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FREQUENTLY ASKED QUESTIONS ABOUT ANTIBIOTIC THERAPY 2. WHAT ANTIBIOTICS ARE USED AND WHAT IS THE DOSAGE? Typically, patients with severe and/or long-standing disease are started with a series of daily intravenous clindamycin for five to seven days. (See Section 11.) The first two days, 300 mg. of clindamycin would be administered in 250 cc 0.9% saline dripped over a 50 to 60 minute period. (D5W is not used because of the yeast overgrowth found in a large percentage of these patients.) The third and fourth day 600 mg. is given, the fifth and subsequent days 900 mg. Some physicians build up to 1200 mg. After the initial daily intravenous series, IVs may be administered once weekly, once every other week or as the physician determines for the individual patient. The IVs are continued until all lab figures return to normal, which can often take longer than a year, sometimes several years for patients with severe and/or long-standing disease. Lab results should then be monitored for several months longer, to be sure that the patient remains stable, before discontinuing the IVs. Various modifications to the late Dr. Brown's original antibiotic protocol regarding the use of IV clindamycin have been made by some physicians currently treating rheumatoid patients today. Some physicians have reported success using clindamycin orally, or in intramuscular injections. Orally, the single dose is 1200 mg. once a week. For intramuscular injections, 300 mg to 600 mg. once a week. For sensitive patients, a local anesthetic may be applied to the injection site. However, simply changing the needle tip, after drawing the medication into the syringe and before injecting it, will avoid the problem of tissue irritation at the injection site, because it is the trace amount of medication on the tip of the needle that causes the tissue irritation. [A. Robert Franco, M.D., a rheumatologist in Riverside, California who has years of experience in using this therapy, often prescribes a seven day series of IV clindamycin every five weeks for four cycles and then reassesses the patient's needs. In some of his patients. Dr. Franco has substituted oral Zithromax (azithromycin) 250 mg. twice daily for two days each week (Tues. Thurs.) in combination with oral Minocin (Mon., Wed., Fri.).] When the initial course of IVs is completed, patients begin oral therapy - minocycline (Minocin) or doxycycline (Vibramycin/Doryx) 100 mg. once or twice daily, or tetracycline 250 mg. to 500 mg. twice daily Monday, Wednesday and Friday. This intermittent therapy (also referred to as pulsing) is effective for most patients. More is not necessarily better; however, in some cases, five or even seven-day a week doses may be necessary for a limited time. The use of higher doses tends to make it more difficult to keep the intestinal tract in balance. Patients with mild to moderate disease are started with this same oral therapy, but often without the initial week-long series of IV clindamycin at the beginning. Erythromycin can be substituted for those patients sensitive to the tetracyclines. Tetracycline is more apt to react with food and must be taken on an
empty stomach. Some patients may need to take doxycycline with food,
especially at first until their body gets used to it, although doxycycline
is better absorbed apart from meals. Taking 3 or 4 ounces of a pharmaceutical
grade aloe vera liquid shortly after taking the antibiotic has been
found beneficial for those with sensitive stomachs. Reliable brands
of aloe vera would include: None of the antibiotics in the tetracycline family (tetracycline, doxycycline, minocycline) should be taken at the same time with calcium supplements, including dairy products, or with any other minerals such as magnesium, iron, etc. which have the same chemical valance as calcium. Ask your pharmacist for advice here because it is known that other minerals can also have similar inhibiting effects as calcium does on the absorption out of the GI tract of all antibiotics in the tetracycline family. Caution: Be sure to drink a full glass of water and to remain sitting upright for at least 30-45 minutes whenever taking any antibiotic in the tetracycline family in order to prevent esophageal injury. For this reason, do not take this medication immediately before going to bed at night, but remain sitting up long enough to be sure the pill reaches the stomach and does not remain stuck in the esophagus, where it might dissolve and cause painful esophageal burning and scarring. Some reported sensitivities to the tetracycline drugs may be caused by the drug being introduced too rapidly and at too high a dose. A slow start, 50 mg. Monday and Friday then gradually building up to the standard dose (100 mg. once or twice Monday, Wednesday and Friday), can often avoid this allergic reaction. Caution: Some oral generic tetracyclines have been found to be ineffective for this therapy. For children under twelve with inflammatory rheumatic disease, EryPed (erythromycin), is prescribed in place of the tetracycline drugs, to avoid staining of teeth. The dosage is one teaspoon (200 mg.) three times a day for 15 to 21 days; then 200 mg. two times a day thereafter, seven days a week - taken with food. The patient is kept on this medication for three to six months after labs return to normal. If labs are still normal after this time, tapering of the drug may begin. Caution: Erythromycin and clindamycin should not be taken together, according to the Nursing Drug Handbook, because erythromycin may block access of clindamycin to its site of action. Caution: Patients should always inform their physician of adverse reactions to any of their medications. Exacerbation of systemic lupus erythematosis has been reported in patients taking minocycline, as has transient lupus-like symptoms. However, while some physicians report they have not had a problem at the low doses used in this protocol, other physicians avoid the risk by prescribing erythromycin for their lupus patients - 333 mg. twice a day Monday, Wednesday and Friday - taken with food. For those patients with sensitive stomachs, Ery-Tabs may be prescribed. [As mentioned previously, taking three or four ounces of a pharmaceutical grade aloe vera shortly after taking the antibiotic, has been found beneficial for those with sensitive stomachs. ] Note: A suspected 'causal' association between mycoplasma hominus and lupus was shown in Cassell GH, Clough W, Septic Arthritis and Bacteremia Due to Mycoplasma Resistant to Antimicrobial Therapy in a Patient with Systemic Lupus Erythematosus, Clin Infec Dis, 1992; 15:402-407, and mycoplasma hominus is known to be resistant to erythromycin, therefore necessitating the use of an antibiotic in the tetracycline family, with Minocin being the most effective. What might be happening, instead, is that the so-called 'lupus flare' is really another example of a Herxheimer reaction which is occurring. Therefore, possibly by reducing the dosage and/or frequency of Minocin, and by monitoring the situation closely with frequent, repeated lab testing, these precautionary measures might be sufficient to resolve this potential problem concerning the use of Minocin in treating lupus patients, before the situation can get too far out of control. ANTI-INFLAMMATORIES: Reducing the inflammatory barrier is essential to allow penetration of the antibiotic. NSAIDS as well as aspirin preparations (preferably enteric coated) are used for this purpose. These drugs and the dosage will need to be tailored to the individual. All of them must be used with caution as they can cause serious side effects. (www.rxlist.com) Other products known to reduce inflammation and safer than NSAIDS include: 1. Cod liver oil (Kirkland's or Carlson's - both mercury free) - suggested
dosage is 1 TB twice a day with 400 IU of vitamin E. In highly sensitized individuals, antihistamines and small doses of corticosteroids (less than 5 mg. a day) are helpful. 'To reduce the inflammatory barrier and allow penetration of the antibiotics, 1 to 5 mg of prednisone may be administered to the patient simultaneously with the antibiotic. Preferably no more than 10 mg. should be administered for flares. Larger doses when required should be given in short interrupted courses. It is of interest that the concomitant use of antibiotics with the steroids makes steroid withdrawal easier. The dosage of the drug must be kept low to avoid interfering with the immune system but high enough to reduce the hypersensitivity or allergic inflammatory reactions of the disease.' Dr. Thomas McPherson Brown in Antibiotic Treatment Plan. INJECTING THE JOINT Thomas McPherson Brown, M.D. et al in Antimycoplasma Approach to the Mechanism and the Control of Rheumatoid Disease from Inflammatory Diseases and Copper, The Humana Press 1982 states: 'Intraarticular injections of clindamycin have been very effective when the reactive state of the joint is so intense that penetrance (of the antibiotic) is not achieved by the oral or IV route. The inflammation must be reduced in most instances for maximum clindamycin effect. The usual treatment plan for large joints, clindamycin 300 mg, plus dexamethasone 4 mg. A reduced amount of the same combination of these medications is used for smaller joints.'
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