Tuesday, June 23, 2009

Pulsed Antibiotics

Below is an excerpt of an interview from Dr J (SC) a highly respected Lyme literate infectious disease expert. He promotes pulsed therapy- which I am currently doing (IV Claforan for 3 days every 3 days). I am doing better (better energy, mood and less sweats)and it is nice to get breaks off antibiotics to rebuild my liver (using acupuncture and Chinese herbs) and gut(lots of probiotics/goat milk kefir, vitamins and minerals).

Here's the interview:

What are some of the most important clinical observations and treatment recommendations you have made with regard to Lyme Borreliosis Complex?

Dr. J:
What I learned a few years ago is that you don't have to treat every day. And with my HIV and infectious disease background, I learned the virtues of combination therapies. When you're dealing with a complex group of infections, there's no one drug that's going to satisfactorily handle the infection unless you're not that sick. It's all about putting your immune system back in charge. And to the extent that you can eliminate the source of the immunosuppression and your immune system

Everyone who's trapped by this illness needs nutritional support, metabolic support, and they need antibiotics. Some people are negative about antibiotics, but you can't evaluate antibiotic therapy in a vacuum or as 'all the same'…that's patently intellectually dishonest. We are, after all, treating multiple, stubborn infections in an immunocompromised host where, by definition, the immune system cannot handle the problem. And our goal is not to see how many days of antibiotics we can administer, but to administer the fewest days needed in order to restore immunologic control. Towards that end, we need to understand the triggers to keep patients out of situations that are going to perpetuate the patient's chronic illness and/or make it unwise to attempt therapy until these destabilizing stressors are reduced, whether the stressor is as basic as a bad support system or involve psychiatric, pain or sleep issues.

In treatment models, I've learned that pulsing makes sense, and I think everyone who's really sick has multiple infections. When I treat the three major infections, which are Borrelia, Bartonella and Babesia, and do that in a certain sequence and in a certain combination, people get better. And I think it's very important for people to go off therapy on an intermittent basis for one or two weeks at a time. Those windows are very important times to see how much immunologic security they have. Patterns develop, and the better the patient is, the longer they can go off drugs. For many years now, we have learned to pulse combination antimicrobial medications in certain patterns, and I have modified our clinical approach from learning the tempo of the disease.

Often you learn more about your patient when they're off treatment than you learn when they are on active treatment. These 'holidays' provide valuable windows for observation and after a time, you learn that cycles of therapy and the way they are sequenced show reproducible patterns of response. You also learn a lot from aspects of the treatment period, whether it's being on treatment, when it's the time to take Flagyl, and certainly the time that they're off treatment is a very important window for you to see how the patient is doing immunologically. And once you learn patterns and understand them, then you know when to intervene and when to back off. One of my patients said, "You're doing a dance with this disease, aren't you?" That's not a bad analogy.

I learned a long time ago that the most common reason for people not to get better is inadequate treatment of co-infections. It's very important to address the co-infections and to do so in an overlapping way, so you're not just treating one thing and then going on to treat something else. I only treat three days a week whether it's oral or IV, and have been doing it this way for at least five years, and exclusively this way for almost three years. And on all my programs, I give a week off of therapy on average every two to four weeks. I don't do it so much at the beginning, but after we get into it, patients get immunologically revved up.

In treating patients at the clinic, we are constantly striving for a balance point in terms of clinical efficacy and manageable toxicity, the latter being an inevitable sidebar to the highly immunogenic and inflammatory lipoprotein storm we see with Borrelia lysis. When the immune system activates, a patient can actually get more toxic, so we have to balance that. It's part of the art of medicine in terms of learning how to balance the toxicity generated and the fact that the patients need to detox. And I prefer to think there's a 'back door' to this illness as regards to the detoxification issues. If the 'back door' is closed, patients may remain unwell for protracted periods. Without question, there are considerable variations in the segment of the population with this illness who are going to be very sick, in terms of the ability to detoxify. This, in fact, may be as critical to outcomes as the infectious load and immunologic/genomic factors. That's the way it was with HIV, too, in a sense.

Sunday, June 21, 2009

Confirming Lyme

At a recent conference the medical director the Igenex medical director recommends doing "primed PCR urine tests if western blot tests are inconclusive. Antibiotics drive the Borrelia into the bladder where they can be detected in the urine. It is also a good clinical trial as you will see if there is any herxing or symptoms while on or immediately after the antibiotics. Be sure to keep a good diary of symptoms- headache, brain fog, fatigue, aches during these days. Your doctor should call Igenex (1-800-832-3200) so you have the correct forms and containers. There are many protocols used some recommend 3 days of collections or 5 days with 3 specimens sent. Here is a typical protocol:

Take Ceftin 500 mg twice daily with Zithromax 250 mg twice daily and collect urine for 5 days. Collect and send 3 separate urine samples during these days to Igenex for PCR tesing.

Igenex actually recommends repeat testing if initial test are inconclusive ie only one specific band is poistive. If you retest be sure to ask your doctor to check for 31kDa box as this will increase specificity. Your doctor must check this off on the back of the requisition paper or it will not be done ( I didn't know about this for 3 years and I'm a doc). 31kDa is highly specific for Lyme and can help clinch the diagnosis in "iffy" cases. If money is an issue and insurance won't cover repeating western blots- just do the urine PCR with antibiotics as it give both a clinical and lab diagnosis.

Tuesday, June 16, 2009

The Yin and Yang of Lyme

I have spent my professional life merging East and West and feel that this is an area of Lyme treatment that is unrecognized. Most Chinese medical practitioners claim that antibiotics are not needed and most Western doctors fail to recognize the problems such as blood stagnation, organ dysfunction,and yin and yang imbalance that results from both the infection and from multiple long term antibiotics. I firmly believe that to become well you can and should combine treatments. This is how I treat hormone imbalance and now because of my illness am learning to do so for chronic Lyme.

I have been taking IV Claforan for 3 weeks now and have felt much better…my spirit and energy improved within days of starting treatment. One of the known side effects of Claforan is to lower the blood counts. As I progressed in my therapy I began to have increasing night sweats, uncontrolled tearfulness and sadness and increasing fatigue despite more rest. Most LLMD’s would say, “Great you are herxing.” But what is herxing really?? I understand that Herx reaction is the body’s reaction to dead bacteria/spirochetes but I also recognize that according to Chinese medicine it is blood/yin/Qi deficiency/liver stagnation, etc.

As I felt more unwell my liver function tests began to rise and my white blood cells began to fall. So I went to my Chinese Herbalist in Chinatown (Boston) and asked who the local acupuncturist is. (Doctors will not survive long in Chinatown if they are not successful with patients). Dr W (who takes insurance, so I pay only my $20 copay), has been practicing for over 25 years. I saw him yesterday. He was immediately angered by my state of health. He carefully explained, “your Yin and Yang are so very weak, and out of balance-stop the antibiotics.” (I was infusing during the exam!). He performed acupuncture and prescribed herbs to balance my organs ($17/week, told me to walk every day, sleep by 10pm, eat more vegetables and less meat and do less. I am used to merging modalities and I know that I will (for now) continue the antibiotics but I will also get my yin and yang balanced.

When I returned home my LLMD has left a message to stop antibiotic infusions because the white cell counts were too low. We discussed my theory and she agreed to adding Chinese Herbs and acupuncture to improve my kidney and liver yin, which will help my counts.

I will keep you posted- but no tears since acupuncture and clear happy head this morning. I will also post here the signs and symptoms of yin/blod and Qi deficiency. The symptoms look (and feel) a lot like Herx reactions…night sweats, tears, dizziness, heat intolerance…

I am do plan to transition off IV antibiotics in the upcoming months (hopefully) - they have done me good but I believe they should not be used long term. I will have a Bicillin injection today to prepare for IV withdrawal. I spoke with Dr S (Maryland) who says that he has less relapse when stopping IV using Bicillin injections in the last weeks of IV and then continues Biciillin (often with Omnicef) after the IV is discontinued. While I do this I will continue to get weekly acupuncture and boil my somewhat ghastly tasting herbs to restore my yin, yang and spirit.

I sincerely hope that this is not confusing to people. It is important to repair/restore the body while taking antibiotics and most "Chinatowns" throughout the world have skilled doctors. I trained in Australia with a Chinese doctor, in Melbourne’s Chinatown. The herbs are ancient and universal and they (the Chinese) have been treating spirochetes (Syphilis) for centuries. We have much to learn from them, and vice versa

I also believe that one does not have to spend a life’s saving to be well. I have lived with Lyme disease most of my life- lived it fully using combined treatments and I plan to live a long full life beyond today in the same way.