In the Lymelight: Law and Clinical Practice Guidelines

Susan J.D. Ronn

Disclosures

South Med J. 2009;102(6):626-630. 

In This Article

Conflicting Guidelines

IDSA published Lyme treatment guidelines in 2000.[10] In November 2006 the society updated its guidelines, narrowing their already relatively restrictive terms. IDSA advises a two-tiered approach to diagnosis, based on laboratory testing, using first the enzyme-linked immunosorbent assay (ELISA) and then the Western blot. Clinical diagnosis is discouraged, absent an erythema migrans rash or positive serology. IDSA's guidelines recommend short-term antibiotics; for early Lyme disease, Lyme arthritis, and late neurologic Lyme disease, in most cases a course of no more than 28 days is recommended. IDSA does not recognize chronic (or persistent) Lyme disease. Rather, the guidelines outline syndromes of post-Lyme disease. If the patient is left with unexplained chronic subjective symptoms following treatment with recommended antibiotic regimens for a previous objective manifestation of Lyme, IDSA's guidelines assume the infection has been eradicated, and the cause of such complaints lies elsewhere or in lingering effects of the disease.[2]

ILADS, on the other hand, advocates the need for a clinical diagnosis of Lyme with testing used as a support; clinical diagnosis is necessary because current testing lacks sensitivity, and diagnostic criteria remain in dispute. ILADS also recognizes a chronic form of the disease in patients whose symptoms persist despite a 28-day course of antibiotics. The ILADS guidelines recommend, in these cases, that duration of therapy should be guided by clinical response, rather than by an arbitrary treatment course. Some patients, ILADS states, require higher dosages of antibiotics, combination antibiotic therapy, and/or long-term treatment. The ILADS guidelines discuss the gulf between IDSA and ILADS philosophies, noting the differences in diagnosis and treatment this creates in the real world of physicians and patients. ILADS believes the research has yet to present a clear path to successful management of the disease.

The 2006 IDSA guidelines caused a stir in the media and action from Lyme advocate organizations. ILADS formally requested a retraction of the web-published guidelines previous to printing,[11] based on the claim that the authors employed exclusionary data selection that substantially biased the resulting diagnosis and treatment recommendations while ignoring opposing or dissenting views about these recommendations. The journal refused. ILADS also publicly noted that adopted guidelines of the American Academy of Neurology (AAN) mirror those of IDSA because the two committees contained overlapping authors.[12]

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