‘Testing patients who have diffuse arthralgias, myalgias or fibromyalgia symptoms alone increases the potential for false positive results & inappropriate treatment.’ —Dr. Bockenstedt
“The ACR has previously recommended against routine screening for Lyme disease as a cause of musculoskeletal symptoms in the absence of a potential exposure to ticks that carry the Lyme bacteria or an appropriate physical exam. Testing patients who have diffuse arthralgias, myalgias or fibromyalgia symptoms alone increases the potential for false positive results and inappropriate treatment.”
Antibiotic regimens for the initial treatment of Lyme arthritis
- For patients with Lyme arthritis, use oral antibiotic therapy for 28 days.
For patients in whom Lyme arthritis has not completely resolved
- In patients with Lyme arthritis with partial response (e.g., mild residual joint swelling) after a first course of oral antibiotic, the panel makes no recommendation for a second course of antibiotic vs. observation. Consideration should be given to exclusion of other causes of joint swelling than Lyme arthritis, medication adherence, duration of arthritis prior to initial treatment, degree of synovial proliferation vs. joint swelling, patient preferences and cost. A second course of oral antibiotics for up to one month may be a reasonable alternative for patients in whom synovial proliferation is modest compared to joint swelling and for those who prefer repeating a course of oral antibiotics before considering intravenous antibiotics.
- In patients with Lyme arthritis with no or minimal response (i.e., moderate to severe joint swelling with minimal reduction of joint effusion) to an initial course of oral antibiotic, the panel suggests a two- to four-week course of IV ceftriaxone over a second course of oral antibiotics.
Treating post-antibiotic (previously known as antibiotic-refractory) Lyme arthritis
- In patients who have had no response or an inadequate response to one course of oral antibiotics and one course of IV antibiotics, the panel suggests referral to a rheumatologist or other trained specialist for consideration of the use of disease-modifying anti-rheumatic drugs (DMARDs), biologic agents, intra-articular steroids or arthroscopic synovectomy. Antibiotic therapy for longer than eight weeks is not expected to provide additional benefit to patients with persistent arthritis if that treatment has included one course of intravenous antibiotics.
“In a small subset of patients treated for Lyme arthritis,” says Dr. Bockenstedt, “the swelling does not subside. In those instances, we don’t recommend continued treatment with antibiotics [because] this strategy has not proved to be effective. You can, however, treat these patients with medications used for rheumatoid and other forms of inflammatory arthritis, including DMARDs or biologics, with successful outcomes. These treatments do not lead to a recrudescence of infection. Current research indicates that persistent inflammation may be due to a failure to regulate the immune response after antibiotics have killed the Lyme bacteria.”
