Lyme disease controversy

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The term "chronic Lyme disease" is controversial and not recognized in the medical literature,[1] and most medical authorities advise against long-term antibiotic treatment for Lyme disease.[2][3][4] Studies have shown that most patients diagnosed with “chronic Lyme disease” either have no objective evidence of previous or current infection with B. burgdorferi or are patients who should be classified as having post-treatment Lyme disease syndrome (PTLDS), which is defined as continuing or relapsing non-specific symptoms (such as fatigue, musculoskeletal pain, and cognitive complaints) in a patient previously treated for Lyme disease.[5]

Background[edit]

The Centers for Disease Control and Prevention states that "approximately 10 to 20% of patients treated for Lyme disease with a recommended 2-4 week course of antibiotics will have lingering symptoms of fatigue, pain, or joint and muscle aches. In some cases, these can last for more than 6 months. Although often called "chronic Lyme disease", this condition is properly known as "post-treatment Lyme disease syndrome" (PTLDS)".[6] The term is often applied to several different sets of patients. One usage refers to people suffering from the symptoms of untreated and disseminated late-stage Lyme disease: arthritis, peripheral neuropathy and/or encephalomyelitis. The term is also applied to people who have had the disease in the past and some symptoms remain after antibiotic treatment, which is also called post-Lyme disease syndrome. A third and controversial use of the term applies to patients with nonspecific symptoms, such as fatigue, who show no objective evidence they have been infected with Lyme disease in the past, since the standard diagnostic tests for infection are negative.[7][1]

Up to one third of Lyme disease patients who have completed a course of antibiotic treatment continue to have symptoms, often termed "post-Lyme syndrome", such as severe fatigue, sleep disturbance, unconsciousness, and cognitive difficulties, with these symptoms being severe in about 2% of cases.[8][9] While it is undisputed these patients can have severe symptoms, the cause and appropriate treatment is controversial. The symptoms may represent "for all intents and purposes" fibromyalgia or chronic fatigue syndrome.[10] A few doctors attribute these symptoms to persistent infection with Borrelia, or coinfections with other tick-borne infections, such as Ehrlichia and Babesia.[11][12] Other doctors believe that the initial infection may cause an autoimmune reaction that continues to cause serious symptoms even after the bacteria have been eliminated by antibiotics.[13]

A review looked at several animal studies that found persistence of live but disabled spirochetes following treatment of B. burgdorferi infection with antibiotics. The authors noted that none of the lingering spirochetes were associated with inflamed tissues and criticized the studies for not considering adequately the different pharmacodynamics and pharmacokinetics of the antibiotics used to treat the animals in the trials versus what would be expected to be used to treat humans. The authors concluded, "There is no scientific evidence to support the hypothesis that such spirochetes, should they exist in humans, are the cause of post-Lyme disease syndrome."[14]

An advocacy group called the International Lyme And Associated Diseases Society (ILADS)[15] argues the persistence of B. burgdorferi may be responsible for manifestations of late Lyme disease symptoms.[16] It has questioned the generalizability and reliability of some of the above trials and the reliability of the current diagnostic tests.[12][16][17] Major US medical authorities, including the Infectious Diseases Society of America, the American Academy of Neurology, and the National Institutes of Health, have stated there is no convincing evidence that Borrelia is involved in the various symptoms classed as chronic Lyme disease, and advise against long-term antibiotic treatment as ineffective and possibly harmful.[2][1][3][4] Prolonged antibiotic therapy presents significant risks and can have dangerous side effects.[18] One death has been reported from an infected catheter as a complication of a 27-month course of intravenous antibiotics for an unsubstantiated diagnosis of chronic Lyme disease.[19] Randomized placebo-controlled studies have shown that antibiotics offer no sustained benefit in "chronic Lyme" patients, a review notes evidence of both placebo effects and significant adverse effects from such treatment.[5]

Antibiotic treatment is the central pillar in the management of Lyme disease. However, in the late stages of borreliosis, symptoms may persist despite extensive and repeated antibiotic treatment.[20] Although these chronic symptoms are possibly due to either autoimmunity or residual bacteria (see immunological studies below), no Borrelia DNA can usually be detected in the joints after antibiotic treatment, which suggests the arthritis may continue, even after the bacteria have been killed.[13] Lyme arthritis that persists after antibiotic treatment may be treated with hydroxychloroquine or methotrexate.[21] Corticosteroid injections into the affected joint are not recommended for any stage of Lyme arthritis.[22]

Patients with chronic neuropathic pain responded well to gabapentin monotherapy with residual pain after intravenous ceftriaxone treatment in a pilot study.[23] Some antibiotics may have a dual effect on Lyme disease, since minocycline and doxycycline have anti-inflammatory effects in addition to their antibiotic actions, including anti-inflammatory effects specific to the inflammation caused by Lyme disease.[24][25] Indeed, minocycline has been suggested for other neurodegenerative and inflammatory disorders, such as multiple sclerosis, Parkinson's disease, Huntington's disease, rheumatoid arthritis and ALS.[26]

Controversy and politics[edit]

While there is general agreement on the optimal treatment for early Lyme disease, there is considerable controversy over the existence, prevalence, diagnostic criteria, and treatment of "chronic" Lyme disease.[15][27][28] The evidence-based perspective is exemplified by a 2007 review in The New England Journal of Medicine, which noted the diagnosis of chronic Lyme disease is used by a few physicians despite a lack of "reproducible or convincing scientific evidence", leading the authors to describe this diagnosis as "the latest in a series of syndromes that have been postulated in an attempt to attribute medically unexplained symptoms to particular infections."[1] Most medical authorities agree with this viewpoint: the Infectious Diseases Society of America (IDSA), the American Academy of Neurology, the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH), advise against long-term antibiotic treatment for chronic Lyme disease, given the lack of supporting evidence and the potential toxicities.[2][3][4]

A minority view holds that chronic Lyme disease is responsible for a range of unexplained symptoms, sometimes in people without any evidence of past infection.[27] This viewpoint is promoted by many patient advocates, notably an advocacy organization,[15] the International Lyme And Associated Diseases Society.[16] Groups of patients, patient advocates, and the small number of physicians who support the concept of chronic Lyme disease have organized to lobby for recognition of this diagnosis, as well as to argue for insurance coverage of long-term antibiotic therapy, which most insurers deny, as it is at odds with the guidelines of major medical organizations.[27][29]

In 2006, Richard Blumenthal, the Connecticut Attorney General, opened an antitrust investigation against the IDSA, accusing the IDSA Lyme disease panel of undisclosed conflicts of interest and of unduly dismissing alternative therapies and chronic Lyme disease. The investigation was closed on May 1, 2008, without charges when the IDSA agreed to submit to a review of its guidelines by a panel of independent scientists and physicians which would occur on July 30, 2009.[30] Views on the motivation and outcome of the investigation varied. Blumenthal's press release described the agreement as a vindication of his investigation and repeated his conflict-of-interest allegations.[31]

The IDSA focused on the fact that the medical validity of the IDSA guidelines was not challenged,[32] and cited mounting legal costs and the difficulty of presenting scientific arguments in a legal setting as their rationale for accepting the settlement.[33] A journalist writing in Nature Medicine suggested some IDSA members may not have disclosed potential conflicts of interest,[27] while a Forbes piece described Blumenthal's investigation as "intimidation" of scientists by an elected official with close ties to Lyme advocacy groups.[29] The Journal of the American Medical Association described the decision as an example of the "politicization of health policy" that went against the weight of scientific evidence and may have a chilling effect on future decisions by medical associations.[34]

The state of Connecticut went on to enact a law on June 18, 2009, "to allow a licensed physician to prescribe, administer or dispense long-term antibiotics for a therapeutic purpose to a patient clinically diagnosed with Lyme disease."[35] The states of Rhode Island,[36] California,[37] Massachusetts,[38] and New Hampshire[39] have similar laws.[40]

The expert panel's review was published in 2010, with the independent doctors and scientists in the panel unanimously endorsing the guidelines, stating "No changes or revisions to the 2006 Lyme guidelines are necessary at this time," and concluding long-term antibiotic treatments are unproven and potentially dangerous.[41] The IDSA welcomed the final report, stating that "Our number one concern is the patients we treat, and we're glad patients and their physicians now have additional reassurance that the guidelines are medically sound."[42]

Paul G. Auwaerter, director of infectious disease at Johns Hopkins School of Medicine, cited the political controversy and high emotions as contributing to a "poisonous atmosphere" around Lyme disease, which he believes has led to doctors trying to avoid having Lyme patients in their practices.[30]

Harassment of researchers[edit]

In 2001, The New York Times Magazine reported that Allen Steere, chief of immunology and rheumatology at Tufts Medical Center and a co-discoverer and leading expert on Lyme disease, had been harassed, stalked, and threatened by patients and patient advocacy groups angry at his refusal to substantiate their diagnoses of "chronic" Lyme disease and endorse long-term antibiotic therapy.[43] Because this intimidation included death threats, Steere was assigned security guards.[44]

Media[edit]

A 2004 study in The Pediatric Infectious Disease Journal stated 9 of 19 Internet websites surveyed contained what were described as major inaccuracies. Websites described as providing inaccurate information included several with the word "lyme" in their domain name (e.g., lymenet.org), as well as the website of the International Lyme And Associated Diseases Society.[45] A 2008 article in The New England Journal of Medicine argued media coverage of chronic Lyme disease ignored scientific evidence in favor of anecdotes and testimonials:

"The media frequently disregard complex scientific data in favor of testimonials about patients suffering from purported chronic Lyme disease and may even question the competence of clinicians who are reluctant to diagnose chronic Lyme disease. All these factors have contributed to a great deal of public confusion with little appreciation of the serious harm caused to many patients who have received a misdiagnosis and have been inappropriately treated."[1]

The 2008 documentary film Under Our Skin: The Untold Story of Lyme Disease opened June 19, 2009, in New York City. This documentary, made by a director whose sister contracted the disease, argues that chronic Lyme disease exists.[46] Lyme disease was also the focus of a major feature in The Times in February 2010[47] that detailed the impact the disease had on British author Alex Wade.

References[edit]

  1. ^ a b c d e Feder, HM; Johnson, BJB; O'Connell, S et al. (October 2007). "A Critical Appraisal of "Chronic Lyme Disease"" (PDF). NEJM 357 (14): 1422–30. doi:10.1056/NEJMra072023. PMID 17914043. 
  2. ^ a b c Wormser GP; Dattwyler RJ; Shapiro ED et al. (November 2006). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clin. Infect. Dis. 43 (9): 1089–1134. doi:10.1086/508667. PMID 17029130. 
  3. ^ a b c Halperin JJ, Shapiro ED, Logigian E, et al. (July 2007). "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 69 (1): 91–102. doi:10.1212/01.wnl.0000265517.66976.28. PMID 17522387. 
  4. ^ a b c ""Chronic Lyme Disease" Fact Sheet". National Institute of Allergy and Infectious Diseases. April 17, 2009. 
  5. ^ a b Marques, Adriana (June 2008). "Chronic Lyme Disease: An appraisal". Infect Dis Clin North Am 22 (2): 341–60. doi:10.1016/j.idc.2007.12.011. PMC 2430045. 
  6. ^ "CDC - Post Lyme Disease Syndrome - Lyme Disease". Cdc.gov. February 7, 2013. Retrieved July 5, 2013. 
  7. ^ "Ten Facts You Should Know About Lyme Disease". Infectious Diseases Society of America. May 10, 2011. Retrieved June 18, 2013. 
  8. ^ Cairns V, Godwin J (December 2005). "Post-Lyme borreliosis syndrome: a meta-analysis of reported symptoms". Int J Epidemiol 34 (6): 1340–45. doi:10.1093/ije/dyi129. PMID 16040645. 
  9. ^ Halperin JJ (2008). "Prolonged Lyme disease treatment: Enough is enough". Neurology 70 (13): 986–87. doi:10.1212/01.WNL.0000291407.40667.69. PMID 17928578. 
  10. ^ Wolfe F (April 2009). "Fibromyalgia wars". J. Rheumatol. 36 (4): 679–83. doi:10.3899/jrheum.081180. PMID 19342721. 
  11. ^ Cameron D, Gaito A, Harris N et al. (2004). "Evidence-based guidelines for the management of Lyme disease". Expert Rev Anti Infect Ther 2 (1 Suppl): S1–13. doi:10.1586/14789072.2.1.S1. PMID 15581390. 
  12. ^ a b Phillips, S (2006-07-30). "Lyme Disease Review Panel Hearing". Infectious Diseases Society of America. Retrieved 2010-12-09. 
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  14. ^ Wormser GP, Schwartz I (July 2009). "Antibiotic treatment of animals infected with Borrelia burgdorferi". Clin. Microbiol. Rev. 22 (3): 387–95. doi:10.1128/CMR.00004-09. PMC 2708393. PMID 19597005. 
  15. ^ a b c Tonks A (November 2007). "Lyme wars". BMJ 335 (7626): 910–12. doi:10.1136/bmj.39363.530961.AD. PMC 2048873. PMID 17974685. 
  16. ^ a b c Stricker RB (July 2007). "Counterpoint: long-term antibiotic therapy improves persistent symptoms associated with Lyme disease". Clinical Infectious Diseases 45 (2): 149–57. doi:10.1086/518853. PMID 17578772. 
  17. ^ "EP&I | Full text | Generalizability in two clinical trials of Lyme disease". Epi-perspectives.com. Retrieved July 5, 2013. 
  18. ^ Dolin, [edited by] Gerald L Mandell, John E Bennett, Raphael (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases (7th ed.). Philadelphia, PA: Churchill Livingstone/Elsevier. pp. Chapter 242. ISBN 978-0-443-06839-3. 
  19. ^ Patel R, Grogg KL, Edwards WD, Wright AJ, Schwenk NM (October 2000). "Death from inappropriate therapy for Lyme disease". Clin. Infect. Dis. 31 (4): 1107–09. doi:10.1086/318138. PMID 11049799. 
  20. ^ Oksi J, Marjamäki M, Nikoskelainen J, Viljanen MK (June 1999). "Borrelia burgdorferi detected by culture and PCR in clinical relapse of disseminated Lyme borreliosis". Annals of Medicine 31 (3): 225–32. doi:10.3109/07853899909115982. PMID 10442678. 
  21. ^ Massarotti EM (March 2002). "Lyme arthritis". Med. Clin. North Am. 86 (2): 297–309. doi:10.1016/S0025-7125(03)00088-9. PMID 11982303. 
  22. ^ Steere AC (November 2006). "Lyme borreliosis in 2005, 30 years after initial observations in Lyme Connecticut". Wien. Klin. Wochenschr. 118 (21-22): 625–33. doi:10.1007/s00508-006-0687-x. PMID 17160599. 
  23. ^ Weissenbacher S, Ring J, Hofmann H (2005). "Gabapentin for the symptomatic treatment of chronic neuropathic pain in patients with late-stage lyme borreliosis: a pilot study". Dermatology (Basel) 211 (2): 123–27. doi:10.1159/000086441. PMID 16088158. 
  24. ^ Bernardino AL, Kaushal D, Philipp MT (May 2009). "The antibiotics doxycycline and minocycline inhibit the inflammatory responses to the Lyme disease spirochete Borrelia burgdorferi". J. Infect. Dis. 199 (9): 1379–88. doi:10.1086/597807. PMID 19301981. 
  25. ^ Webster G, Del Rosso JQ (April 2007). "Anti-inflammatory activity of tetracyclines". Dermatol Clin 25 (2): 133–5, v. doi:10.1016/j.det.2007.01.012. PMID 17430750. 
  26. ^ Blum D, Chtarto A, Tenenbaum L, Brotchi J, Levivier M (December 2004). "Clinical potential of minocycline for neurodegenerative disorders". Neurobiol. Dis. 17 (3): 359–66. doi:10.1016/j.nbd.2004.07.012. PMID 15571972. 
  27. ^ a b c d Ballantyne C (November 2008). "The chronic debate over Lyme disease". Nat. Med. 14 (11): 1135–9. doi:10.1038/nm1108-1135. PMID 18989271. 
  28. ^ Correspondence, "Reinfection versus Relapse in Lyme Disease", New England Journal of Medicine, March 14, 2013. (This exchange of three letters nicely illustrates the controversy and some of the issues at stake.)
  29. ^ a b Whelan, David (2007-03-12). "Lyme Inc". Forbes. Retrieved 2008-06-24. 
  30. ^ a b Landers, Susan J (2008-06-09). "Lyme treatment accord ends antitrust probe". American Medical News. Retrieved 2008-06-24. 
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  32. ^ "Agreement Ends Lyme Disease Investigation By Connecticut Attorney General: Medical Validity of IDSA Guidelines Not Challenged" (Press release). Infectious Diseases Society of America. 2008-05-01. Retrieved 2013-08-28. 
  33. ^ Klein JO (November 2008). "Danger ahead: politics intrude in Infectious Diseases Society of America guideline for Lyme disease". Clin. Infect. Dis. 47 (9): 1197–99. doi:10.1086/592247. PMID 18821849. 
  34. ^ Kraemer JD, Gostin LO (February 2009). "Science, politics, and values: the politicization of professional practice guidelines". JAMA 301 (6): 665–67. doi:10.1001/jama.301.6.665. PMID 19211474. 
  35. ^ "An act concerning the use of long-term antibiotics for the treatment of Lyme disease". Connecticut General Assembly. 2009-06-18. Retrieved 2009-07-05. 
  36. ^ "Lyme Disease and the Law". Rhode Island Department of Health. 2009. Archived from the original on May 2, 2005. Retrieved 2009-07-05. 
  37. ^ California Business and Professions, Section 2234.1, AB 592, passed August 29, 2005.ftp://leginfo.public.ca.gov/pub/05-06/bill/asm/ab_0551-0600/ab_592_bill_20050831_enrolled.pdf
  38. ^ Section 12DD Administration of long-term antibiotic therapy upon diagnosis of Lyme disease MGL Chapter 112 Section 12DD (2010)
  39. ^ "New Hampshire General Court, HB 295, approved June 9, 2011". Gencourt.state.nh.us. Retrieved 2012-12-15. 
  40. ^ "Lyme treatment: Doctor, patient should have freedom to decide on best course of action". Pennlive.com. Retrieved 2012-12-15. 
  41. ^ Singer, Stephen (2010-04-22). "No changes to Lyme disease treatment". Associated Press. 
  42. ^ Special Review Panel Unanimously Upholds Lyme Disease Treatment Guidelines: Short-term Antibiotics Proven to be Best Treatment for Patients Infectious Diseases Society of America. April 22, 2010.
  43. ^ Grann, David (2001-06-17). "Stalking Dr. Steere Over Lyme Disease". The New York Times Magazine. Retrieved 2008-06-25. 
  44. ^ Abbott A (February 2006). "Lyme disease: uphill struggle". Nature 439 (7076): 524–25. doi:10.1038/439524a. PMID 16452949. 
  45. ^ Cooper, JD; Feder Jr, HM (December 2004). "Inaccurate information about lyme disease on the internet". PediatrInfectDisJ 23 (12): 11050–58. PMID 15626946. 
  46. ^ "Film Focuses on Lyme Patients". The Washington Post. June 17, 2008. Retrieved September 12, 2008.
  47. ^ Lyme disease: 'I knew whatever was troubling me wasn't a sports injury' The Times, February 23, 2010[verification needed]