I had a patient who was quite reluctant to consider antibiotic treatment for Lyme disease after being unabIe to tolerate his initial treatment.  He was able to tolerate treatment by starting.   with a lower dose of antibiotics.

 I have patients with issues with gastroparesis, leaky gut, diarrhea, candida, yeast, constipation, and irritable bowel that has made it difficult to tolerate antibiotics.  I have patients who have had a Herxheimer reaction after an antibiotic for another conditions. A Herxheimer reaction also known as Jarisch-Herxheimer reaction (JHR) is a transient clinical phenomenon that occurs in patients infected by spirochetes who undergo antibiotic treatment.  I have patients who cannot swallow pills and others who cannot tolerate liquids.

 I refer my patients to specialists as needed to determine if there is another underlying cause for their difficulties with medications.  I refer to gastroenterologist if rule out other causes for stomach problems. I refer to other specialists to rule out an autonomic disorder as a cause for their stomach issues.

 I also have patients who are still sick after changes in their diet and alternative medicine.  I review the risk of antibiotics against the risk of remaining sick with Lyme disease.  Some of these patients are still unwilling to consider antibiotics.  I advise my patients to avoid alcohol and processed sugars.

Here are a few treatment options I have incorporated in my practice for those willing to be treated. I introduce treatment slowly. I start out with single therapy rather than combination therapy.  I have started patients with 50 mg of doxycycline instead of 100 mg. I have started with 25 mg of doxycycline at times with a liquid formulation.  I  have lowerd the dose of cefuroxime from 500 twice a day to 250 twice a day. I have prescribed Zithromax 250 every other day or every third day as Zithromax has a long half-life. I have lower the liquid atovaquone at 750 mg twice a day to atovaquone at 250 mg twice a day or a pediatric dose of atovaquone at 62.5 twice a day. The lower doses of atovaquone are available in an oral form combined with proguanil.

 I have start with once a day for some patient.  I typically raise the dose if tolerated. I find the lower doses helpful in some patient without having to increase the dose.

 I have not found intravenous ceftriaxone as helpful as I would like. IV ceftriaxone enters the stomach through the circulatory system leaving me with the same gastrointestional issues. Moreover, intravenous ceftriaxone is not the treatment of choice for tick-borne co-infections.

I follow by patients starting at one month to determine if they are tolerating the lower dose and to determine their response to treatment.  I advise my patient to contact me if they are having problem with tolerating the lower dose to work out a solution.