DRIVE-THRU PHARMACY FOR LYME DISEASE TREATMENT WITH DOXYCYCLINE?
The Infectious Diseases Society of America (IDSA) guidelines advise that patients receive a single 200 mg dose of doxycycline after a tick bite to prevent Lyme disease. The International Lyme and Associated Diseases Society (ILADS) opposes that recommendation. Nevertheless, a pharmacist-run clinic within the Veterans Health Administration implemented IDSA’s single-dose Lyme disease treatment with doxycycline as a post-exposure prophylaxis (PEP) following a tick bite.
The clinic’s program and its effectiveness are described in a recent article by Portman, “Implementing a pharmacist-run Lyme disease postexposure prophylaxis clinic augmented by academic detailing within the Veterans Health Administration.”¹
In April 2018, VA Butler Healthcare in Pennsylvania opened a pharmacist-run Lyme disease PEP clinic, known as PharmLD clinic. At the center, clinical pharmacy specialists were allowed to prescribe doxycycline for PEP purposes.
According to the retrospective review, 40 patients were referred to the PharmLD clinic. Their visit was augmented by academic detailing. The academic detailing took about 27 minutes per patient.
- 18 individuals (45%) were prescribed a single 200 mg dose as a postexposure prophylaxis for a tick bite;
- 12 individuals (30%) received only education;
- 10 patients (25%) were referred to their primary care physician for further evaluation.
The pharmacist-run clinic was able to cut down the number of doctor visits, but it was not able to determine treatment outcomes for their patients.
ILADS position on single 200 mg dose of doxycycline for a tick bite.
The ILADS guidelines concluded that a single 200 mg dose might prevent an erythema migrans rash. The ILADS guidelines could not find evidence that a single 200 mg dose of doxycycline could prevent other manifestations of Lyme disease including Lyme carditis, Lyme arthritis, and neurologic Lyme disease. In addition, the ILADS guidelines raised a concern that a single 200 mg dose of doxycycline might prevent the development of a positive blood test.
The ILADS guideline authors recommended shared medical decision-making when treating patients with a tick bite. “The preferred regimen is 100 – 200 mg of doxycycline, twice daily for 20 days,” wrote the authors. They added,
“Some patients will value avoiding unnecessary antibiotics and prefer to not treat a tick bite prophylactically. Hence, treatment risks, benefits, and options should be discussed with the patient in the context of shared medical decision-making.”²
Editor’s note: I am one of the authors of the ILADS guidelines and an advocate for shared medical decision-making.
- Portman DB. Implementing a pharmacist-run Lyme disease postexposure prophylaxis clinic augmented by academic detailing within the Veterans Health Administration. J Am Pharm Assoc (2003). 2020 Feb 12. pii: S1544-3191(20)30006-6.
- Cameron, DJ, Johnson LB, Maloney EL. Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. Expert Rev Anti Infect Ther. 2014 Sep; 12(9): 1103–1135.
I couldn’t agree with Dr. Cameron more. Getting bitten by a tick is just the beginning of a complex journey. This is not as simple as the CDC/IDSA makes it out to be. Tick-borne illness (TBI) deserves time and attention to detail – and follow-up. It is obvious that the way it’s been handled isn’t working – more and more people are getting infected per year and more are struggling with persistent symptoms.
They say that insanity is doing the same thing over and over and expecting different results, yet that is precisely what the CDC/IDSA does regarding TBI.
Also concerning: a single 200 mg dose of doxycycline might prevent the development of a positive blood test.