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Physician Assistant Scholarly Project Posters Department of Physician Studies

2019 Treatment Options for Post Treatment Syndrome Barbara Bowman University of North Dakota

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Recommended Citation Bowman, Barbara, "Treatment Options for Post Treatment Lyme Disease Syndrome" (2019). Physician Assistant Scholarly Project Posters. 131. https://commons.und.edu/pas-grad-posters/131

This Poster is brought to you for free and open access by the Department of Physician Studies at UND Scholarly Commons. It has been accepted for inclusion in Physician Assistant Scholarly Project Posters by an authorized administrator of UND Scholarly Commons. For more information, please contact [email protected]. TREATMENT OPTIONS FOR POST TREATMENT LYME DISEASE SYNDROME Barbara Bowman, PA-S Department of Physician Assistant Studies, University of North Dakota School of Medicine & Health Sciences Grand Forks, ND 58202-9037

Abstract Literature Review Discussion Applicability to Clinical

With the high incidence of Lyme disease in the endemic Evidence of PTLDS . Rebman et al. (2017) found that 59% of participants in the Practice areas of North America, it is important to appropriately . Infectious Diseases Society of America proposed a case study with PTLDS were either misdiagnosed or diagnosis was . PTLDS case definition (Nemeth et al., 2016, Table 1): diagnosis and treat this condition to prevent post treatment definition for PTLDS in 2006 (Nemeth et al., 2016). delayed. This stresses the importance of keeping Lyme Lyme disease syndrome (PTLDS). Background information disease in the differential diagnosis for typical symptoms -An adult or child with a documented episode of early or . Middelveen et al. (2018) confirms the presence of live regarding Lyme disease is given. The purpose of this occurring in endemic areas or those who have travelled to late Lyme disease Borrelia spirochetes with positive cultures in patients who research is to discuss the treatment options available for endemic areas. were treated with but remained symptomatic. -Treatment with a generally accepted treatment regimen, those patients that fit the case definition of PTLDS. A . Further research needs to be done to develop more specific with resolution of the objective manifestation literature review was conducted using several different and sensitive lab tests so that concrete diagnoses can be -Onset of any of the following subjective symptoms within electronic databases finding peer reviewed research made when clinical symptoms are not as straight forward as 6 months of the diagnosis and persistence of continuous articles pertaining to the treatment options available for erythema migrans. or relapsing symptoms for at least 6 months after PTLDS. Extended use is shown to be not completion of antibiotic therapy: beneficial in most cases. Alternative treatment options listed on the internet are shown to be not evidence based. .Fatigue, widespread musculoskeletal pain, Therefore, symptomatic treatment options seem to be the complaints of cognitive difficulties, or subjective best positive outcome-based option available for providers symptoms with such severity that, when present, they to use. These options are discussed in detail throughout result in substantial reduction in previous levels of this research. Though much more research is needed occupational, educational, social or personal regarding the topic, this will give providers the information Treatment Options activities. currently available that they will need to know when treating Extended Antibiotic Use . Extended use of antibiotics should not be prescribed. patients with PTLDS. Hopefully this will provide the . Studies going back to 2001 but most recently Berende et al. Patients must be warned that the efficacy of treatments patients with PTLDS the best outcome possible for (2016) have shown that extended use of antibiotics does not listed on the internet are not evidence based and should improving their quality of life post Lyme disease. be avoided. Treating the patients according to their improve symptoms more than the placebo groups In patients who were treated appropriately for Lyme disease but symptoms and following the recommended guidelines for (p=<0.001). develop PTLDS, does extended course antibiotic therapy versus each is the most effective form of treatment for PTLDS as Based on Symptoms symptomatic treatment versus alternative treatments help Introduction of now. Myalgic encephalomyelitis/ (CFS) relieve PTLDS symptoms most effectively? . Lyme disease is the most common vector borne illness • Similarities between PTLDS and CFS suggest treatment of • Numerous studies have shown that the use of extended in the USA (Rebman et al., 2017). diet, exercise, counseling, , and/or off-label use antibiotics is not beneficial and increases the risk of adverse References effects. . Lyme disease is endemic in the Northeast and upper of methylphenidate may be beneficial (DynaMed Plus, Arvikar, S. L. & Steere, A. C. (2015). Diagnosis and treatment of Lyme disease. Infectious Disease Clinics of North America, 29(2), 269-280. https://dx.doi:10.1016/j.idc.2015.02.004 Midwest states but can also be found along the Pacific chronic fatigue syndrome, 2018). • There have been potential studies showing that alternative Berende, A., ter Hofstede, H. J., Vos, F. J., van Middendorp, H., Vogelaar, M. L., Tromp, M.,…Kullberg, B. J. (2016). coast (Rebman et al., 2017). Randomized trial of longer-term therapy for symptoms attributed to Lyme disease. The New England Journal of Medicine, Lyme therapies may be something of use in the future. Further 374(13), 1209-1220. https://dx.doi:10.1056/NEJMoa1505425 research needs to be done to establish the efficacy on DynaMed Plus (Internet). Ipswich (MA): EBSCO Information Services. 1995-. Record No. 114365, Lyme desease; (updated . Presenting symptoms include erythema migrans, Lyme . With triplicate data sets, Ramesh, Martinez, Martin, &Philipp 2018 Jul 26, cited 2018 Nov 03); [about 27 screens]. Available from , and cranial nerve palsy which are treated with humans. http://www.dynamed.com/login.espx?direct=true&site=DynaMed&id=114365. Registration and log in required. (2017) showed that dexamethasone significantly reduced DynaMed Plus (Internet). Ipswich (MA): EBSCO Information Services. 1995-.Record No.115094, Chronic fatigue syndrome; . Hospitalization and IV ceftriaxone are often (updated 2018 Sep 10, cited 2018 Dec 01); [about 30 screens]. Available from levels of -induced inflammatory cytokines • That leaves the only option currently available as assessing http://www.dynamed.com/login.aspx?direct=true&site=DynaMed&id=115094. Registration and log in required. required for Lyme carditis and neurologic Lyme disease every individual patient separately and treating the individual Feng, J., Zhang, S., Wanliang, S., Zubcevik, N., Miklossy, J., & Zhang,Y. (2017). Selective essential oils from spice or or chemokines over meloxicam (p<0.05, p<0.01, p<0.001). culinary herbs have high activity against stationary phase and biofilm Borrelia burgdorferi. Frontiers in Medicine, 4:169. other than cranial nerve palsy (DynaMed Plus, Lyme patient’s symptoms appropriately. https://dx.doi.10.3389/fmed.2017.00169 Lyme disease-associated facial palsy Jowett, N., Gaudin, R. A., Banks, C. A., & Hadlock, T. A. (2017). Steroid use in Lyme disease-associated facial palsy is disease., 2018). – Fatigue, musculoskeletal pain, and cognitive difficulties are associated with worse long-term outcomes. The Larygoscope, 127(6), 1451-1458. https://dx.doi:10.1002/lary.26273 • Jowett, Gaudin, Banks, & Hadlock (2017) show worse Lantos, P. M., Shapiro, E. D., Auwaerter, P. G., Baker, P. J., Halperin, J. J., McSweegan, E., & Wormser, G. P. (2015). . Misdiagnosis or inappropriate treatment may lead to an so similar to CFS that treatment options such as a healthy Unorthodox alternative therapies marketed to treat Lyme disease. Clinical Infectious Diseases, 60(12), 1776-1782 outcomes when corticosteroids and antivirals are used with Middelveen, M., Sapi, E., Burke, J., Filush, K. R., Franco, A., Fesler, M. C., & Stricker, R. B. (2018). Persistent Borrelia increase in likelihood of developing PTLDS. diet, exercise, counseling, acupuncture, and/or off-label use infection in patients with ongoing symptoms of Lyme disease. Healthcare, 6(2), antibiotics versus monotherapy of antibiotics alone. pii:E33.https://dx.doi:10.3390/healthcare6020033 of methylphenidate may be appropriate. Nemeth, J., Bernasconi, E., Heininger, U., Abbas, M., Nadal, D., Strahm, C., & Weber, R. (2016). Update of the Swiss Lyme arthritis guidelines on post-treatment Lyme disease syndrome. Swiss Medical Weekly. 146:14353. https://doi.4414.smw.2016.14353 – Dexamethasone for Lyme neuroborreliosis is recommended Nicolson, G. L., Settineri, R., & Ellithorpe, R. (2012). Lipid replacement therapy with a glycophospholipid formulation with NADH and CoQ10 significantly reduces fatigue in intractable chronic fatiguing illnesses and chronic Lyme disease patients. Statement of the Problem . NSAIDS (ibuprofen or naproxen) and DMARDs except in the case where facial palsy is present. International Journal of Clinical Medicine, 3:163-170. https://dx.doi:10.4236/ijcm.2012.33034 (hydroxychloroquine or methotrexate) are shown to be Ramesh, G., Martinez, A. N., Martin, D. S., & Philipp, M. T. (2017). Effects of dexamethasone and meloxicam on Borrelia Feng et al. (2017) have estimated that approximately 10- – NSAIDS and DMARDS can be considered with persistent burgdorferi-induced inflammation in glial and neuronal cells of the central nervous system. Journal of Neuroinflammation, effective after initial treatment (Arvikar & Steere, 2015) 14(1), 28. https://dx.doi:10.1186/s12974-017-0806-9 20% of patients continue suffering from chronic symptoms Lyme arthritis. Rebman, A. W., Bechtold, K. T., Yang, T., Mihm, E., Soloski, M. J., Novak, C. B., & Aucott, J. N. (2017). The clinical, symptom, and quality-of-life characterization of a well-defined group of patients with posttreatment Lyme disease syndrome. described as PTLDS following the standard antibiotic Alternative Treatments Frontiers in Medicine, 4:224. https://dx.doi.10.3389/fmed.2017.00224 treatment of 2-4 weeks for early or late Lyme disease. The • Lantos et al. (2015) showed that oxygen therapy, and question remains that even if these symptoms are a direct radiation, metal chelation, nutritional supplements and Acknowledgements or indirect consequence of Lyme disease, how can biological therapies found on the internet through Google did providers appropriately treat these patients. not substantiate any efficacy in treatment of Lyme disease. I would like to thank the UND PA faculty for their continued Essential oils support and dedication throughout program. I would like to thank my advisor, Professor Russ Kauffman, for his insight • Oregano and cinnamon bark showed remarkable activity for and direction throughout my PA education. I thank all of my Research Question complete eradication of the stationary phase of Borrelia preceptors who have helped guide my education and learning burgdorferi in animals (Feng et al., 2017). In patients who were treated appropriately for Lyme experiences. I would also like to thank Riann Collar (PA-S), disease but develop PTLDS, does extended course Supplements Robert Frenchick (stats professor), and Sara Shuster antibiotic therapy versus symptomatic treatment versus • Nicolson, Settineri, & Ellithorpe (2012) showed a 30.7% (PharmD) for their input into this final project. Lastly, a sincere alternative treatments help relieve PTLDS symptoms reduction in fatigue within 60 days of using a daily ATP fuel thank you to my husband, family and friends for their love and most effectively? supplement (p<0.001). support through this challenging but rewarding endeavor.