Treating Inflammatory Arthritis Post Lyme Disease

The authors of a small study that assesses treatment options after a Lyme disease infection, question the value of delaying treatment with disease-modifying anti-rheumatic drugs once autoimmune joint disorders set in.

“Our study demonstrates that when inflammatory arthritis develops in the context of Lyme disease, clinicians need to distinguish among three possibilities:  patients who have active infection in joints, those who have post infectious Lyme arthritis, and those who have another form of inflammatory arthritis following Lyme disease,” wrote researchers who led by Sheila Arvikar, M.D., of Massachusetts General Hospital in Boston.

The study, which appears in the December 28 online issue of Arthritis & Rheumatology, is based on a review medical records for 30 patients who were referred to the Massachusetts General Hospital for suspected Lyme arthritis between 2003-2015. The patients developed a new-onset systemic autoimmune joint disorders a median of four months following Lyme disease, with the most common disorders being rheumatoid and psoriatic arthritis. They also found that patients with Lyme arthritis may be taking antibiotics without benefit when disease-modifying anti-rheumatic drugs (DMARDs) may be more appropriate.

“Since the incidence of Lyme disease is increasing dramatically in the U.S. (with an estimated 300,000 new cases annually), more rare manifestations of the disease, including post-infectious complications, may be increasing. It is important for clinicians to be aware that a spectrum of infectious and autoimmune joint disorders may occur within the context of Lyme Disease. Patients may have active B burgdorferi infection in joints, antibiotic-refractory Lyme synovitis, or another form of autoimmune arthritis following Lyme disease,” researchers wrote.

Of the 30 referred patients, 15 patients were diagnosed with rheumatoid arthritis, 13 with psoriatic arthritis and two with peripheral spondyloarthritis (SpA). While the time frame for joint symptoms to appear after a Lyme disease diagnosis ranged from two weeks to two years, the median duration onset was four months, researchers wrote.

Lyme arthritis is condition known to be a late manifestation of Lyme disease. Historically, about 60 percent of patients with Lyme disease not treated with antibiotics develop Lyme arthritis. While many patients with Lyme arthritis respond well to antibiotic therapy, other patients can experience post-infectious antibiotic-refractory arthritis. These patients require an alternative plan for treatment.

In this study, patients with systemic autoimmune joint diseases were more likely to be older (54 vs. 44 years), have a higher body mass index, and a family history of autoimmune disease compared to the 43 control patients with Lyme arthritis. Most patients with systemic autoimmune joint disorders tested positive for B burgdorferi IgG antibodies. However, these same patients had significantly lower titers and lower frequencies of Lyme disease–associated autoantibodies than patients with Lyme arthritis.

“Prior to our evaluation, these patients had often received additional antibiotics for presumed Lyme arthritis, without benefit. We prescribed anti-inflammatory agents, most commonly disease-modifying anti-rheumatic drugs, resulting in improvement,” the researchers wrote.

Additionally, the 30 patients with autoimmune systemic joint disorders typically had polyarthritis, and those with psoriatic arthritis or spondyloarthritis often had previous psoriasis, axial involvement or enthesitis.  

Most patients with systemic autoimmune joint disorders tested positive for B burgdorferi IgG antibodies. However, these same patients had significantly lower titers and lower frequencies of Lyme disease–associated autoantibodies than patients with Lyme arthritis.

“Regardless of whether the occurrence of systemic autoimmune joint disease following infection is coincidental, induced nonspecifically by adjuvant effects of infection, or related to specific Lyme disease–associated autoimmune responses, an important point for clinicians is that post-infectious joint disorders that occur after recommended antibiotic treatment for Lyme disease should be treated with DMARDs (rather than with additional antibiotic),” researchers wrote.

“Delaying appropriate DMARD treatment of autoimmune joint disorders, by pursuing further therapy with antibiotic agents, may lead to poorer clinical outcomes.”

Important considerations:

• Lyme arthritis is characterized by monoarticular or oligoarticular involvement of large joints, and anti-biotic refractory arthritis generally affecting one large joint (most commonly a knee) in which resolution does not occur with antibiotic treatment.
• Systemic autoimmune joint diseases usually cause polyarthritis or may also have features of SpA.
• In this study, patients with systemic autoimmune disease had significant enrichment of typical risk factors such as family history of autoimmunity or obesity.
• Patients with systemic arthritis were more likely to have had erythema migrans (rash associated with a tick bite) that had been treated appropriately with antibiotics. Such therapy would abort the development of subsequent Lyme arthritis.
• In most Lyme arthritis patients, joint involvement presents first. In this study, no patients received antibiotic therapy prior to the development of arthritis.
• It is very unlikely that patients who develop polyarthritis after antibiotic-treated erythema migrans (EM) would have Lyme arthritis.

Disclosures:

Support for this research was provided in part by Rheumatology Research Foundation, National Institutes of Health, the English-Bonter-Mitchell Foundation, the Ounsworth-Fitzgerald Foundation, the Littauer Foundation, the Lillian B. Davey Foundation, and the Eshe Fund.

References:

Sheila L. Arvikar, Jameson T. Crowley, Katherine B. Sulka, et al. “Autoimmune Arthritides, Rheumatoid Arthritis, Psoriatic Arthritis, or Peripheral Spondyloarthritis Following Lyme Disease,” Arthritis & Rheumatology. Published online December 28, 2016. DOI: 10.1002/art.39866.