BOSTON — Antibiotic therapy decreases the duration of persistent joint inflammation in Lyme arthritis, and disease-modifying antirheumatic drugs can reduce its severity in individuals with antibiotic-refractory disease, Dr. Alan Steere reported at a rheumatology conference sponsored by Harvard Medical School, Boston.
Antibiotics remain the cornerstone of treatment for Lyme arthritis, with most patients responding to a 1-month course of oral doxycycline or amoxicillin, said Dr. Steere of Massachusetts General Hospital, Boston. In patients with mild, residual joint swelling, the oral antibiotic regimen is repeated for an additional 30 days. When joint swelling is moderate to severe, an additional month of intravenous antibiotic therapy with ceftriaxone, cefotaxime, or penicillin is a standard course, he said.
To assess postantibiotic treatment strategies in refractory patients and to compare disease course in antibiotic-responsive and -refractory patients, Dr. Steere and his colleagues reviewed the outcomes of 117 patients seen from November 1987 through May 2004. Of the study group, 50 were antibiotic responsive and 67 had antibiotic-refractory Lyme arthritis.
All patients met Centers for Disease Control and Prevention criteria for Lyme arthritis as well as the Infectious Diseases Society of America guidelines for antibiotic treatment. The antibiotic-refractory patients tended to receive intra-articular steroids more often than the antibiotic-responsive patients did, but “the majority of the refractory patients were not given this medication,” he said.
“In patients with antibiotic-responsive arthritis, a 1-month course of oral doxycycline was usually successful, while patients with refractory arthritis tended to have persistent disease even after 2 months of oral antibiotics and 1 month of IV ceftriaxone,” Dr. Steere said.
Of the 67 patients with refractory arthritis, 22 were treated with NSAIDs or intra-articular corticosteroids. If arthritis persisted for 12–24 months, they underwent arthroscopic synovectomy. In the remaining 45 patients, DMARD therapy (primarily hydroxychloroquine) was added to the regimen if polymerase chain reaction (PCR) testing was negative for Borrelia burgdorferi. If the arthritis persisted, patients received oral methotrexate for 3–4 months, or two to four infusions of intravenous inifliximab, after which arthroscopic synovectomy was offered, if needed.
Data on 20 of the 22 patients treated with NSAIDs or intraarticular corticosteroids showed that 11 had complete resolution of arthritis within a median of 11 months after the start of antibiotic therapy, and 9 underwent arthroscopic synovectomies. “Arthritis resolved in the all of the patients within a median of 14 months,” Dr. Steere said.
Follow-up data on 42 patients treated with DMARDs showed that 34 had resolution of arthritis within a median of 8 months after the start of antibiotic therapy, 3 of the remaining 8 patients who did not respond to treatment with hydroxychloroquine elected to have arthroscopic synovectomies, which was successful in only 1 patient.
The two patients with failed synovectomies, plus the remaining five with unresolved arthritis, received methotrexate or intravenous inifliximab. Both drugs induced responses, he said, but “inifliximab resulted in particularly marked reductions in joint inflammation.”
Overall, arthritis persisted in the 42 patients who received DMARDs for a median of 9 months. One of these patients had a breakthrough case of persistent infection.
Based on these findings, a “reasonable management plan” for Lyme arthritis that persists after 60 days of antibiotics (including 30 days of intravenous therapy) should include an additional month of oral antibiotic therapy if PCR testing for B. burgdorferi DNA is still positive; treatment with NSAIDs if PCR results for B. burgdorferi DNA are negative; and the addition of 200 mg oral hydroxychloroquine twice daily if arthritis still persists. If arthritis persists for 3–6 more months, arthroscopic synovectomy should be considered, Dr. Steere said.
Because Lyme arthritis eventually resolves even without antibiotic therapy, he and his colleagues also sought to determine whether antibiotic therapy altered the natural course of the disease in patients with antibiotic-refractory arthritis.
They compared the current findings to those of 21 patients treated for Lyme arthritis in the late 1970s “before the etiologic agent of Lyme disease was known,” he said.
Those patients received NSAIDs and intra-articular steroids, but not antibiotics, and had episodes of arthritis for a median of 43 months. For the antibiotic-responsive patients and the antibiotic-refractory patients in the current study, the median total time of arthritis episode was 4 and 16 months, respectively.