Intermittent Therapy
Why Is It Important to Prescribe Antibiotics Every Other Day

Medical Journal Update

It is acknowledged that tetracycline antibiotics have many properties among which are antimicrobial, anti-inflamma-tory, anticollagenase and immuno-suppressive. All of these properties play a part in the antibiotic's effectiveness when used to treat an inflammatory form of rheumatoid disease.

Thomas McPherson Brown, M.D., an originator in the use of antibiotics for the treatment of rheumatoid diseases, found that low doses would do the job, were the most effective dose, and the safest dose to use. Because rheumatoid disease includes a hypersensitivity aspect, arthritic patients can exhibit a delayed sensitivity to drugs which can block treatment effectiveness. Dr. Brown believed mycoplasma to be the primary sensitizers in the rheumatoid complex.

The signs of delayed sensitivity are those of slight loss of appetite, excessive fatigue, increased pain in areas where pain was being gradually reduced, and at times increased fluid retention, often in the legs and feet. When these signs are noted, the medication is interrupted for a week to ten days and then resumed, usually at the same level that it was given before or at a reduced frequency and amount.

Dr. Brown chose tetracycline drugs because, unlike many other drugs, they are not accumulative, their sensitizing effect is virtually nil and bacterial resistance is not a problem because mycoplasma do not have a cell wall where resistance develops. The development of drug resistance is nearly non-existent even when intermittent therapy is used for years.

For best results the tetracycline derivative is usually prescribed every other day (intermittent therapy) or Monday, Wednesday and Friday - once a day for minocycline and doxycycline and twice a day for tetracycline. Clindamycin is often used on an alternate day in combination with a tetracycline, either orally or IV.

The tetracyclines and clindamycin have different modes of action, and therefore may be a useful combination. The tetracyclines appear to prevent protein synthesis by reacting with the 30S portion of the ribosome thus preventing the binding of the amino acid tRNA complex to mRNA. Clindamycin reacts with the 50S portion of the ribosome and inhibits peptide bond formation.

In the complex chemistry which makes up the human immune response, oxidation is a common occurrence. Excessive oxidation can cause damage to tissues. Tetracyclines can cause toxicity to these same tissues. Intermittent therapy gives the tissues time to recover between doses which daily doses do not allow.

Constant exposure to antibiotics is necessary when dealing with a virulent, pathogenic organism, but not in the case of mycoplasma. In the highly reactive state, very little antimicrobial medication is needed to further control the disease as is the case in tuberculosis, brucellosis and chronic rheumatic fever. If too much is given, the body begins to react against the medication itself which defeats the main purpose of the treatment. In this situation more is not necessarily better. Daily or twice daily doses of antibiotic used long-term can make the response to the treatment in some patients worse than the disease, and can also permanently inhibit the oxidative respiratory enzymes. Intermittent therapy gives tissues already sensitized by inflammation, a chance to recover.

The tetracycline is often ineffective without first preparing the way for its action to be fulfilled by prescribing daily anti-inflammatories. If the inflammatory barrier is not controlled, the antibiotic may not be able to penetrate. With inflammation in control, the antibiotic is able to reach the source of antigen production and begin to eliminate it. The treatment must be pursued long enough to eventually suppress antigen formation; for some patients this may be a lifetime.

From a lecture by Thomas McP. Brown, M.D., Guidelines for Infectious Hypersensitivity Approach to the Treatment of Rheumatoid Arthritis

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