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.

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