In an adult with normal renal function, no tetracycline allergy, and not pregnant, should prednisone be used to treat Lyme arthritis in addition to doxycycline?

Treatment of Lyme Arthritis: Avoid Corticosteroids During Active Infection

Do not use prednisone or other corticosteroids during the initial treatment phase of Lyme arthritis while treating with doxycycline—intra-articular corticosteroids should be avoided until bacterial eradication is confirmed. 1, 2

Initial Treatment Approach

• Start with oral doxycycline 100 mg twice daily for 28 days as first-line therapy for Lyme arthritis in adults without neurologic involvement 1, 2
• Doxycycline is preferred over amoxicillin because it provides equivalent efficacy with additional coverage against Human Granulocytic Anaplasmosis, which may co-occur with Lyme disease 2
• The 28-day duration is critical—shorter courses have not been adequately studied for arthritis 1, 2

Why Corticosteroids Are Contraindicated Initially

The IDSA guidelines explicitly state that intra-articular corticosteroid injections are not recommended during the initial treatment phase before confirming bacterial eradication 1, 2. This recommendation exists because:

• Corticosteroids may impair the immune response needed to clear the infection 1
• Introducing steroids before antibiotic therapy has eliminated Borrelia burgdorferi could theoretically worsen or prolong the infection
• There is no evidence supporting benefit from concurrent corticosteroid use during active infection 1

When Corticosteroids May Be Considered

Corticosteroids only become an option after completing both oral AND intravenous antibiotic courses without resolution (antibiotic-refractory Lyme arthritis) 1, 2:

• Wait several months after completing antibiotics to allow inflammation to resolve naturally, as this process is inherently slow even after successful bacterial eradication 1, 2
• Confirm PCR testing of synovial fluid (and tissue if available) is negative for B. burgdorferi 1
• At this stage, intra-articular corticosteroid injections become a reasonable symptomatic treatment option alongside NSAIDs, DMARDs like hydroxychloroquine, or arthroscopic synovectomy 1, 2
• Referral to a rheumatologist is recommended at this antibiotic-refractory stage 2

Management Algorithm for Inadequate Response

If arthritis persists after the initial 28-day doxycycline course 1, 2:

1. Observe for several months first—inflammation resolves slowly even after successful treatment 1, 2
2. If modest improvement but incomplete resolution: Consider a second 28-day course of oral antibiotics 1, 2
3. If no improvement or worsening: Switch to IV ceftriaxone 2 g once daily for 2-4 weeks 1, 2
4. If still no resolution after IV therapy: Confirm negative PCR, then transition to symptomatic management including possible corticosteroids 1, 2

Critical Pitfall to Avoid

Before starting any oral antibiotic therapy, carefully screen for subtle neurologic symptoms such as distal paresthesias or memory impairment 1. These patients may develop overt neuroborreliosis and require IV ceftriaxone from the outset rather than oral therapy 1. Five patients in the landmark trial developed neuroborreliosis after oral treatment, and all had subtle neurologic symptoms at baseline that were initially overlooked 1.

NSAIDs vs. Corticosteroids

• NSAIDs may be used during the initial treatment phase for symptomatic relief while awaiting resolution 1
• This contrasts with corticosteroids, which should be avoided until infection is cleared 1, 2