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Some doctors prescribe “Actigall” to dissolve biliary stone formation, especially if the patient is starting to complain of epigastric pain or nausea.

Some doctors order an ultrasonogram of the gall bladder prior to initiating ceftriaxone therapy to identify those patients who might be at greatest risk of forming gall stones.

Note 2: While the ease of administration is enhanced when ceftriaxone is administered intravenously through a Mid-line or a PICC line, the presence of this indwelling line also increases the risk of systemic infection and serious blood clots. Therefore, patients need to remember to flush their PICC or Mid-line daily, to keep the PICC line site clean, and to not engage in “jerky” arm movements, such as might occur when washing windows or playing tennis or golf. IN the evaluation of the patient prior to insertion of a PICC line or a Mid-Line, the clinician order blood tests to determine if the patient is at higher risk of forming blood clots or inquire about one’s family history of blood clotting. Note 3: Rarely ceftriaxone can trigger hemolytic anemia and pancreatitis. Note 4: Cefotaxime (Clarforan) is also a 3rd generation intravenous antibiotic.

While Cefotaxime is less likely to cause gallstones, it requires 3x daily dosing which for most patients is too difficult to maintain. Given that it is essential for efficacy that the drug be administered every 8 hours, cefotaxmine is less commonly used than ceftriaxone.

Benzathine Penicillin (Bicillin-LA) Benzathine Penicillin is an intramuscular form of penicillin that has the advantage of being long-acting and allowing for consistently high blood and tissue levels of penicillin.

Early studies indicated that it was helpful for neurologic Lyme disease, but not nearly as effective as intravenous ceftriaxone (Rocephin).

The blood levels after benzathine penicillin are almost as high as after IV ceftriaxone.

Because of the intramuscular administration, the risk of gastrointestinal side effects and yeast infections are lower than with oral antibiotics.

Note: In most individuals Bicillin is self-administered, often in the muscle of the buttocks. A lidocaine-like anesthetic cream can be applied topoically30-60 minutes before to reduce the injection site pain.

The downside to benzathine penicillin is that many people do not want to inject themselves. Because once injected, it can’t be removed, it is important to make sure the individual is not allergic to this medication before initiating treatment. Azithromycin and clarithromycin are macrolide antibiotics that have been studied in humans for the treatment of Lyme disease.

Both are better tolerated than the older macrolide antibiotic erythromycin in having fewer gastrointestinal side effects. Both azithromycin and clarithromycin are considered second-line agents for Lyme disease among individuals who cannot tolerate doxycycline, amoxicillin, or cefuroxime. (Erythromycin is considered inferior to the other first line agents such as doxycycline or amoxicillin and is therefore not recommended as a primary agent for Lyme disease.) In addition to their benefits as antimicrobial agents, azithromycin and clarithromycin also have anti-inflammatory properties that can lead to symptom improvement. There are study design problems with the research studies of azithromycin and clarithromycin; therefore, it is hard to know whether they are truly less efficacious than the first-line agents for early Lyme disease.

Macrolides however should be used with caution given the risk of interaction with other medications.

The key to consider is that these antibiotics impact the liver enzymes that help to metabolize other medications; specifically they can affect the cytochrome P450 1A2 and 3A4 isoenyzmes. For example, erythromycin or clarithromycin can lead to dangerously increased blood levels of the anticonvulsant drug carbamazepine (Tegretol) as well as increases in the anti-anxiety drug alprazolam (Xanax).

Erythromycin and clarithromycin can also lead to an increase in the blood levels of the anti-asthmatic drug, theophylline, which can put the patient at risk for seizures or arrhythmias.

When macrolides are used with paroxetine (Paxil) – an anti-depressant drug, there may be an unexpected increase in the blood level of the parosetine due to the macrolide-inducted inhibition of the liver enzyme metabolism; this could lead to mania or serotonin syndrome. These approaches are considered for those patients who have persistent symptoms that have not abated or resolved after antibiotic therapy.

When symptoms persist, it is very important to take a fresh look at the patient and determine whether other problems have emerged (possibly unrelated to Lyme disease) that may be causing the symptoms.

For example, fatigue may be due to anemia or thyroid deficiencies. Numbness and tingling may be due to vitamin deficiency (B1, B6, B12), diabetes, carpal tunnel sydnrome, or autoimmune causes.

While infection with Borrelia burgdorferi itself can cause many of the symptoms below and thus require antibiotic treatment, these symptoms may also be triggered but not sustained by the prior infection; this may be due to residual inflammation, ongoing immune activation, tissue damage, or neurotransmitter/neural circuitry changes.

In this situation, symptom-based therapies can be quite helpful.

Because the suggestions listed below have not yet been studied in clinical trials of Lyme disease , these suggestions are based on evidence obtained from other disorders with similar clinical features. None of these treatments have been FDA-approved for the treatment of Lyme disease-related symptoms. Neuropathic pain (numbness, tingling, burning, shooting) and central "brain" pain syndromes can often be helped with agents such as gabapentin ("Neurontin") or pregabalin ("Lyrica"). There was a small open label trial that showed that gabapentin was quite helpful in reducing neuropathic pain for a group of Lyme patients complaining of persistent fatigue (Weissenbacher 2005).

Neuropathic, muscular, and arthritic pain can often be helped with agents such as amitriptyline, cyclobenzaprine, or SNRIs (e.g., duloxetine (Cymbalta), milnacipran (Savella), venlafaxine (Effexor)). The SNRIs are particularly useful for patients with persistent LYme-related symptoms as they are quite effective for reducing pain as well as for improving mood and decreasing anxiety. It should be noted however that to obtain the pain relief from a medication such as venlafaxine, in most patients the dose needs to be increased to 225-300 mg/day in order to obtain the benefits for pain and mood.

Neuropathic pain that has an autoimmune etiology (possibly triggered by the prior infection with B.burgdorferi) may benefit from treatment with intravenous gammaglobulin therapy .

Musculoskeletal pain may be helped by low-dose naltrexone, as 2 published trials have reported benefit in fibromyalgia.

Arthritic pain that persists after antibiotic therapy may be reduced by nonsteroidal anti-inflammatory drugs (NSAIDS) that reduce inflammation. Beware however that long-term use of NSAIDS increases the risk of gastric ulcers and kidney damage.

For patients whose arthritis is not helped by NSAIDS, published reports indicate that methotrexate or hydroxychloroquine can be helpful; these are called disease-modifying anti-rheumatic drugs.

Mindfulness meditation and Yoga can reduce stress and pain and enhance energy. We have a research study that examines the use of meditation and Yoga for patients with persistent fatigue and pain after antibiotic treatment for Lyme disease. Qigong is a mind-body-spirit practice that integrates posture, movement, breathing technique, self-massage, sound, and focused attention. In one randomized controlled trial, fatigue and mental functioning were significantly improved in the experimental group compared to the wait-list controls. Ensure quality sleep of seven to eight hours per night. Undiagnosed sleep disorders need to be ruled-out (e.g, sleep apnea).

Because fatigue can be a prominent symptom of depression, it is important to ensure a low-grade depression hasn't gone untreated.

Bupropion is an anti-depressant agent that boosts norepinephrine and dopamine and tends to improve mood, energy, and cognitive focus.

Onset of improvement is usually seen after two to four weeks of daily treatment.

Modafinil (Provigil) or Armodafinil (Nuvigil) are both wakefulness promoting agents that have been reported to help fatigue in other diseases.

Amantidine Acupuncture has been studied as a treatment for fatigue, primarily in China.

In a randomized, sham-controlled trial of acupuncture of 127 individuals diagnosed with "chronic fatigue syndrome" (two sessions per week for four weeks), the acupuncture group showed moderately large reductions in physical and mental fatigue.

Mindfulness meditation and Yoga can reduce stress and pain and enhance energy. We have a research study that examines the use of meditation and Yoga for patients with persistent fatigue and pain after antibiotic treatment for Lyme disease. Qigong is a mind-body-spirit practice that integrates posture, movement, breathing technique, self-massage, sound, kimoxil amoxicillin and focused attention. In one randomized controlled trial, fatigue and mental functioning were significantly improved in the experimental group compared to the wait-list controls.

Poor sleep can lead to daytime fatigue, impaired cognition, and musculoskeletal pain. Clinicians should ask the patient about sleep behaviors, as poor sleep hygiene can induce insomnia. Undiagnosed sleep disorders should be ruled out, including restless leg syndrome, narcolepsy, sleep apnea.

Avoid substances that would impair sleep (e.g., alcohol, appetite suppressants, caffeine). Improving sleep hygiene is the best approach for insomnia.

However, when behavioral changes don't work, pharmacologic therapies should be considered. Cognitive behavior therapy and relaxation techniques (e.g., mindfulness; stretching) can be helpful Lemon balm and melatonin: While there are many supplements that people use to help with sleep as alternatives to conventional sleep medications, the ones considered safe that are commonly used include lemon balm and melatonin. The botanical lemon balm (Melissa officinalis) has not been well-studied but open label trials suggest it is helpful in reducing anxiety and improving sleep. Neither lemon balm nor melatonin are considered safe in pregnancy. Some concerns exist about whether melatonin may exacerbate autoimmune illness. Medications: Certain medications can help both sleep and reduce pain. These include low doses of amitriptyline, cyclobenzaprine, and doxepin. Low doses of mirtazipine, trazodone, or quetiapine may also improve sleep onset and duration.

Gabepentin can help to improve sleep as well as reduce nerve pains and restless leg syndrome. Short-acting medications are best for people complaining of delayed sleep onset (e.g, zolpidem, lorazepam, ramelteon).

Longer-acting medications can be helpful for those who report a hard time maintaining sleep (long acting zolpidem, temazepam, eszopiclone, low dose doxepin, low dose trazodone) Note: suvorexant ("Belsomra") is not recommended for patients being treated for Lyme disease as it can interact with many medications used by infectious disease doctors.

It is not recommended for people who are on medications that inhibit the liver enzyme CYP3A such as clarithromycin ("Biaxin") or ketoconazole ("Nizoral") or fluconazole ("Diflucan") or erythromycin.

Both psychotherapy and pharmacotherapy have proven benefits for improving mood. Psychotherapy has many different types — such as supportive, dynamic, cognitive behavioral, dialectical behavior therapy, transference focused psychotherapy — each of which offers benefit.

For depression the first-line options usually are SSRIs, SNRIs, Tricyclics or other agents with more unique modes of action.

A few noteworthy tips on anti-depressant agents: Most anti-depressant agents also help in reducing anxiety. Specific anti-anxiety agents such as clonazepam or diazepam may not necessarily help fight depression.

Most anti-depressants take three to eight weeks before an effect is seen. Therefore, it is unwise to stop an anti-depressant after only three or four weeks, as staying on it another two to three weeks may lead to a good response.

Some anti-depressants work fine at low doses; some medications however are effective only at higher doses.

Some medications are more effective as the dose is i increased. Other antidepressants (such as the tricyclic antidepressants) may have a therapeutic range — one has to achieve at least a certain dosage (to get to the right blood level).

In Lyme disease, short-term memory problems and word-retrieval problems are common. These often improve substantially with appropriate antibiotic therapy.

Over time, most patients regain their cognitive function.

When memory is a problem, consider that this could due to a primary problem with attention or with mood. An individual who can't focus won't be able to remember because he/she didn't "attend" to the item in the first place.