Early lyme disease

OB/GYN News, July 1, 2004 by Mitchel L. Zoler, Heidi Splete

Management of Lyme disease focuses on treatment rather than prevention. A vaccine for Lyme disease, which was seemingly safe and effective but also carried a high price tag, was pulled from the market in February 2002 because of low sales and concerns about possible complications.

Infection with Lyme disease is characterized as early or late. Early infection refers to symptoms within 6 months of a bite from an infected tick; late-stage Lyme disease refers to symptoms that have persisted for 6 months or longer. Erythema migrans, the characteristic bull's-eye rash, appears only in the early stage; neurologic involvement may develop at any time. Lyme disease is not contagious and is rarely, if ever, fatal.

The ideal time to treat Lyme disease is in the early phase. Oral dosing with doxycycline or amoxicillin is the treatment of choice for most patients. The optimal duration of treatment for early disease remains controversial. The Infectious Diseases Society of America (IDSA) in 2000 recommended initial treatment with oral antibiotics for 14-21 days, but some experts now suggest treatment for 10-14 days is adequate. They cite study results showing that a 10-day course of doxycycline was as effective as treatment for 20 days.

For patients who realize they've been bitten by a tick that has been attached and feeding for some time (more than 48 hours), a single 200-mg dose of doxycycline taken with food has been shown to be 87% effective in preventing Lyme disease. However, since only one-third of Lyme disease patients recall a tick bite, the absence of a bite in a patient's history does not rule out Lyme disease. Guidelines on treating Lyme disease from the IDSA were published in 2000 (Clin. Infect. Dis. 31[suppl. 1]:S1-14, 2000).

Drug           Cost/Day*  Dosage  What the Experts Say**

doxycycline      $0.22    100 mg  A top choice for early-stage infection
hyclate                   b.i.d.  because it is also effective against
 [Doryx]        [$6.12]           other tick-borne pathogens. May cause
 [Vibramycin]   [$9.02]           photosensitivity, so patients should
                                  be cautioned about using a good
                                  sunblock or avoiding sun exposure.
                                  Take with food for best results; space
                                  doses 12 hours apart if possible.
                                  Duration of treatment is
                                  controversial; recommendations range
                                  from 10 to 21 days. May be used by
                                  pregnant women in their first
                                  trimester but not in second or third
                                  trimester; compatible with breast-
                                  feeding. No dosage adjustment needed
                                  for patients aged 70 years and older
                                  or for patients with renal failure.
amoxicillin      $0.39    500 mg  Best alternative for early-stage
 [Amoxicot]     [$0.90]   t.i.d.  infections in people who can't limit
 [Moxilin]      [$0.51]           their sun exposure or can't take
 [Trimox]       [$1.29]           tetracyclines but can take
                                  penicillins. Ideally, doses should be
                                  spaced 8 hours apart. Dosage can also
                                  be 875 mg b.i.d. Duration of treatment
                                  is controversial; recommendations
                                  range from 10 to 21 days. Safe for
                                  pregnant or lactating women. No dosage
                                  adjustment needed for patients aged 70
                                  years and older.
cefuroxime      $16.04    500 mg  Oral cefuroxime has been shown
axetil                    b.i.d.  comparable to oral doxycycline for
 [Ceftin]      [$18.84]           efficacy. Considered second-tier agent
                                  because of higher cost; indicated only
                                  for patients who cannot take
                                  amoxicillin or doxycycline. Safe in
                                  all stages of pregnancy and when
                                  breast-feeding. No dosage adjustment
                                  needed for patients 70 years and
                                  older. For late Lyme disease, if
                                  arthritis or neurologic manifestations
                                  such as meningitis occur, intravenous
                                  treatment may be needed at dosage of
                                  750-1,500 mg t.i.d.
ceftriaxone    no           2 g/  Available only in trade formulation.
               generic    day IV  Preferred initial treatment for
               available          patients with early Lyme disease who
[Rocephin]     [$97.50]           have symptoms of meningitis or
                                  atrioventricular heart block;
                                  otherwise, no better than oral
                                  options. Usual regimen is daily
                                  treatment for 6-12 weeks. Once
                                  symptoms improve, patient may switch
                                  to oral regimen. Safe in all stages of
                                  pregnancy or when breast-feeding. No
                                  dosage adjustment needed for patients
                                  aged 70 years and older.

* Cost/day for most generic formulations is based on the federal upper
limit for Medicaid reimbursement in the 2003 Red Book. Cost/day for
generic cefuroxime axetil is based on the average wholesale price from
the generic manufacturer listed in the 2003 Red Book. Cost/day for trade
formulations is based on the average wholesale price for a 100-unit
container, or closest size, in the 2003 Red Book.
** Comments reflect the opinions and expertise of the following sources:
Gerald G. Briggs, B.Pharm., pharmacist clinical specialist, Women's
Hospital, Long Beach (Calif.) Memorial Medical Center. Source on drug
safety in pregnant and nursing women.
Dr. Sam T. Donta, professor of medicine (retired), Boston University.
Dr. Stephen J. Gluckman, chief of Infectious Diseases Clinical Services,
Hospital of the University of Pennsylvania, Philadelphia.
Ralph Raasch, Pharm.D., division of pharmacotherapy, University of North
Carolina at Chapel Hill.