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For more information on the treatment approaches used in diagnosing and treating Lyme disease, see:

1.  Wormser GP, RJ Dattwyler, ED Shapiro, AJ Halperin, AC Steere, MS Klempner, PJ Krause, JS Bakken, F Strle, G Stanek, L Bockenstedt, D Fish, JS Dumler, and RB Nadelman. The clinical assessment, treatment, and prevention of Lyme  disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006; 41(1 November): 1089.

Available at www.journals.uchicago.edu/CID/journal/issues/v43n9/40897/40897.web.pdf

2.  The International Lyme and Associated Diseases Society. ILADS Evidence-based guidelines for the management of Lyme disease. Expert Rev. Anti-infect. Ther. 2004; 2(1): S1–S13.  Available at www.ilads.org.

3.  The National Guidelines Clearinghouse (www.guideline.gov); enter Lyme in the search box.

Intravenous Treatment Consent Form

In certain situations, intravenous (IV) medications are preferred or may be used to supplement oral medications. IV treatment is sometimes recommended when there is neurological involvement, heart problems, severe joint inflammation, or inadequate response to oral medications. Because the GI system is bypassed, IV dosing greatly increases the probability of adequate medication blood levels and reduces gastrointestinal symptoms. IV antibiotics also may penetrate the blood brain barrier more effectively. There are additional risks associated with IV treatment. IV treatment usually involves the installation of an intravenous line in my vein to allow easier IV treatment.  PICC lines may result in local infection, or if unchecked, systemic infection.  If signs of skin inflammation occur, the line may need to be removed.  Rarely, PICC lines break off when they are being removed and may then require surgical removal.  There is also a chance that, upon insertion, a nerve near the vein could be damaged.  There is a risk of blood clots from PICC line insertion. If a clot forms, the PICC line may be removed and I may be hospitalized for the initiation of anti-coagulation therapy. The risk of clot development is decreased, although not eliminated, by flushing the PICC line twice daily with saline and heparin and by avoiding vigorous repetitive motion activity of the arm in which the PICC line is placed. The major side effects of ceftriaxone, an intravenous antibiotic often used for treating persistent Lyme disease, include rash (in about 1.7% of all cases), diarrhea (2.7%), changes in liver function (approximately 3%) and gallstones (less than 1%).  Ceftriaxone is related to penicillin, and a small percentage of patients with penicillin allergies will have allergic reactions to ceftriaxone (5-8%).  Some patients when treated with ceftriaxone develop pain that seems like gallbladder disease.  This usually goes away after the medication is stopped.  However, some patients using ceftriaxone have had their gallbladders removed.  Some doctors believe that this risk can be reduced by taking a medication called Actigall with the ceftriaxone. Other antibiotics commonly used to treat Lyme disease are not known to have gallbladder side effects.  Monitoring my blood may help detect the development of any liver or gallbladder problems, but does not guarantee that gallbladder or liver problems will not ensue.  

My questions have all been answered in terms I understand. I am aware of the risks in foregoing IV treatment as well as the potential side effects if I undergo this treatment, and I consent to the use of IV treatment.

Signature: __________________________________ Date_________________________   

Print Name:_______________________________Witness:________________________

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