Page 2 - Antibiotic Therapy for Rheumatic Disease

RECENT NUANCES tablet taken two hours after breakfast and another
at bedtime.
As experience among practitioners has matured,
so have additional insights. Unfortunately all of Importantly I follow the study format of dosing (100
this is highly anecdotal. Perhaps most importantly, mg 2x/day) every single day. For older or smaller
the tetracycline analogue, doxycycline can be patients, it may be best to start with only 100 mg or
considered for patients on minocycline developing even 50 mg per day, since these patients may be more
hyperpigmentation but otherwise doing well on it. apt to experience dizziness or headaches if begun on
Doxycycline appears to be devoid the standard dose. Sufficient time must transpire
of the cutaneous darkening phenomenon and may before concluding that it is effective—or non-
give the patient time to see if the minocycline side effective. I cannot state what this precisely means for
effect slowly lessens. The usual dose for doxycycline individual patients, but clearly unacceptable arthritis
is also 100 mg twice a day. Overall I do not think that activity after several months warrants rethinking.
doxycycline is as effective as minocycline for RA.*
Tolerability is, in general, excellent. After longer-term
Clearly minocycline can provide adjunctive use darkening to portions of the skin, particularly
therapy for RA. In other words, minocycline can in those that are sun-exposed, may occur. This
be combined with any other available agent. There darkening is caused by minocycline stimulating the
are no exceptions! Examples include Plaquenil, skin cells that create a tan. Fortunately the problem
methotrexate, Arava, anti-TNF compounds like is infrequent and usually slowly reversible after
Enbrel & Humira and the new intravenous drug, drug discontinuation. Rarely, the gum line next
abetacept (Orencia). Decreased doses of one or both to teeth or even the whites of the eyes can darken.
agents may help to avoid gastrointestinal side effects. While it does not otherwise damage the skin, gum
This regimen usually reflects a desire to obtain or eyes or lead to skin cancer, it can be cosmetically
additional improvement or to gradually convert to unacceptable. Laser removal is possible for the face
the safer drug, minocycline. Examples include 1. but that procedure is difficult and expensive.
Not having to increase the dose of methotrexate and
2. By increasing the dose of minocycline additional Are Generic Minocycline Preparations as Effective as
improvement and /or stability may be gained. the brand name Minocin product? Both MIRA and
Perhaps use of two oral drugs might preclude the RAIN studies used Minocin. For at least the MIRA
necessity for an injectable effort, it was intended to use the highest grade of
and more expensive drug. Obviously judging the net product possible in the trial. Verbal opinions that
effect of either drug is difficult or impossible. The the quality control of cheaper generic counterparts
same impasse may arise if a clinical or laboratory side could be found accordingly, clinical use of brand
effect occurs. name Minocin continued thereafter. Increased
purchases of Minocin led to price escalations and
POORLY INFORMED USE subsequently the sale of manufacturing rights
to other firms. Lack of availability and refusal of
Time and time again I have observed that patients payment by third party payers has occurred as well.
have started minocycline in what I consider a sub- Fortunately this reviewer now harbors the opinion
optimal fashion. Internet citations and directions that modern forms of minocycline (generic) are just
abound that describe less well-studied antibiotics as as effective as Minocin.
well as varying ways to administer minocycline.**
Personally I have extrapolated the exact protocol of Thoughts about Scleroderma and Minocycline
the MIRA and RAIN studies into my clinical use. This reviewer thinks that the cutaneous and
This involves 100 mg taken twice a day on an empty musculoskeletal aspects of early stage scleroderma
stomach. Similar to thyroid may benefit from this dose of minocycline as well.
replacement hormones, optimal absorption of The caveat that the concept remains a political “hot
minocycline appears to peak on an empty stomach. potato” should also be re-stated up front.
For many patients, this is best accomplished by 1