Oral Doxy for Lyme meningo-radiculitis in US

Topics with information and discussion about published studies related to Lyme disease and other tick-borne diseases.
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RitaA
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Oral Doxy for Lyme meningo-radiculitis in US

Post by RitaA » Thu 21 May 2015 5:23

http://www.ncbi.nlm.nih.gov/pubmed/25988066
Oxf Med Case Reports. 2014 Dec 27;2014(9):162-3. doi: 10.1093/omcr/omu061. eCollection 2014.

Lyme meningo-radiculitis responsive to oral doxycycline therapy in the USA.

Jassam YN1, Thaler DE1.

Author information

1 Department of Neurology , Tufts Medical Center , Boston, MA , USA.

Abstract

The spirochete strains that cause Lyme disease are different between the USA and Europe. This leads not only to a variation in clinical presentations, but it was also thought to alter responsiveness to antibiotic treatment. Unlike in Europe, in the USA there are no head-to-head trials of oral and intravenous antibiotics in the treatment of neuroborreliosis. Guidelines from the American Academy of Neurology (AAN) state that oral doxycycline is probably safe and effective in treating neuroborrliosis without parenchymal involvement, this was mainly extrapolated from European studies data with no reports from North America. To the best of our knowledge, this is the first reported case of Lyme meningo-radiculitis successfully treated with oral doxycycline alone in the USA. This comes in support of the oral doxycycline as an initial and even monotherapy for non-parenchymal Lyme disease of the nervous system in the USA.

PMID: 25988066 [PubMed]
Edited to add:

The full article is now available here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4370023/
Last edited by RitaA on Sat 23 May 2015 6:21, edited 1 time in total.

RitaA
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Re: Oral Doxy for Lyme meningo-radiculitis in US

Post by RitaA » Thu 21 May 2015 6:58

The Rel-Risk blogger has provided some additional information here:

http://rel-risk.blogspot.com/2015/05/oral-doxy.html
Wednesday, May 20, 2015

Oral Doxy

Notes from:
Jassam YN, Thaler DE. Lyme meningo-radiculitis responsive to oral doxycycline therapy in the USA. Oxf Med Case Reports. 2014 Dec 27;2014(9):162-3.


The clinical manifestations of neuroborreliosis are different between the USA and Europe perhaps due to different prevalence of spirochete strains. Guidelines published in 2007 by the AAN state that both intravenous ceftriaxone and oral doxycycline are probably effective and safe in treating CNS Lyme without parenchymal involvement. To the best of our knowledge, treatment of Lyme radiculitis with oral doxycycline has not been reported previously in the USA.

The triad of meningitis, cranial neuritis and radiculoneuritis is known in Europe as Garin-Bujadoux-Bannwarth syndrome. The incidence of radiculoneuritis in the USA is ~3% but may be under-recognized. Prevalent strains are different in Europe and the USA, so it is unclear whether treatment effects might also differ. The CSF concentration of doxycycline after oral administration exceeds the minimum inhibitory concentrations of most strains of B. burgdorferi in pharmacological studies.

In our patient, the response was demonstrated clinically, radiologically and through improvement of CSF results, which is in agreement with previous reports from Europe and adds to our understanding of Lyme disease here in the USA.

The patient:

A 61-year-old Caucasian female presented with progressive left leg and lower back pain following 3 weeks of fever and headache. She did not recall any tick bites but lives on a farm in southern Massachusetts. Serology was abnormal for a positive C6 index .5.0 (normal value, 0.90) and Lyme IGM western blot (kD 23, kD 41 IgM bands reactive). The Lyme IgG western blot as negative (kD41, kD45 reactive).

Martian
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Re: Oral Doxy for Lyme meningo-radiculitis in US

Post by Martian » Fri 22 May 2015 3:10

This is good news, isn't it?

Oral doxycycline is much more convenient, safer and cheaper than intravenous ceftriaxone.

The data that I am missing is the dosage. Since it's a case of neuroborreliosis I am guessing 400 mg per day.

velvetmagnetta
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Re: Oral Doxy for Lyme meningo-radiculitis in US

Post by velvetmagnetta » Fri 22 May 2015 4:48

Martian wrote:This is good news, isn't it?

Oral doxycycline is much more convenient, safer and cheaper than intravenous ceftriaxone.

The data that I am missing is the dosage. Since it's a case of neuroborreliosis I am guessing 400 mg per day.

I agree with you, Martian. IV antibiotics always seemed so risky to me if you can get the same benefit from taking oral. IV may look and feel like it is a stronger treatment, but in reality, in the reports I've seen about bio-availability, it's about the same - and you can't get sepsis from antibiotics taken by mouth as far I know. I always found it a wonder that IVs were used in Lyme cases - an even greater wonder that any patient would prefer a treatment with the possible side-effect of death!

RitaA
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Re: Oral Doxy for Lyme meningo-radiculitis in US

Post by RitaA » Fri 22 May 2015 14:18

Martian wrote:This is good news, isn't it?

Oral doxycycline is much more convenient, safer and cheaper than intravenous ceftriaxone.

The data that I am missing is the dosage. Since it's a case of neuroborreliosis I am guessing 400 mg per day.
I agree with you and velvetmagnetta that this is good news since oral doxycycline is indeed more convenient, safer, and far less expensive than intravenous ceftriaxone.

I wondered about the dosage too. There is compelling evidence by European researchers (that I have posted elsewhere and will try to find later *) that 400 mg of doxycycline is preferable to 200 mg in treating neuroborreliosis. Even the American Academy of Neurology allows for up to two doses of 200 mg of doxycycline per day in their treatment recommendations.

http://www.ncbi.nlm.nih.gov/pubmed/17522387
Neurology. 2007 Jul 3;69(1):91-102. Epub 2007 May 23.

Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.

Halperin JJ1, Shapiro ED, Logigian E, Belman AL, Dotevall L, Wormser GP, Krupp L, Gronseth G, Bever CT Jr; Quality Standards Subcommittee of the American Academy of Neurology.

Author information

1 Department of Neurosciences, Overlook Hospital, NYU School of Medicine, Summit, NJ, USA.

Erratum in
Neurology. 2008 Apr 1;70(14):1223.

Abstract

OBJECTIVE:

To provide evidence-based recommendations on the treatment of nervous system Lyme disease and post-Lyme syndrome. Three questions were addressed: 1) Which antimicrobial agents are effective? 2) Are different regimens preferred for different manifestations of nervous system Lyme disease? 3) What duration of therapy is needed?

METHODS:

The authors analyzed published studies (1983-2003) using a structured review process to classify the evidence related to the questions posed.

RESULTS:

The panel reviewed 353 abstracts which yielded 112 potentially relevant articles that were reviewed, from which 37 articles were identified that were included in the analysis.

CONCLUSIONS:

There are sufficient data to conclude that, in both adults and children, this nervous system infection responds well to penicillin, ceftriaxone, cefotaxime, and doxycycline (Level B recommendation). Although most studies have used parenteral regimens for neuroborreliosis, several European studies support use of oral doxycycline in adults with meningitis, cranial neuritis, and radiculitis (Level B), reserving parenteral regimens for patients with parenchymal CNS involvement, other severe neurologic symptomatology, or failure to respond to oral regimens. The number of children (> or =8 years of age) enrolled in rigorous studies of oral vs parenteral regimens has been smaller, making conclusions less statistically compelling. However, all available data indicate results are comparable to those observed in adults. In contrast, there is no compelling evidence that prolonged treatment with antibiotics has any beneficial effect in post-Lyme syndrome (Level A).

Comment in

Re: Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. [Neurology. 2008]

PMID:
17522387
[PubMed - indexed for MEDLINE]
From the full article: http://www.neurology.org/content/69/1/91.full
Table 2

Antimicrobial Regimens for the Treatment of Lyme Disease Neuroborreliosis

Doxycycline* (Vibramycin) 100 to 200 mg, twice per day

Children eight years or older: 4 to 8 mg per kg per day in two divided doses, maximum is 200 mg per dose

Although it is likely that US patients with the same manifestations of neuroborreliosis will similarly be doxycycline responsive, there are differences between the B burgdorferi strains and species prevalent in the United States and Europe; hence the data may not be fully applicable. However, European studies 38,39 assessing the susceptibility of different Borrelia strains to multiple antimicrobials, including doxycycline, have found no significant differences in minimal inhibitory concentrations among the different species. Minimal bactericidal concentrations (MBCs) have been more variable 39 but for doxycycline were comparable for all species. In light of these observations, treatment responses might be expected to be comparable in US and European patients; however, this remains untested.
Here are some European studies that indicate oral doxycycline is as effective as intravenous ceftriaxone -- at least in the majority of cases.

http://www.ncbi.nlm.nih.gov/pubmed/16012005
Scand J Infect Dis. 2005;37(6-7):449-54.

Intravenous ceftriaxone compared with oral doxycycline for the treatment of Lyme neuroborreliosis.

Borg R1, Dotevall L, Hagberg L, Maraspin V, Lotric-Furlan S, Cimperman J, Strle F.

Author information

1 Department of Infectious Diseases, Sahlgrenska University Hospital, Göteborg, Sweden.

Abstract

This prospective, open-label, non-randomized trial at the University Departments of Infectious Diseases in Ljubljana, Slovenia, and Göteborg, Sweden, was conducted to compare the kinetics of the cerebrospinal fluid (CSF) mononuclear cell count after 10-14 d of ceftriaxone or doxycycline for treatment of Lyme neuroborreliosis. 29 patients were treated with intravenous ceftriaxone 2 g daily in Ljubljana and 36 patients with oral doxycycline 400 mg daily in Göteborg. The study protocol included lumbar puncture before and 6-8 weeks after treatment initiation. There was a marked decrease (1.2 log10 x 10(6)/l) of the median CSF mononuclear cell count following treatment. With the assumption of a linear regression of the logarithmic mononuclear cell counts between the 2 lumbar punctures, no significant difference between the 2 antibiotic treatments could be found. All patients were clinically much improved after treatment. At 6 months follow-up 23 (79%) of the ceftriaxone- and 26 (72%) of the doxycycline-treated patients were completely recovered. Intravenous ceftriaxone or oral doxycycline was found to be effective, safe, and convenient for treatment of Lyme neuroborreliosis.

PMID:
16012005
[PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/18567539
Lancet Neurol. 2008 Aug;7(8):690-5. doi: 10.1016/S1474-4422(08)70119-4. Epub 2008 Jun 21.

Oral doxycycline versus intravenous ceftriaxone for European Lyme neuroborreliosis: a multicentre, non-inferiority, double-blind, randomised trial.

Ljøstad U1, Skogvoll E, Eikeland R, Midgard R, Skarpaas T, Berg A, Mygland A.

Author information

1 Department of Neurology, Sørlandet Hospital HF, Kristiansand, Norway

Erratum in
Lancet Neurol. 2008 Aug;7(8):675.

Abstract

BACKGROUND:

Use of intravenous penicillin and ceftriaxone to treat Lyme neuroborreliosis is well documented, although oral doxycycline could be a cost-effective alternative. We aimed to compare the efficacy of oral doxycycline with intravenous ceftriaxone for the treatment of Lyme neuroborreliosis.

METHODS:

From April, 2004, to October, 2007, we recruited consecutive adult patients from nine hospitals in southern Norway into a non-inferiority trial. Inclusion criteria were neurological symptoms suggestive of Lyme neuroborreliosis without other obvious causes, and presence of any of the following: a CSF white-cell count of more than five per mL; intrathecal production of specific Borrelia burgdorferi antibodies; or acrodermatitis chronicum atrophicans. Patients were randomly allocated to receive 200 mg oral doxycycline or 2 g intravenous ceftriaxone once per day for 14 days, in a double-blind, double-dummy design. A composite clinical score (range 0 to 64, 0=best) was based on standardised interviews and clinical neurological examination. The primary outcome was reduction in clinical score at 4 months after the start of treatment. Analysis was per protocol. This trial is registered with ClinicalTrials.gov, number NCT00138801.

FINDINGS:

Of 118 patients who underwent randomisation, 102 completed the study (mean clinical score at baseline 8.5 [SD 4.1]). 4 months after the start of treatment, mean score improvement in the doxycycline group (n=54) was 4.5 (95% CI 3.6 to 5.5) points and that in the ceftriaxone group (n=48) was 4.4 (3.4 to 5.4) points (95% CI for difference between groups -0.9 to 1.1; p=0.84). 26 (48%) patients in the doxycycline group and 16 (33%) in the ceftriaxone group had total recovery (95% CI for difference between groups -4% to 34%; p=0.13). Side-effects possibly related to treatment were reported in 21 (37%) and 26 (46%) patients in these groups, respectively (-28% to 9%; p=0.30). Three patients discontinued ceftriaxone treatment owing to adverse events.

INTERPRETATION:

Oral doxycycline is as efficient as intravenous ceftriaxone for the treatment of European adults with Lyme neuroborreliosis.

Comment in
Oral doxycycline for neuroborreliosis. [Lancet Neurol. 2008]
PMID:
18567539
[PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/24684211
Eur J Neurol. 2014 Sep;21(9):1162-7. doi: 10.1111/ene.12420. Epub 2014 Mar 29.

Oral doxycycline for Lyme neuroborreliosis with symptoms of encephalitis, myelitis, vasculitis or intracranial hypertension.

Bremell D1, Dotevall L.

Author information

1 Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden.

Abstract

BACKGROUND AND PURPOSE:

The treatment recommendation for Lyme neuroborreliosis with central nervous system (CNS) symptoms is intravenous ceftriaxone, according to current American and European guidelines. For Lyme neuroborreliosis with peripheral nervous system (PNS) symptoms, treatment with intravenous ceftriaxone and oral doxycycline is considered equally effective. The purpose of this study was to evaluate the efficacy of oral doxycycline in the treatment of Lyme neuroborreliosis with CNS symptoms.

METHODS:

Patients with Lyme neuroborreliosis who had undergone cerebrospinal fluid (CSF) sampling before and after treatment at the Department of Infectious Diseases, Sahlgrenska University Hospital, during the period 1990-2012, were included in this retrospective study. The CSF mononuclear cell count was used as a surrogate marker of treatment outcome. Comparisons of CSF mononuclear cell counts were made between patients with CNS symptoms and patients with PNS symptoms before and after treatment with oral doxycycline.

RESULTS:

Twenty-six patients classified as having CNS symptoms and 115 patients classified as having PNS symptoms were included. The decline in CSF mononuclear cell counts did not differ significantly between the two groups of patients. All patients with CNS disease showed a marked clinical improvement after treatment, even though 62% had remaining symptoms at the end of follow-up.

CONCLUSION:

Treatment with oral doxycycline resulted in a similar decrease in CSF mononuclear cell counts in patients with Lyme neuroborreliosis with CNS symptoms compared with patients with Lyme neuroborreliosis with PNS symptoms. The results indicate that oral doxycycline is an effective treatment for Lyme neuroborreliosis irrespective of the severity of symptoms.

© 2014 The Author(s) European Journal of Neurology © 2014 EAN.

KEYWORDS:
Lyme borreliosis; Lyme neuroborreliosis; central nervous system Lyme disease; doxycycline

Comment in

Oral treatment of parenchymal central nervous system neuroborreliosis--are we there yet? [Eur J Neurol. 2014]

PMID:
24684211
[PubMed - indexed for MEDLINE]
Edited to add:

* Here is one of the articles that I had in mind when it comes to treating neuroborreliosis with a total of 400 mg of doxycycline as opposed to 200 mg daily:

http://www.ncbi.nlm.nih.gov/pubmed/2782858
Antimicrob Agents Chemother. 1989 Jul;33(7):1078-80.

Penetration of doxycycline into cerebrospinal fluid in patients treated for suspected Lyme neuroborreliosis.

Dotevall L1, Hagberg L.

Author information

1 Department of Infectious Diseases, University of Göteborg, Sweden.

Abstract

Twelve patients were treated orally with 100 mg of doxycycline twice a day (b.i.d.) and 10 patients were treated with 200 mg b.i.d. for suspected tick-borne neuroborreliosis (Lyme borreliosis). At 5 to 8 days after the start of therapy, the mean concentrations in serum were 4.7 micrograms/ml for the doxycycline dose of 100 mg b.i.d. and 7.5 micrograms/ml for 200 mg b.i.d., 2 to 3 h after the last drug administration. The corresponding levels for cerebrospinal fluid were 0.6 and 1.1 micrograms/ml. Since a doxycycline concentration in cerebrospinal fluid above the estimated MIC for Borrelia burgdorferi (0.6 to 0.7 microgram/ml) is wanted in patients treated for severe neuroborreliosis, the higher dose is preferable.

PMID:
2782858
[PubMed - indexed for MEDLINE]
PMCID:
PMC176065
Free PMC Article
Last edited by RitaA on Fri 22 May 2015 22:39, edited 1 time in total.

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ChronicLyme19
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Re: Oral Doxy for Lyme meningo-radiculitis in US

Post by ChronicLyme19 » Fri 22 May 2015 15:20

I would caution though that not everyone is able to absorb the oral antibiotics well or their gut might not be able to handle the high doses of antibiotics. I would think they should be checking blood levels to confirm. I also worry about doxycycline round bodies like it did in the Sapi study.

Infect Drug Resist. 2011;4:97-113. doi: 10.2147/IDR.S19201. Epub 2011 May 3.
Evaluation of in-vitro antibiotic susceptibility of different morphological forms of Borrelia burgdorferi.
Sapi E1, Kaur N, Anyanwu S, Luecke DF, Datar A, Patel S, Rossi M, Stricker RB.

I do agree with you all though, that if this really is as effective, that it has less serious risks than a PICC line.

I've had this discussion several times over with my own doc on whether or not it's worth putting me on IVs. In the end we decided to use the oral route, with extended release doxycycline and extended release amoxicillin. The extended release versions are much easier on your gut and showed better improvement than the regular versions.
Half of what you are taught is incorrect, but which half? What if there's another half missing?

RitaA
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Re: Oral Doxy for Lyme meningo-radiculitis in US

Post by RitaA » Sat 23 May 2015 6:20

From an earlier post:
Martian wrote: The data that I am missing is the dosage. Since it's a case of neuroborreliosis I am guessing 400 mg per day.
The full article is now available here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4370023/

Unfortunately, the dosage of doxycycline used to treat this patient is not mentioned even in the full article, however the following does explain why IV ceftriaxone was not used:
Due to a history of anaphylaxis to ceftriaxone, she was treated with oral doxycycline for 6 weeks.
Also from the full article:
In conclusion, oral doxycycline may be sufficient as the initial treatment of neuroborreliosis without parenchymal involvement in the USA. More studies are needed to establish the role of oral doxycycline in the management of North American Lyme disease and to characterize the syndromes in which intravenous antibiotics are required.

RitaA
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Re: Oral Doxy for Lyme meningo-radiculitis in US

Post by RitaA » Mon 25 May 2015 3:46

I just came across this study (published in 1994) that compared IV penicillin to oral doxycycline, and was surprised to see that the dosage of doxycycline was just 200 mg for 14 days. Maybe that's enough for some patients with Lyme neuroborreliosis.

http://www.neurology.org/content/44/7/1203.abstract
Articles

Comparison of intravenous penicillin G and oral doxycycline for treatment of Lyme neuroborreliosis

M. Karlsson, MD, PhD, S. Hammers-Berggren, MD, L. Lindquist, MD, PhD, G. Stiernstedt, MD, PhD and B. Svenungsson, MD, PhD

Karolinska Institute; and the Departments of Infectious Diseases, Danderyd Hospital (Drs. Karlsson and Hammers-Berggren) and Huddinge Hospital (Drs. Lindquist, Stiernstedt, and Svenungsson), Stockholm, Sweden.

doi: 10.1212/WNL.44.7.1203 Neurology July 1994 vol. 44 no. 7 1203

ABSTRACT

To compare the efficacy of oral doxycycline and IV penicillin G for the treatment of neuroborreliosis, we randomized consecutive patients with Lyme neuroborreliosis to receive either IV penicillin G (3 g q 6 h) or oral doxycycline (200 mg q 24 h) for 14 days. All patients had antibodies against Borrelia burgdorferi in serum, CSF, or both, or had a positive CSF culture. Twenty-three patients randomized to penicillin G and 31 patients to doxycycline were included in the study. All patients improved during treatment, and there were no significant differences between the two treatment groups in patient scoring, CSF analysis, or serologic and clinical follow-up during 1 year. There were no treatment failures, although one patient in each treatment group was re-treated because of residual symptoms. In conclusion, oral doxycycline is an adequate and cost-effective alternative to IV penicillin for the treatment of Lyme neuroborreliosis.

© 1994 by the American Academy of Neurology

RitaA
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Re: Oral Doxy for Lyme meningo-radiculitis in US

Post by RitaA » Mon 25 May 2015 4:51

This is a nice recap of the rationale for prescribing 400 mg of doxycycline per day when treating Lyme neuroborreliosis, and why minocycline might be a feasible alternative to oral doxycycline in some cases:

http://cid.oxfordjournals.org/content/30/1/237.2.full
Clin Infect Dis. (2000) 30 (1): 237-238. doi: 10.1086/313604

Minocycline versus Doxycycline in the Treatment of Lyme Neuroborreliosis

Burke A. Cunha

Infectious Disease Division, Winthrop-University Hospital, Mineola, and State University of New York School of Medicine, Stony Brook, New York

Sir—Dotevall and Hagberg [1] from Göteborg University (Göteborg, Sweden) deserve praise for their well-done study on oral doxycycline treatment of Lyme disease—associated facial palsy and meningitis. This study confirms that oral doxycycline is equivalent to parenteral ceftriaxone in the treatment of Lyme disease—associated palsy and/or meningitis. Experience indicates 21 days of oral doxycycline therapy is equivalent to 14 days of ceftriaxone therapy [3], and Swedish investigators have demonstrated that equivalent results are achieved with doxycycline therapy for ≤2 weeks (median, 10.8 days).

Dotevall and Hagberg correctly point out that there has been some reluctance to use oral antibiotics in the treatment of Lyme neuroborreliosis because of fear of inadequate CSF and/or CNS penetration [2, 3]. Doxycycline is preferred over conventional tetracycline for this purpose because of its lipid solubility characteristics [4–6], as stated by Dotevall and Hagberg.

Doxycycline is 5 times more lipid soluble than conventional tetracycline, which is an important determinant of permeability of the blood-brain barrier [7, 8]. Dotevall and Hagberg showed that most patients had highly elevated CSF protein levels, which is the best index of antibiotic permeability of the blood-brain barrier. Aside from emphasizing a shorter duration of therapy, these researchers stressed the use of high dosages of doxycycline (e.g., 400 mg/d) for treatment of Lyme neuroborreliosis.

It is not commonly appreciated that ill patients treated with doxycycline (e.g., patients with legionnaires' disease) should be given a loading regimen of 200 mg iv q12h for the first 72 h, because of doxycycline's lipid solubility characteristics and long half-life. Since 5 serum half-lives are usually required to achieve steady-state serum concentrations, and early therapeutic effect, a loding regimen rather than a loading dose permits rapid saturation of the serum. If doxycycline is administered in the usual dosage of 100 mg q12h, then it takes 4–5 days to achieve steady-state kinetics and an observable therapeutic response. In Lyme neuroborreliosis, rapid saturation of the CNS compartment is key to the efficacy of short-course regimens (≤14 days). Doxycycline is usually given in dosages of 100 mg q12h, which means that the first week of treatment is virtually lost in achieving steady-state equilibrium, and equilibrium results require 3 weeks [7–10]. Dotevall and Hagberg correctly used 400 mg of doxycycline daily and decreased treatment time to ∼10.8 days.

Because of its pharmacokinetic characteristics, doxycycline may be given at a dosage of 200 mg q12h or may be given as a single daily dose of 400 mg. Gastrointestinal upset is minimal if the tablet form of the formulation is used and taken with meals. CSF concentrations achieved with high doses of doxycycline are approximately twice those achieved with conventional dosing and are achieved more rapidly. There is no toxic liability associated with the high-dose doxycycline regimen [9, 10]. Use of 400 mg of doxycycline daily assures clinicians that CNS concentrations of doxycycline are predictably and rapidly achieved above the MIC90 for Borrelia burgdorferi [1, 6].

Dotevall and Hagberg did not use or comment on minocycline as an alternative to doxycycline. Minocycline is even more highly lipid soluble than doxycycline and has excellent CSF penetration making it potentially useful in treating Lyme neuroborreliosis [7–11]. Minocycline is 2 times more lipid soluble than doxycycline, thereby making it a potential alternative for treatment of Lyme neuroborreliosis. I have treated several patients with Lyme neuroborreliosis with minocycline, and our results are comparable with those of Dotevall and Hagberg. Because minocycline is so highly lipid soluble, 100 mg orally q12h is comparable with 400-mg daily doses of doxycycline in terms of CNS concentrations which are also in excess of the MIC90 for B. burgdorferi.

Although serum levels of doxycycline and minocycline are comparable at any given dose, there are important differences in CSF and/or CNS concentrations (figure 1) [11]. The high lipid solubility of minocycline may cause vestibular side effects in some patients. This side effect limits the administration of minocycline to 100 mg q12h rather than 200 mg q12h [7–9]. Because of this, doxycycline (400 mg daily) remains the preferred oral antibiotic for treatment of Lyme neuroborreliosis in most patients [1]. For patients for whom treatment fails (those with persistent symptoms and/or active CNS disease), minocycline may be a therapeutic option.

Dotevall and Hagberg call for a randomized trial comparing oral doxycycline to iv ceftriaxone to determine the optimal dose and/or duration of treatment for Lyme neuroborreliosis. I would suggest that minocycline also be included in such future comparative studies. Minocycline may permit a shorter duration of treatment in Lyme neuroborreliosis than high dose oral doxycycline because of its excellent CNS penetration.

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Re: Oral Doxy for Lyme meningo-radiculitis in US

Post by ChronicLyme19 » Tue 26 May 2015 15:58

Minocycline may permit a shorter duration of treatment in Lyme neuroborreliosis than high dose oral doxycycline because of its excellent CNS penetration.
This was exactly the rational of the one IDSA doc who first diagnosed me. We were having trouble getting a positive test despite CNS symptoms (this was before the CVID was found). She couldn't put me on IVs without a positive test, so we went this route instead.
Half of what you are taught is incorrect, but which half? What if there's another half missing?

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