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Oral or IV for Lyme Encephalitis

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Posted 9/27/2017 1:18 AM (GMT 0)
My doctor believes that oral is just as effective as IV and safer for the treatment of Lyme. However, I have some swelling in my mid brain confirmed by an MRI with contrast. Swelling of the brain is Encephalitis, if my research is correct. And upon research for treatment, the recommendation is IV abx.

Should I demand IV, or should oral be fine?
Posted 9/27/2017 4:47 AM (GMT 0)
Hi Hoagie -

Most of the current information I have come across comparing IV and oral antibiotic treatments in crossing the blood-brain-barrier shows that they are fairly comparable.

The primary advantage IV has over orals is that IV delivery is a little less harsh on the GI. IV doesn't bypass the GI entirely because there are blood vessels that feed the GI but it is a better option for those who have severe GI issues.

Other than in those circumstances, I wouldn't recommend IV tx. I wrote a long detailed post on what IV tx entails for people trying to make that decision if you're interested. I can't post it right now (I'm on my phone) but will try to come back to this thread.

-p
Posted 9/27/2017 5:25 AM (GMT 0)
" Most of the current information I have come across comparing IV and oral antibiotic treatments in crossing the blood-brain-barrier shows that they are fairly comparable. "


Interesting you should mention this, Pirouette.

I just listened to an interview with Dr. J. who said the question of antibiotics not crossing the blood-brain barrier is a 'misnomer'.

He said its a misnomer that IV drugs get into the brain and oral drugs don't.
....Some oral drugs get into the brain through the blood/brain barrier, and most IV drugs do, but some don't.

All the drugs that are used get into the brain through vascular channels.

So perhaps we've been overly concerned about which antibiotics penetrate the blood/brain barrier better.
They don't necessarily need to - since they are carried through the vascular system.
Posted 9/27/2017 8:30 AM (GMT 0)
Rocephin and a lot of bvt did help my encephalitis but so did bart tx...maybe its myco or cpn(similar tx)..i think i even have hh6 and rmsf..

dr frid has a vid on her dx and treatment involving ivig

Post Edited (bluelyme) : 9/27/2017 2:36:04 AM (GMT-6)

Posted 9/27/2017 10:48 AM (GMT 0)
it depends on antibiotic no ? some have poor CSF/BBB penetration, some have very good. Usually the BBB penetration is proportional to the liposolubility of the chemical (how much of it dissolves in fat). So the more fat soluble a substance is, the easier it gets in the brain.

Examples that penetrate the brain well
- rifampin
- doxy - 5 times more than tetracycline
- mino - 2 times more than doxy => 10 times more than tetracycline
- cephalosporines like - ceftin, rocephin
- nitromidazoles - tinidazole, metronidazole
- azythromycin - this is more weird, it gets well absorbed in the brain but it does not stay in the CSF
- fluoroquinolones

Some people think that if an antibiotic is inserted in blood directly, it is somehow much better than anything else. This is not always the case, some antibiotics are injectable like simple penicilin, yet have poor BBB penetration.

Another example is daptomycin, a very powerful IV antibiotic that has almost non existent brain penetration...
Posted 9/27/2017 4:47 PM (GMT 0)

mpost said...
it depends on antibiotic no ? some have poor CSF/BBB penetration, some have very good. Usually the BBB penetration is proportional to the liposolubility of the chemical (how much of it dissolves in fat). So the more fat soluble a substance is, the easier it gets in the brain.

Examples that penetrate the brain well
- rifampin
- doxy - 5 times more than tetracycline
- mino - 2 times more than doxy => 10 times more than tetracycline
- cephalosporines like - ceftin, rocephin
- nitromidazoles - tinidazole, metronidazole
- azythromycin - this is more weird, it gets well absorbed in the brain but it does not stay in the CSF
- fluoroquinolones

Some people think that if an antibiotic is inserted in blood directly, it is somehow much better than anything else. This is not always the case, some antibiotics are injectable like simple penicilin, yet have poor BBB penetration.

Another example is daptomycin, a very powerful IV antibiotic that has almost non existent brain penetration...

Hi Mpost. Could you clarify how you came up with this? One of the more famous LLMDs in Wilton, CT uses tetracycline over doxy for its BBB penetration. Keep in mind that you have to dose tetracycline much higher than doxy (in MG) just because it is a different drug and metabolized differently.
Posted 9/27/2017 5:55 PM (GMT 0)

mpost said...
it depends on antibiotic no ? some have poor CSF/BBB penetration, some have very good. Usually the BBB penetration is proportional to the liposolubility of the chemical (how much of it dissolves in fat). So the more fat soluble a substance is, the easier it gets in the brain.


FWIW - According to Dr. J - this isn't really relevant (see my post above)
Posted 9/27/2017 5:58 PM (GMT 0)

Sheeks175 said...

mpost said...
it depends on antibiotic no ? some have poor CSF/BBB penetration, some have very good. Usually the BBB penetration is proportional to the liposolubility of the chemical (how much of it dissolves in fat). So the more fat soluble a substance is, the easier it gets in the brain.

Examples that penetrate the brain well
- rifampin
- doxy - 5 times more than tetracycline
- mino - 2 times more than doxy => 10 times more than tetracycline
- cephalosporines like - ceftin, rocephin
- nitromidazoles - tinidazole, metronidazole
- azythromycin - this is more weird, it gets well absorbed in the brain but it does not stay in the CSF
- fluoroquinolones

Some people think that if an antibiotic is inserted in blood directly, it is somehow much better than anything else. This is not always the case, some antibiotics are injectable like simple penicilin, yet have poor BBB penetration.

Another example is daptomycin, a very powerful IV antibiotic that has almost non existent brain penetration...

Hi Mpost. Could you clarify how you came up with this? One of the more famous LLMDs in Wilton, CT uses tetracycline over doxy for its BBB penetration. Keep in mind that you have to dose tetracycline much higher than doxy (in MG) just because it is a different drug and metabolized differently.

Tetracycline isn't one that most LLMD's use.
Posted 9/27/2017 8:51 PM (GMT 0)
/doi.org/10.1086/313604

"Doxycycline is 5 times more lipid soluble than conventional tetracycline, which is an important determinant of permeability of the blood-brain barrier.

....
Minocycline is 2 times more lipid soluble than doxycycline, thereby making it a potential alternative for treatment of Lyme neuroborreliosis. I have treated several patients with Lyme neuroborreliosis with minocycline, and our results are comparable with those of Dotevall and Hagberg"
Posted 9/27/2017 9:24 PM (GMT 0)
Read the FAQ here. Question #5. Dr P is a smart dude. He studied at Yale and currently has a long wait list. He didn't directly imply that tetra penetrates the BBB better, but it is implied.

http://www.stevenphillipsmd.com/faq-s-documents
Posted 9/27/2017 9:31 PM (GMT 0)

Sheeks175 said...
Read the FAQ here. Question #5. Dr P is a smart dude. He studied at Yale and currently has a long wait list. He didn't directly imply that tetra penetrates the BBB better, but it is implied.

http://www.stevenphillipsmd.com/faq-s-documents

I read question #5 and I don't see anything implying that tetra penetrates the BBB better...

He just says he prefers tetra because the standard dose is over 7 times higher than doxy dose; as well as having some effect on persisters.



5. Why tetracycline and not doxy? I usually prefer tetracycline over doxycycline. The standard dose of tetracycline is over 7 times higher than the standard dose of doxy and surprisingly, doxy isn’t materially stronger than tetracycline. In fact, tetracycline has been published to have some effect against B. burgdorferi persisters, whereas doxy has not, and studies of patients who have failed doxy have demonstrated that they can get better with tetra. Still, a minority of patients, most of whom have had bartonella in my experience, do better with other tetracycline class antibiotics such as doxy or minocycline rather than tetra. On the whole however, tetra usually seems to be better, plus it causes far less sunburn than doxy as well as less GI irritation per unit measure. Also, in adults and anyone over 8 years old it does not generally produce the vertigo, thyroid dysfunction, skin and tooth pigmentation which minocycline can produce.
Posted 9/27/2017 9:44 PM (GMT 0)
What is his point about regarding the dosage being 7x higher then? What is the benefit of that?
Posted 9/27/2017 9:46 PM (GMT 0)

Sheeks175 said...
What is his point about regarding the dosage being 7x higher then? What is the benefit of that?

That doesn't tell me it's more effective if that much more is needed.
That doesn't have anything to do with b/b barrier penetration.

The standard dosage of amoxicillin is 3,000 mg to 6,000 mg daily.
It's not more effective than other abx...that use less - like minocycline 100 mg twice daily.
Posted 9/27/2017 10:22 PM (GMT 0)

Girlie said...

Sheeks175 said...
What is his point about regarding the dosage being 7x higher then? What is the benefit of that?

That doesn't tell me it's more effective if that much more is needed.
That doesn't have anything to do with b/b barrier penetration.

The standard dosage of amoxicillin is 3,000 mg to 6,000 mg daily.
It's not more effective than other abx...that use less - like minocycline 100 mg twice daily.

LOL. I know... I was going to make that same argument. I am saying he must be saying there is a benefit to the dosage being 7x higher. What is that benefit?
Posted 9/27/2017 10:46 PM (GMT 0)

Sheeks175 said...

Girlie said...

Sheeks175 said...
What is his point about regarding the dosage being 7x higher then? What is the benefit of that?

That doesn't tell me it's more effective if that much more is needed.
That doesn't have anything to do with b/b barrier penetration.

The standard dosage of amoxicillin is 3,000 mg to 6,000 mg daily.
It's not more effective than other abx...that use less - like minocycline 100 mg twice daily.

LOL. I know... I was going to make that same argument. I am saying he must be saying there is a benefit to the dosage being 7x higher. What is that benefit?

Yah, he's mentioning the higher dosage for a reason...but doesn't explain ...
Posted 9/28/2017 2:31 AM (GMT 0)
I think it's really important in these kinds of discussions to remember that while well and even top regarded doctor's have their preferential abx's and abx combo's none of them are true solutions. If they were we would all be on the same protocol and we'd have been well long ago.

Some doctor's are in constant contact with the research teams and other's use older research. An article written about meds that's more than two years old can have dated info. There are so many variables at play. Let's not discount anyone's findings.
Posted 9/28/2017 5:58 AM (GMT 0)

Girlie said...

5. Why tetracycline and not doxy?

if you are interested to learn more about tetracyclines, it's useful to read this paper, it goes into detail about tetracyclines (tetra, doxy, mino) in context of borrelia infection:

/doi.org/10.1086/313604
Posted 9/28/2017 6:04 AM (GMT 0)
mpost - You know I was quoting someone else who said that...right?

You made it look like I said it...lol.

I did read it though.

Interesting - the study found the doxy as effective as Rocephin....just need a little longer time treating.


"This study confirms that oral doxycycline is equivalent to parenteral ceftriaxone in the treatment of Lyme disease—associated palsy and/or meningitis. Experience indicates 21 days of oral doxycycline therapy is equivalent to 14 days of ceftriaxone therapy "
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