Treat neuroborreliosis with oral doxycycline

European clinical trials demonstrated that oral doxycycline (200 mg daily for 14-21 days) is as effective as IV ceftriaxone for early Lyme neuroborreliosis caused by B. garinii. A landmark non-inferiority trial by Ljøstad et al. (2008) and a 2020 equivalence trial confirmed this finding for peripheral nervous system involvement including meningitis, cranial nerve palsy, and radiculopathy.

Why It Works

Doxycycline achieves adequate CSF concentrations to kill Borrelia in the central nervous system. European guidelines (EFNS/IDSA) now recommend oral doxycycline as equivalent to IV ceftriaxone for most neuroborreliosis presentations. This avoids the risks and costs of IV access.

Tips

• IV ceftriaxone remains preferred for parenchymal CNS disease (encephalitis, myelitis)
• A follow-up trial showed 2 weeks of doxycycline was non-inferior to 6 weeks for European neuroborreliosis
• B. garinii neuroborreliosis often presents as Bannwarth syndrome: severe radicular pain, cranial nerve palsies, and CSF pleocytosis
• Monitor for photosensitivity and GI side effects