Title: PharmaNote
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Title: PharmaNote
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Creator: University of Florida College of Pharmacy
Publisher: College of Pharmacy, University of Florida
Publication Date: January 2003
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Ashley Trask, Pharm.D.

As an emerging infectious disease, Lyme dis-
ease (LD) presents a challenge to clinicians. The
Centers for Disease Control (CDC) conclude Lyme
disease is currently the most common vectorborne
disease in the United States.1 The latest data pub-
lished by the CDC indicate that 16,273 cases of LD
were reported in 1999. Although this number is a
3% decrease from cases reported in 1998, it is a
21% increase from cases reported in 1997.1 In
1999, most cases of LD were reported in the north-
eastern, mid-atlantic, and north central states. The
following states reported incidences higher than the
national average (6.0 cases/100,000 people): Con-
necticut, Rhode Island, New York, Pennsylvania,
Delaware, New Jersey, Maryland, Massachusetts,
and Wisconsin.1 Florida is considered a low risk
state with an incidence of 0.4 cases per 100,000
people for 1999. Also between 1990 and 1999,
there were a total of 382 cases reported.
Lyme disease appears to target the young (<15),
and middle-aged (30-59) more frequently than
other age groups.1 It affects both sexes equally. The
most frequent months of reported onset of illness
are June and July.1 Persons at highest risk of con-
tracting LD are those living in areas where the dis-
ease is endemic, who spend time outdoors in over-
grown brush or wooded areas due to occupational
or recreational activities. This article will focus on
the latest treatment guidelines for LD and methods
of preventing transmission of the infection.

Lyme disease is caused by Borrelia burgdor-
feri, a leptospire residing in the gut of infected ticks
of the Ixodes ricinus complex. Ixodes scapularis,
also know as the blacklegged or deer tick, is the
vector in the eastern United States, whereas Ixodes
pacificus, or the western blacklegged tick, is the
vector in the western United States. The nymphal
stage of the tick's life cycle occurs during late
spring and early summer. It is during this stage of
the tick's life cycle that the majority of Lyme dis-
ease cases are transmitted to humans. The CDC es-
timates the prevalence of B. burgdorferi-infected
ticks in the United States is approximately 15-30%
of scapularis nymphs and up to 14% of pacifi-
cus nymphs. However, in the southern United
States, the prevalence of infection in I. scapularis
ticks is generally 0%-3%.2 Thus the risk of con-
tracting LD varies not only with geographic loca-
tion but also with presence of B. burgdorferi-
infected ticks in a specific area and amount of ex-
posure to those ticks by an individual. These three
factors are important aspects for clinicians to con-
sider when deciding a patient's degree of risk for
contracting Lyme disease and considering vaccina-
Transmission of Lyme disease involves a vector
(Ixodes ricinus ticks), human hosts, and the use of
an animal host (white-tailed deer) to complete the
life cycle of B. burgdorferi. Deer are an important
link in the life cycle of B. burgdorferi and are abun-
dant in areas where Lyme disease is endemic.3 B.
burgdorferi is maintained in nature through hori-
zontal transmission from infected nymphs (ticks)
to white-tailed deer to larval ticks, which then molt
to become infected nymphs. Infected nymphs are
responsible for spreading B. burgdorferi to hu-

Pha rma Note Volume 18, Issue 4 January 2003




Volume 18, Issue 4 January 2003

Table 1. Early Signs of Lyme Disease3

Early manifestations can appear as localized
disease in the form of a solitary erythema migrans
lesion, most frequently in the area surrounding the
tick attachment, or patients can present with symp-
toms of early disseminated disease such as fever,
lymphadenopathy, multiple erythema migrans le-
sions, carditis, cranial-nerve palsy, meningitis, or
acute radiculopathy.4 A summary of early signs and
symptoms of LD are presented in Tables 1 & 2.

Late manifestations of LD include arthritis
(oligoarticular, commonly of the knees), encephalo-
pathy (characterized by memory deficit, irritability,
and somnolence), and neuropathy (manifested pri-
marily by distal paresthesias or radicular pain).4

CNS Involvement
CNS symptoms usually include but are not lim-
ited to severe headache, nuchal rigidity, meningitis,
or acute radiculopathy. Patients presenting with
CNS symptoms are treated in a different manner
than patients with early or late manifestations of
LD. A lumbar puncture is performed along with a
neurological evaluation of all patients suspected of
having CNS involvement. Although patients may
present with either early or late manifestations of
Lyme disease in addition to CNS symptoms, pa-
tients are treated separately and more aggressively
based on the emergence of CNS symptoms.
There has been controversy over how to classify
and treat patients presenting with seventh cranial
nerve palsy. Clinicians argue over whether this
symptom, by itself, should be classified as a CNS
symptom. Some clinicians treat seventh cranial
nerve palsy with a lumbar puncture (LP) and follow
CNS treatment protocols; others look for other evi-
dence of CNS involvement, such as severe head-
ache or nuchal rigidity, before choosing to treat
with CNS protocols.4

Chronic LD or Post-Lyme Disease Syndrome
Patients who have been treated successfully and
appropriately for Lyme disease may complain of
residual symptoms of arthralgia, myalgia, or fatigue
continuing for weeks or months beyond treatment.
These patients have been classified as having
"chronic Lyme disease" or "post-Lyme disease syn-


Erythema chronicum migrans
Multiple annular lesions

No. Pts (%)
314 (100)*
150 (48)

regional 128 (41)
generalized 63 (20)
Pain on neck flexion 52 (17)
Malar rash 41(13)
Erythematous throat 38 (12)
Conjunctivitis 35 (11)
Right upper quadrant tenderness 24 (8)
Splenomegaly 18 (6)
Hepatomegaly 16 (5)
Muscle tenderness 12 (4)
Periorbital edema 10 (3)
Evanescent skin lesions 8 (3)
Abdominal tenderness 6 (2)
Testicular swelling 2 (1)
*Erythema chronicum migrans was required for inclusion in the study

drome." The Infectious Disease Society of America
(IDSA) does not recognize this classification as a
separate diagnostic entity. They claim these symp-
toms are common following treatment of many in-
fectious diseases, and are difficult to distinguish
from LD because "the prevalence of fatigue and/or
arthralgias in the general population is greater than
ten percent."4 Also, the IDSA concludes there are
no convincing published data showing repeated or
prolonged courses of oral or intravenous antimicro-
bial therapy are effective for such patients.

The diagnosis of LD is based primarily on the
presence of a characteristic clinical picture, and ex-
posure in an endemic area. Treating patients based
on these findings alone is appropriate according to
the CDC.2 However, an elevated antibody response
to B. burgdorferi can be used as diagnostic evi-
dence or as a means of confirming a suspected LD
infection. B. burgdorferi is most readily cultured
from erythema migrans lesions because growing a
culture from other sites is difficult.3 It grows best in
a Barbour-Stoenna-Kelly medium at 33C.3
Serologic testing has been found to be very

Pha rma Note Volume 18, Issue 4 January 2003

Diagnostic Evaluation


Volume 18, Issue 4 January 2003

Table 2. Early Symptoms of Lyme Disease3
S m Number of Pts (%)
Symptom n=314
Malaise, fatigue, and lethargy 251(80)
Headache 200 (64)
Fever and chills 185 (59)
Stiff neck 151 (48)
Arthralgias 150 (48)
Myalgias 135 (43)
Backache 81(26)
Anorexia 73 (23)
Sore throat 53 (17)
Nausea 53 (17)
Dysesthesia 35 (11)
Vomiting 32 (10)
Abdominal pain 24 (8)
Photophobia 19 (6)
Hand stiffness 16 (5)
Dizziness 15 (5)
Cough 15 (5)
Chest pain 12 (4)
Ear pain 12 (4)
Diarrhea 6 (2)

helpful in providing valuable supportive diagnostic
information in patients with manifestations of later-
stage disseminated LD and in asymptomatic LD in-
fections.2 Less than 5% of patients who are sero-
negative go on to develop late manifestations.5 This
figure can be explained by the strong seroreactivity
and expanded WB immunoglobin (IgG) banding
patterns to diagnostic B. burgdorferi antigens that
patients with early disseminated or late-stage LD
demonstrate.2 These findings indicate serologic
testing in LD can be performed with a high degree
of specificity and sensitivity.2
In fact, the CDC recommends initial tests be
performed with a sensitive test such as an enzyme
linked immune sorbent assay (ELISA) or an indi-
rect fluorescent antibody test, followed by more
specific testing with Western immunoblot to con-
firm positive or indeterminate results.2 PCR is also
helpful for amplifying genomic DNA of B.
burgdorferi in blood, skin, CSF, and synovial fluid
but has not yet been standardized for routine diag-

However, serologic testing early after infection
will be insensitive because the specific immune re-
sponse in LD develops slowly. Whereas 30-40% of
patients with erythema migrans lesions are sero-
positive in acute phase sera, 60-70% are seroposi-
tive two to four weeks later.3 The specific IgM re-
sponse peaks between the third and sixth week of
infection, while the specific IgG response develops
gradually over several months.3 After the first 4-6
weeks of infection, 90% of patients have an ele-
vated IgG response to the spirochete.3

Role of Antimicrobials

Oral First Line Therapies
Doxycycline is preferred for early manifesta-
tions of Lyme disease without CNS complica-
tions.3'4'6 It is administered at a dose of 100 mg bid
to adults, and can be prescribed to children older
than 8 years at a dose of 1-2 mg/kg/bid, not to ex-
ceed 100 mg/dose. Table 3 summarizes the antim-
icrobials used in the treatment of Lyme disease.
Another recommended oral medication in the
treatment of early Lyme disease is amoxicillin.3'4
Amoxicillin is administered to adults at a dose of
500 mg tid, and at 50 mg/kg/d divided into 3 doses,
not to exceed 500 mg/dose for children. Amoxicil-
lin is also available in a liquid formulation for those
unable to take solid dosage forms.
An alternative oral medication is cefuroxime
axetil at 500 mg bid for adults, and 30 mg/kg/d di-
vided into 2 doses with a maximum of 500 mg/dose
for children.3'4 This agent can be reserved for per-
sons unable to take amoxicillin or doxycycline, but
is more costly than the other choices. Cefuroxime is
also available as a liquid but has poor palatability.

Oral Second Line Therapies
Macrolide antibiotics are viewed as second line
therapies, indicated when patients are unable to tol-
erate doxycycline, amoxicillin, or cefuroxime
axetil.3'4 They are not to be used as first line thera-
pies. Of the macrolide class of antibiotics, the fol-
lowing agents are acceptable for use in the treat-
ment of Lyme disease: azithromycin, 500 mg qd for
adults, 10 mg/kg/d (maximum 500 mg/dose) for
children; erythromycin, 500 mg qid for adults, 12.5
mg/kg qid (maximum 500 mg/dose) for children; or
clarithromycin 500 mg bid for adults, 7.5 mg/kg
bid (maximum 500 mg/dose) for children.

Pha rma Note Volume 18, Issue 4 January 2003


Volume 18, Issue 4 January 2003

Table 3. Antimicrobials Used for the Treatment of Lyme Disease4
Drug Adult Dosage Duran Pediatric Dosage
Preferred oral
Amoxicillin 500 mg tid 14-21 50 mg/kg/d, divided into 3 doses (max 500 mg/dose)
Doxycycline 100 mg bid 14-21 = 8 years, not recommended
> 8 years, 1-2 mg/kg bid (max 100 mg/dose)
Alternative oral
Cefuroxime axetil 500 mg bid 14-21 30 mg/kg/d, divided into 2 doses (max 500 mg/dose)
Azithromycin 500 mg qd 7-10 10 mg/kg/d (max 500 mg/dose)
Clarithromycin 500 mg bid 14-21 7.5 mg/kg bid (max 500 mg/dose)
Erythromycin 500 mg qid 14-21 12.5 mg/kg qid (max 500 mg/dose)
Preferred parenteral
Ceftriaxone 2 g qd 14-28 75-100 mg/kg qd (max 2 g)
Alternative parenteral
Cefotaxime 2 g tid 14-28 150-200 mg/kg/d, divided into 3-4 doses (max 6 g/d)
Penicillin G 3-4 million units q4h* 14-28 200,000-400,000 units/kg/d, divided into q4h doses
(max 18-24 million units/d)
*Pts with normal renal function

Intravenous First Line Therapies
Ceftriaxone is used for early or late manifesta-
tions of Lyme disease with CNS complications.3'4
Ceftriaxone has good CSF penetration and is ad-
ministered at a dose of 2 g once daily for adults. In
children, ceftriaxone can be used at a dose of 75-
100 mg/kg/d in a single daily intravenous dose
(maximum of 2 g per day).

Intravenous Alternative Therapies
Alternative intravenous therapies include peni-
cillin G at a dose of 18-24 million units daily, di-
vided into doses given every four hours for adult
patients with normal renal function.3'4 For children
with normal renal function, penicillin G is given at
a dose of 200,000-400,000 units/kg/d (max. 18-24
million units/d) divided into doses given every four
Another alternative is cefotaxime at a dose of
2 g every eight hours for adults, or 150-200 mg/kg/
d divided into 3 or 4 doses (maximum 6 g/d) in
For adults and children (>8 yrs) who cannot tol-
erate penicillin or cephalosporins because of a beta
lactam allergy or otherwise, parenteral doxycycline
is acceptable. Doxycycline should be administered
at a dose of 200-400 mg/d in two divided doses.4

Guidelines for Treatment

There is some debate over which individuals
exposed to tick bites should receive treatment for
Lyme disease. The newest IDSA guidelines devel-
oped four options to this dilemma and evaluated the
advantages versus disadvantages of treating indi-
viduals according to each option.

Option 1
Treating with antimicrobials all persons who
remove vector ticks that have become attached.
This option involves liberal management of ex-
posed individuals which not only is costly, but was
found by the IDSA to have greater risks of antibi-
otic-associated adverse reactions than benefits from
treating the infection. Also, patients treated accord-
ing to this option were no more likely to develop
LD from a tick bite than they were to have an anti-
biotic-associated adverse reaction.4

Option 2
Treating with antimicrobials only persons be-
lieved to be at high risk. Although this option nar-
rows the amount of potentially treatable patients, it
still examines a large group of candidates and could
be costly. Also, this option becomes difficult to fol-

Pha rma Note Volume 18, Issue 4 January 2003


Volume 18, Issue 4 January 2003

low because one cannot always be certain the bite
or wound was inflicted by a tick, or that the tick
was the species Ixodes, or that the tick was from
the species Ixodes and was infected with B. burk-
dorferi. In addition, there is no standardized
method for screening ticks for evidence of infec-
tion with B. burkdorferi. Even if patients in this
category were given prophylactic antibiotics based
on the assumption that any tick was attached for
greater than 72 hours, no studies have shown that
antibiotics can reduce the development of infection
after a tick bite has occurred.

Option 3
Treating with antimicrobials only persons who
develop erythema migrans or other clinical mani-
festations of Lyme disease. Again, progression
from option 2 to option 3 has narrowed the percent-
age of treatable patients; however, this option re-
quires patients show symptoms of a tick-borne ill-
ness. While option 3 is beneficial for patients who
develop erythema migrans or other symptoms, it
provides no treatment for individuals who are as-
ymptomatic with active LD.

Option 4
Treating with antimicrobials all persons who
seroconvert from negativity to positivity for serum
antibodies to B. burgdorferi when acute and fol-
low-up serum samples are tested simultaneously.
Option 4 does not appear to be the best option due
to limitations of currently available serological as-
says for detecting LD and current recommenda-
tions by IDSA not to use serological testing as a
method of screening individuals exposed to a tick

After reviewing all options, the IDSA reached
the following conclusions. "Routine use of antim-
icrobial prophylaxis or serological tests after a tick
bite is not recommended."4 "Persons who remove
attached ticks should be monitored closely for
signs and symptoms of tick-borne diseases for up
to 30 days and specifically for the occurrence of a
skin lesion at the site of the tick bite."4 "Persons
who develop a skin lesion or other illness within
one month after removing an attached tick should
promptly seek medical attention for assessment of
the possibility of having acquired a tick-borne dis-

ease."4 The CDC makes similar recommendations
regarding who should and should not be treated for
a potential Lyme disease infection.2

Duration of Treatment
Length of treatment is a highly disputed issue
surrounding Lyme disease, and continues to be
challenged by practitioners. Most controlled trials
have been conducted in adults using doxycycline or
amoxicillin with treatment durations of 3 weeks (20
days) for early and late manifestations of LD with-
out evidence of CNS complications.4 However,
Nowakowski showed that 14-day regimens of
doxycycline were as efficacious, with similar ad-
verse events, as 20-day regimens of doxycycline.6
Looking at these findings, one would argue 20-day
regimens are unnecessary, more costly, and could
put patients at greater risk for experiencing adverse
events. Because of the controversy and emerging
findings like Nowakowski's, the IDSA has left
room in their recently published guidelines for cli-
nicians to individualize treatment rather than follow
a directed duration. The IDSA Guidelines recom-
mend treating patients for 14-21 days with any of
the three preferred oral antimicrobials.4
Late manifestations without CNS complications
involving complaints primarily of arthritis involve
extending treatment for a full 28 days.4 Some argue
whether 28 days is long enough to see resolution of
symptoms. New opinions suggest patients with late
LD should be treated until clinical symptoms re-
solve, regardless of duration.7 Guidelines adopted
by the Lyme Disease Foundation (LDF) recom-
mend treating patients with early disseminated dis-
ease for a minimum of 4-6 weeks, and late LD for a
minimum of 4-6 months.8 LDF's lengthy treatment
recommendation is based on the claim that LD pa-
tients experience cyclic flares occurring every 4
weeks. It is postulated that these flares are part of
the organism's cell cycle. Similar to antineoplastic
treatment strategies, antibiotics target killing in the
growth phase of the organism and therefore must
be administered for at least 4 weeks in order to en-
sure a growth phase has occurred.8 However, the
phenomenon of cyclic flaring and targeted antibi-
otic killing is not embraced by the IDSA and CDC.
CNS complications in LD warrant the use of
intravenous ceftriaxone for good penetration into
the CSF, at high doses to ensure good tissue levels

Pha rma Note Volume 18, Issue 4 January 2003


Volume 18, Issue 4 January 2003

for a longer duration (14-28 days) than other LD
therapies.3'4 Again, LDF guidelines recommend
treating these patients until symptoms resolve
rather than set an endpoint. These extra measures,
including the extended duration of treatment, re-
flect the high risk of this patient population and the
necessity to provide concentration-dependent and
time-dependent killing to maximize outcomes for
patients with CNS complications.


Personal Measures
The simplest way to prevent infection of LD is
to minimize exposure to ticks by avoiding tick-
infested areas.4 If avoidance is not possible, the
next best option to reduce transmission of infection
is to wear light-colored protective clothing. Long
sleeves and pants tucked into boots expose less skin
to the environment and keeps tick-attachment to a
minimum. Light-colored articles help to visualize
ticks. The use of an insect repellant such as DEET
(n,n diethyl m-toluamide) has been shown to re-
duce tick attachment.2 Permethrin has been shown
to kill ticks on contact and therefore its application
to clothing also increases protection.2
A visual inspection of the body should be per-
formed after exposure to tick infested areas. Those
residing in endemic areas should perform this ex-
amination on a daily basis. Prompt tick removal is
important since attachment for longer than 48 hours
is necessary for transmission of B. burgdorferi. The
area surrounding a tick bite should be carefully
watched for up to one month after the bite occurred
for signs of LD infection (see Tables 1 & 2).

A vaccine for the prevention of Lyme disease
has been developed and received FDA approval in
December 2000.9 LYMErix uses recombinant B.
burgdorferi lipidated outer-surface protein A
(rOspA) as immunogens.2 This vaccine is adminis-
tered as a series of 3 shots: at 0, 1 month, and 1
year. Although phase III clinical trials showed LY-
MErix to be nearly 80% effective in preventing
Lyme disease, information on safety and efficacy
beyond the third shot is not yet available nor is it
known if additional boosters will be necessary to
maintain immunity.9 The vaccine is indicated for
persons age 15-70. The most common adverse

event occurring in Phase III clinical trials was sore-
ness at the injection site, followed by LD-like
symptoms of myalgia, influenza-like illness, fever
and chills. Among the 10,936 subjects in these
phase III clinical trials, there were no reported epi-
sodes of immediate hypersensitivity in the vaccine
group.2 Efficacy of LYMErix against symptomatic
LD was shown to be 49% and 76% after two and
three shots respectively. Efficacy against asympto-
matic LD infection was 83% one year after receiv-
ing the vaccination and 100% two years after re-
ceiving the vaccination.2
Although a vaccine is now available, its role in
the treatment and prevention of LD is controversial
due to published low cost-effectiveness data. Infor-
mation compiled by the CDC indicates that use of
the vaccine results in a net cost to society of $5692
per case averted, and $35,375 per complicated neu-
rologic or arthritic case avoided. This data also re-
veals that the cost of vaccinating will exceed the
cost of not vaccinating until incidence of LD is
greater than 1973 cases per 100,000 persons per
year.2 The overall incidence of LD reported in the
United States in 1999 was 6 cases per 100,000
population. However, certain geographic areas
show higher risk. The county with the highest inci-
dence of LD was Nantucket County, Massachu-
setts, at 950.7 cases per 100,000 population.
Twenty-four other counties reported incidences of
LD exceeding 100 cases per 100,000 population.
These counties were located in Connecticut, Mary-
land, Massachusetts, Minnesota, New Jersey, New
York, Pennsylvania, Rhode Island, and Wisconsin.1
Although the reported cases for 1999 remain below
that which establishes the vaccine as cost-effective,
they are not far from the mark. Thus, use of the
vaccine should be based on an individual's risk for
contracting LD.2 This recommendation is supported
by the Advisory Committee on Immunization Prac-
tice, Public Health Service, U.S. Department of
Health and Human Services.2
Meltzer and colleagues also published similar
cost-effectiveness results on the LD vaccine.10 His
report concluded that communities with average in-
dividual probabilities of less than 0.01 of contract-
ing LD may benefit from interventions that im-
prove the probability of early diagnosis and treat-
ment.10 Meltzer's article mentions results from a
forthcoming Institute of Medicine report which

Pha rma Note Volume 18, Issue 4 January 2003


Volume 18, Issue 4 January 2003

Table 4. Cost Comparison of Adult IV and PO Regimens
Drug Regimen Formulation (S)*

500 mg tid x20 d 500 mg capsules 17
100 mg bid x20 d 100 mg capsules 17
Cefuroxime axetil
500 mg bid x20 d 500 mg tablets 284
500 mg bid x20 d 250 mg/5 ml suspension 243
600 mg qd x6 d# 600 mg tablets 101
500 mg qd x8 d 200 mg/5 ml suspension 118
500 mg bid x20 d 500 mg tablets 131
500 mg bid x20 d 250 mg/5 ml suspension 288
500 mg qid x20 d 500 mg tablets (base) 22
2 g q24h x28 d 2 g bag 1172
2 g q8h x28 d 2 g bag 2236
Pen G x28 d
20 million U/d q4h 20 million U vial 224
*Prices obtained from drugstore.com (March, 2001)
#Regimen differs from recommended guideline

uses cost per quality-adjusted life year (QALY)
saved to judge economic benefit of the vaccine.
The authors of this report estimate costs greater
than $100,000 per QALY saved if the vaccine were
administered "...to resident infants born in, and im-
migrants of any age to, geographically defined high
risk areas." Thus, the authors conclude universal
use of the vaccine is "less favorable," the lowest
ranking priority for vaccine development and a par-
alleled finding in many of these studies.10

Comparative Cost

Comparative costs of the various recommended
oral and parenteral agents are presented in Table 4.


Lyme disease is an emerging infectious disease
that requires early recognition for maximum out-
comes. Borrelia burgdorferi, the causative organ-
ism causes an infection through vector ticks of the
Ixodes species. These ticks have been found in
various areas of the United States. Lyme disease
involves multiple stages including early and late
manifestations and CNS involvement. Diagnosis is

based upon clinical subjective findings and/or sero-
logic testing. The Infectious Disease Society of
America (IDSA) published updated guidelines for
the treatment of Lyme disease in July 2000.4 The
IDSA recommends treating patients who present
with subjective complaints of LD, such as erythema
migrans, and a documented exposure (tick bite)
rather than prophylactically treating all persons
with a documented tick bite. Preventive measures
such as avoidance of tick-infested areas and the use
of protective clothing and repellants to deter tick
attachment are encouraged. Persons residing in en-
demic areas should perform a daily body check for
attached ticks. LYMErix, a vaccine for the preven-
tion of LD in persons aged 15-70, was developed
and received FDA approval in February 2000.
Early reports on the cost-effectiveness of this vac-
cine indicate it should be reserved for use in indi-
viduals at high risk of contracting LD and not used
universally. Because of its complicated infectious
process and symptoms mimicking other infectious
diseases such as rheumatoid arthritis and malaria,
early recognition, treatment, and prevention of
Lyme disease will continue to be a challenge for
clinicians in the years to come.


1. Centers for Disease Control. Lyme Disease ---
United States, 1999 [editorial]. MMWR CDC
Weekly SurveillSumm 2001. March 16; 50
2. Centers for Disease Control. The Advisory
Committee of Immunization Practices Recom-
mendations for the Use of Lyme Disease Vac-
cine. MMWR CDC Weekly Surveill Summ
1999. June 04; 48(RR07):1-17.
3. Mandell, Douglas, Bennett, editors. Principles
and Practiceof Infectious Diseases. 4th ed. Chur-
chill Livingstone; 1995. p. 2143-2155.
4. Wormser GP, Nadelman RB, et al. Practice
Guidelines for the Treatment of Lyme Disease.
Clinical Infectious Disease 2000;31 Suppl 1:1-
5. Wilson, editor. Harrison's Principles of Internal
Medicine. 12th ed. McGraw-Hill, Inc; 1991. p.
447, 547, 667-669.
6. Nowakowski J, Nadelman RB, et al. Doxycy-
cline versus tetracycline therapy for Lyme dis-
ease associated with erythema migrans. J Amer

Ph ra ot Vlue 8,Isue4 anar 20


Volume 18, Issue 4 January 2003

Acad Derm 1995;32:223-7.
7. Liegner K. Disseminated Lyme Disease: Ap-
proach to Treatment. 11th International Scien-
tific Conference on Lyme Disease and Other
Spirochetal & Tick-Borne Disorders. 1998 LDF
Conference Abstract -- New York City, NY.
8. Burrascano Jr JJ. The New Lyme Disease. In Di-
agnostic Hints and Treatment Guidelines for
Tick Borne Illnesses. 12th ed.
9. Shaver K, editor. Safety of Lymerix Lyme Dis-
ease Vaccine. Pharmacist's Letter. Detail Num-
ber: 170304, March 2001.
10.Meltzer MI, Dennis DT, Orloski KA. The Cost
Effectiveness of Vaccinating against Lyme Dis-
ease. Emerging Infectious Diseases 2000;5(3)


New Indications

Altocor Primary prevention of CHD in
patients without CV symptoms
who have average to moderately
elevated Total-C and LDL-C and
below average HDL-C.
Avapro Diabetic nephropathy in patients
with hypertension.
Cancidas Esophageal candidiasis.
Cozaar Diabetic nephropathy in patients
with hypertension.
Valtrex Cold sores in healthy adults.

Zetia" (ezetimibe) is the first in a new class
of cholesterol-lowering agents that inhibits
the intestinal absorption of cholesterol. The
usual adult dosage is 10mg once daily and
has been approved alone or together with
stations in patients with high cholesterol to
reduce LDL-C and total cholesterol.



Liposomal formulation of NRA
(nicotine receptor agonist). It
has angiogenic activity and is
being used for myocardial
ischemia (Phase III).

Liprostin Liposomal form of PGE-1
derived locally as an adjunct to
angioplasty for critical limb
ischemia (Phase III).
LibiGel Topical testosterone gel applied
to the arms, shoulders, or
abdomen, for treating female
sexual dysfunction (Phase II).

Avandamet (rosiglitazone maleate and
metformin HC1) is a new antidiabetic
combination indicated for use in patients
already taking rosiglitazone and metformin
as separate tablets, or for those patients not
adequately controlled on metformin alone. It
is available in lmg/500mg, 2mg/500mg, and
4mg/500mg tablets.

The PharmaNote is Published by:
The Department of Pharmacy Services,
UF Family Practice Medical Group,
Departments of Community Health
and Family Medicine and Pharmacy
University of Florida

John G. Gums Editor

R. Whit Curry, M.D. Associate Editor

John M. Tovar Assistant Editor

Pha rma Note Volume 18, Issue 4 January 2003


Volume 18, Issue 4 January 2003

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