GLA Disagrees with NEJM Study Conclusions

The March 31, 2016 issue of the New England Journal of Medicine published a study of antibiotic treatment for long-term Lyme disease (Berende et al.). Individuals were treated with a two-week course of intravenous ceftriaxone, an antibiotic, followed by additional oral medications or placebo. The study concluded that longer-term antibiotic therapy for persisting symptoms does not confer additional benefits beyond short-term therapy.

We disagree with the conclusions of this study for the following reasons:

1. This study compared shorter-term therapy (ceftriaxone followed by placebo) with longer-term therapy (ceftriaxone followed by more antibiotics), in patients with sustained symptoms. However, there was no “true” placebo group that was completely untreated. All three study groups reported significant, yearlong improvement in SF-36 scores, which measure health quality. The improvement could be attributed to the ceftriaxone given at the beginning, because even the group subsequently treated with placebo responded to the ceftriaxone after two weeks and beyond (Figure 2).
2. Since they observed no significant difference in outcome in the various treatment groups, the study’s authors concluded that there was no benefit from continued antibiotics. However, with this study design, it is impossible to conclude that long term antibiotics are ineffective for treatment of chronic Lyme disease, as reported and distorted by the lay press.
3. Doxycycline and clarithromycin, antibiotics used in two of the study arms, are poor at eradicating the antibiotic tolerant or persistent forms of Borrelia infection, which may be one cause of chronic Lyme disease (Feng 2015, Sharma 2015)
4. Hydroxychloroquine is a drug used to treat autoimmune diseases. This was given along with clarithromycin to one of the three study groups. If persistent symptoms of Lyme disease are due to immune system malfunction, then we should have expected additional improvement, beyond that of the other two groups, after the three month treatment period. This did not occur.
5. CDC diagnostic guidelines dictate that IgG, not IgM antibodies against Lyme bacteria indicate infection after the first 4-6 weeks. The patients in this study have had symptoms for more than two years. The authors do not explain why positive IgM was used as a criterion for inclusion into the study. These patients may be different than those who are positive for IgG.
6. No consideration was given to co-infections by other tick-borne pathogens as the explanation for continuing symptoms which would not have responded to the oral antibiotics used in the study. Furthermore, the Borrelia species in Europe, where the study took place, differ in virulence and symptomatology from those in North America, limiting the study’s geographic relevance to that location.

Global Lyme Alliance (GLA) is disheartened by the inaccurate reporting and superficial reading of this study by the media and lay press. GLA has never blindly endorsed long-term antibiotic use for people with continued Lyme disease symptoms. In fact, GLA supports evidence-based, rigorous research into post-treatment Lyme disease in order to discover more effective antibiotic strategies. We are disappointed that this flawed study has been accepted without critical judgment.

The position of GLA is simple – Until there is an effective cure, the treatment of patients with tick-borne diseases should be in the hands of the physician.

For over 17 years, GLA and its predecessor organizations have supported research on behalf of the Lyme community. We have three major goals. The first is to reduce the number of new Lyme cases through awareness. The second is to reduce the number of patients who go on to suffer from chronic symptoms by funding research that will hopefully lead to better and earlier diagnostics, resulting in prompt treatment and fewer treatment failures. The third is to fund meaningful research leading to a better understanding of the chronic condition and effective therapies.

There are many unknowns in Lyme disease and other tick-borne illnesses. However, these facts are indisputable:

1. There are over 300,000 new cases of Lyme disease every year in the United States, a number endorsed by the Centers for Disease Control and Prevention.
2. At least 10% to 20% of these patients go on to experience chronic symptoms, including chronic pain, fatigue and neurological issues (Aucott J, SLICE 1). Chronic outcome is correlated with delays in treatment, truncated treatment, poor antibiotic choice, and a potentially inappropriate immune response to the pathogen. Even at the low end, this means 30,000 new chronic cases annually.
3. Not every patient demonstrates a signature erythema migrans rash. We cannot rely on a rash to make the diagnosis.
4. Current diagnostic tests may miss up to 60% of patients with acute Lyme disease. There is broad acknowledgement that the current diagnostic tests are unreliable.

In conclusion, we need truly controlled, well-designed clinical trials to identify efficacious therapeutic options for individuals with long-term symptoms attributed to Lyme disease. Unfortunately, the study by Berende et al. was not such a trial, and does not convincingly rule out long-term antibiotic therapy as a treatment for persisting Lyme disease. The search for effective therapies, which may include new antibiotic strategies, will continue.