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Early lyme disease.

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.

--Mitchel L. Zoler, Editor

--Heidi Splete, Writer
COPYRIGHT 2004 International Medical News Group
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2004 Gale, Cengage Learning. All rights reserved.

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Title Annotation:Drug Update
Author:Zoler, Mitchel L.; Splete, Heidi
Publication:OB GYN News
Date:Jul 1, 2004
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