2
- Clinical trials demonstrate that 90-95% of patients achieve resolution within 1-3 months after completing oral therapy 3, 4
Critical pitfall: Avoid intra-articular corticosteroids during initial treatment before bacterial eradication is confirmed, as this significantly prolongs time to resolution and increases the number of antibiotic courses required 2, 5
Management Algorithm for Inadequate Response
Mild Residual Swelling After First Course
- Observe for several months before re-treatment, as inflammation resolves slowly even after successful bacterial eradication 1, 2
- A second 28-day course of oral antibiotics may be reasonable for patients with modest synovial proliferation who prefer avoiding IV therapy 1, 2
- Consider medication adherence, duration of arthritis prior to treatment, and degree of synovial proliferation versus joint effusion 1
No or Minimal Response After First Course
- Administer IV ceftriaxone 2 g once daily for 2-4 weeks for patients with moderate to severe joint swelling and minimal reduction of effusion 1, 2
- This represents the appropriate escalation when oral therapy fails 1, 3
Antibiotic-Refractory Arthritis (After Both Oral and IV Courses)
- Refer to rheumatology rather than continuing antibiotics 2, 6
- Treatment options include DMARDs (hydroxychloroquine), biologic agents, intra-articular corticosteroid injections (now appropriate after bacterial eradication attempts), and arthroscopic synovectomy 2
- Certain genetic markers (HLA-DR4) and immune markers (OspA reactivity) are associated with antibiotic-refractory disease 3, 4
Important Caveats and Warnings
Do not prescribe additional antibiotics for persistent nonspecific symptoms (fatigue, pain, cognitive impairment) without objective evidence of active disease such as documented joint swelling, meningitis, or neuropathy 1, 2, 7
- Subjective symptoms persist in 35% at day 20,24% at 3 months, and 17% at 12 months post-treatment without indicating treatment failure 2, 6
- Treatment failure rate with appropriate initial therapy is only approximately 1% 7
Avoid ineffective antibiotics: First-generation cephalosporins, fluoroquinolones, carbapenems, vancomycin, metronidazole, and tinidazole are ineffective against B. burgdorferi 2
Macrolides are inferior: Azithromycin and clarithromycin are less effective than first-line agents and should only be used when patients cannot tolerate doxycycline, amoxicillin, or cefuroxime 2
Monitoring for Neuroborreliosis
- Remain vigilant for development of neurological manifestations during treatment, as neuroborreliosis developed in 5 of 38 patients (13%) treated with oral antibiotics in one trial, with 4 of these cases occurring in the amoxicillin group 3
- This does not contraindicate oral therapy but emphasizes the importance of clinical monitoring 3