Clinicians Clash Over New Lyme Disease Guidelines

The sticking point is appropriate use of antibiotics -- and for how long

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By
HealthDay Reporter

FRIDAY, July 13, 2007 (HealthDay News) -- Lyme disease can be a confusing ailment, with symptoms differing between patients -- and sometimes even within the same patient -- as the infection runs its course.

That confusion now has spread to its treatment, with physicians locked in a fierce debate over how long the course of antibiotics needed to kill the infection should last.

The Infectious Disease Society of America (IDSA) came up with new guidelines in November, stating that "95 percent of cases of Lyme disease are cured with 10 to 28 days of oral antibiotics."

The guidelines also strongly object to the use of antibiotics in patients beyond 30 days, since long-term antibiotic treatment can cause drug resistance and create other medical risks.

But a substantial number of doctors and patients are arguing against the guidelines, saying that chronic cases of the infection require antibiotic treatment for much longer than one month.

About 20,000 Americans contract Lyme disease every year, said Dr. Gary Wormser, the infection disease specialist who chaired the panel that created the new guidelines.

Lyme disease has been reported in nearly all states, but more than 98 percent of all cases are found in coastal New England and the mid-Atlantic states, as well as Wisconsin, Minnesota and northern California.

The IDSA last updated its guidelines in 2001. The new guidelines represent the latest in scientific knowledge about Lyme disease, Wormser said.

"The available scientific evidence is compelling that there is no indication to treat patients with months-on-end of antibiotic therapy," said Wormser, who is chief of the division of infectious disease and vice chairman of the department of medicine at New York Medical College, in Valhalla, N.Y.

"Indeed, such prolonged antibiotic therapy is not only not beneficial but also places the patient at risk for serious adverse effects from the antibiotics, some of which can be life-threatening," Wormser added.

Other doctors disagree, arguing that the guidelines could keep chronic sufferers from receiving the antibiotics that would cure them.

"We're seeing the danger," said Dr. Raphael Stricker, president of the International Lyme and Associated Diseases Society, the largest medical organization devoted to Lyme illnesses, and medical director of Union Square Medical Associates in San Francisco. "You've got literally thousands of people with chronic infection and persistent symptoms that are often disabling and can disrupt their whole life and work, and they are facing the prospect of treatment that will not cure them."

Lyme disease is caused by the bacterium Borrelia burgdorferi and is transmitted to humans by the bite of infected deer ticks, according to the U.S. Centers for Disease Control and Prevention.

One of the first signs of Lyme disease can be a rash at the site of the tick bite, beginning as a small red spot and growing larger, according to the American Academy of Family Physicians. The center of this rash, called erythema migrans, may fade, creating a "bull's eye" or ring appearance.

Other symptoms include fever, chills, headaches, stiff neck, fatigue, muscle aches and joint pain. In some cases, Lyme disease can spread to the heart or the nervous system, causing an irregular or slow heartbeat.

If Lyme disease goes untreated, it can spread to other parts of the body, causing arthritis and nervous system problems. Trouble concentrating, loss of memory, muscle weakness, and tingling and numbness in the arms and legs can be caused by late-stage Lyme disease, although it rarely causes such nervous system problems, according to the academy.

Stricker and other opponents of the IDSA guidelines said they could lead to more people suffering chronic Lyme disease. Although there's no rule that physicians must follow the IDSA's ruling, insurance companies often base their coverage on these types of guidelines. State medical boards could also refer to the guidelines when investigating allegations of malpractice.

"They don't allow for a clinician's best judgment," Stricker said. "Guidelines usually give you an idea of 'you can do this, you can do that.' These guidelines tell you that you can't do this, you can't do that. They are very restrictive."

Wormser disagrees, saying the guidelines allow for re-treating an exceptional patient who doesn't respond to the recommended course of antibiotics. "The guidelines clearly and expressly acknowledge that they do not substitute for a practitioner's clinical judgment in the care of individual cases," he said.

Stricker believes the federal government ultimately will have to intervene to help resolve the dispute.

"What's going to resolve this controversy is everyone sitting down under the aegis of some government organization and coming to a meeting of the minds," Stricker said. "If it goes as it has been going, the people who are going to suffer are going to be the patients."

More information

To learn more about Lyme disease, visit the U.S. Centers for Disease Control and Prevention.

SOURCES: Gary Wormser, M.D., chief, division of infectious disease, and vice chairman, department of medicine, New York Medical College, Valhalla, N.Y.; Raphael Stricker, M.D., president, International Lyme and Associated Diseases Society, and physician and medical director, Union Square Medical Associates, San Francisco

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