Renewed call for dialogue on Lyme disease
"Lyme disease: time for a new approach? Many more questions than answers" is the headline of an editorial published in the December 2015 issue of the British Medical Journal (BMJ). The authors emphasize concerns physicians have over the many unanswered questions surrounding the illness and call for more dialogue within the medical and research communities.
by Daniel J. Cameron, MD, MPH
“We need more national and international debates on Lyme disease, complemented by a solid research agenda and a focus on cutting edge biological technologies,” writes Borgermans and colleagues. “The medical community has been collectively forced out of its comfort zone on Lyme disease by increasing evidence of the complexity of this multisystem disease.” 
“Most patients will present to family physicians, who often have few subsequent resources when the initial treatment proves unsuccessful.” Borgermans recommends that discussions include family doctors, who could be instrumental in advancing the dialogue. “Family physicians can act as important partners alongside infectious disease specialists and others to drive this debate forward.”
Additionally, the International Lyme and Associated Diseases Society (ILADS) should be one of the groups included in the dialogue. As an internationally recognized medical society specializing in the diagnosis and treatment of tick-borne diseases, ILADS members belong at the discussion table.
ILADS has repeatedly called for a dialogue, but requests have largely been ignored. This is unfortunate, as the 2014 ILADS evidence-based treatment guidelines adhere to the Institute of Medicine’s (IOM) guideline requirements and provide valuable diagnostic and treatment information.
For example, the guidelines review the risks versus benefits of treatment for patients. “In assessing the balance between the risks and benefits of antibiotic treatments for Lyme disease, the panel weighed the burden of disease, the magnitude and relative importance of patient-centered outcomes as well as treatment-associated risks and the risks attendant on not treating.” 
Borgermans and colleagues’ editorial recounts the following questions raised two years earlier in the International Journal of Family Medicine that have yet to be answered.
- Range of clinical presentations, including between sexes
- Diagnostic criteria and tools
- Treatments and their efficacy
- Transmission modes and vectors
- Role of coinfections
- Uncertainty over clinical definition of chronic Lyme disease and whether detection of active infection is essential
- Whether and for how long the pathogen can persist
- Role of psychoneuroimmunology, host-pathogen interactions, and autoimmunity to residual or persisting antigens
- Role of toxins or other bacterial products in symptoms and signs
- Contribution of environmental factors 
Borgermans and colleagues remind the reader about the consequences of putting off a dialogue, citing the medical communities long delay in recognizing the role Helicobacter pylori played in gastric disease. This demonstrates the “consequences of ignoring findings that contradict our current beliefs about a disease.”
The editorial concludes with an urgent call for action. “In an era where patient centered care is considered the cornerstone of high quality and integrated medicine, we cannot allow ourselves to repeat past mistakes at our patients’ expense. The suffering of many affected patients obliges us to learn more about this disease.”
- Borgermans L, Perronne C, Balicer R, Polasek O, Obsomer V. Lyme disease: time for a new approach? BMJ, 351, h6520 (2015).
- 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, 1-33 (2014).
- Borgermans L, Goderis G, Vandevoorde J, Devroey D. Relevance of chronic lyme disease to family medicine as a complex multidimensional chronic disease construct: a systematic review. Int J Family Med, 2014, 138016 (2014).