PRACTICE PARAMETER: TREATMENT OF NERVOUS SYSTEM LYME DISEASE (AN EVIDENCE-BASED REVIEW): REPORT OF THE QUALITY STANDARDS SUBCOMMITTEE OF THE AMERICAN ACADEMY OF NEUROLOGY Neurology 2008;70;1719-1720
To the Editor: We wish to point out a serious ethical problem with the recently adopted Lyme disease treatment guidelines of the American Academy of Neurology (AAN).1 These guidelines have been touted as an "independent corroboration" of the Lyme guidelines published by the Infectious Diseases Society of America (IDSA) in November 2006.2 Nothing could be further from the truth. The IDSA and AAN guidelines committees were clearly not independent in terms of personnel or philosophy.
The AAN guidelines were put together by a committee of nine members, three of whom also served on the IDSA Lyme guidelines panel, including the chairman of each committee. The overlapping chairs virtually assured that the form and substance of the AAN guidelines would be like-minded—essentially a repackaging of the IDSA guidelines—by controlling the panel selection and scope of the process. AAN published its guidelines after the Attorney General of Connecticut launched an unprecedented investigation into potential anti-trust violations in the IDSA guidelines formulation.
The AAN guidelines were, not surprisingly, quickly endorsed by IDSA and presented to the medical community as "independent corroboration" despite the overlapping panels and questions raised by the Connecticut investigation. Thus the timing of the AAN guidelines and the IDSA endorsement compounded the conflict of interest for both organizations.
Two medical societies, IDSA and the International Lyme and Associated Diseases Society (ILADS), have published peer-reviewed, evidence based guidelines listed by the government sponsored National Guidelines Clearinghouse and offering divergent treatment approaches for Lyme disease.(2,3). Under the IDSA guidelines recapitulated by AAN, patients who fail to respond to the IDSA protocols are denied longer antibiotic treatment. In contrast, the ILADS guidelines consider these patients to have chronic Lyme disease and provide the only viable treatment option for them. The conflicting guidelines have established two standards of care for Lyme disease.(4)
Responsible medical societies have an obligation to acknowledge scientific uncertainty and lack of consensus when controversy exists regarding the treatment of medical conditions such as tick-borne diseases.(4) It is unacceptable to repackage the beleaguered guidelines of another medical society and allow overlapping panel members with clear conflicts of interest to control the process. To ignore the conflicts of interest in these circumstances represents a serious ethical breach that discredits AAN and misleads the broader medical community, which relies on the ethical accountability of guidelines panels.(5)
Raphael B. Stricker, Lorraine Johnson, San
Francisco, CA  |