- Ross Protocol
- Acute Tick Bite
- Q+A Webinars
- Books
- LymeUNITED
- Online Lyme Guide
The Lyme Disease Treatment Guide
lyme disease 101
germ control & more
Version 4 Update, June 17, 2024
The Ross Lyme & Tick-borne Diseases Protocol–Version 4 update, released 6/17/24, has a number of significant changes.
Name change. In Version 4, I have updated our name to include "tick-borne". This recognizes that people can have Bartonella, Babesia, or other tick-borne diseases, separate from having Lyme (Borrelia) infection.
But there are more significant updates than our name change. Version 4
These are support and treatment guidelines to treat chronic Lyme or tick-borne infections. This protocol addresses most problems that keep a person from getting well. It is more comprehensive than the antibiotic focused Infectious Disease Society of America (IDSA), International Lyme and Associated Disease Society (ILADS), and United States Centers for Disease Control and Prevention guidelines. While herbal and prescription antibiotics may decrease the germ load in chronic Lyme and tick-borne infections, they often do not correct the underlying problems that cause ongoing symptoms.
The Ross Lyme Support Protocol includes essential steps for the beginning and throughout a chronic Lyme disease or tick-borne infection treatment. It is designed to:
While the following Lyme disease and tick-borne infection treatment approach focuses on a limited number of areas, it may correct most of the problems like:
Herxheimer Reactions. When a person starts a Lyme disease or tick-borne infection treatment or changes herbal and prescription antibiotics, it is common to experience some worsening in symptoms. See Herxheimer Die-off Reaction: Inflammation Run Amok for more information about this and the steps you can take to treat it.
Treatment Length and Persistence. Generally, it takes a minimum of six months to see if these supports and treatments will help. Supplements can speed recovery, but treating Lyme still takes time. Once you have marked improvement, then you can likely stop many of these nutritional supports except for probiotics, curcumin, ashwagandha, and a good multivitamin. See Getting Healthy: Will I? When? How Do I? for more information about Lyme disease and tick-borne infection treatment length and persistence.
About Supplements. Throughout this protocol I include supplements as nutritional supports based on their known functions. Basic research and my clinical experience show they may help the various symptoms and problems in Lyme disease and tick-borne infections.
These guidelines are based on the best available research, and what I find clinically useful in my Seattle practice. The ideas and recommendations on this website and in this guideline are for informational purposes only. For more information about this, see the sitewide Terms & Conditions.
Generally I avoid recommending specific supplement products within this protocol, but use generic ingredients instead. However, in Part 3. Intestinal Microbiome, I use specific product names to avoid confusion over products I find useful. Regarding these specific products:
* These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.
The Ross Lyme & Tick-borne Diseases Protocol is a set of support and treatment guidelines. Read or watch the following articles found on Treat Lyme for information about diagnosis, tests, and relapse prevention.
Mold toxin illness can look just like Lyme disease or chronic tick-borne infections. Both mold toxicity and chronic infections trigger a reaction in the immune system that produces too many inflammation chemicals called cytokines, which cause most of the problems seen in both illnesses.
If your illness began while you were living or working in a building with obvious mold, I suggest treating for mold toxin illness first. To clarify this point, if you were in good health, then you had an obvious mold exposure, and got sick—treat mold toxicity first. I find correcting this issue may prevent the need to treat Lyme disease or tick-borne infections, even if you test positive for infection. Once the mold toxins are removed, the immune system can keep Lyme or other infections under control.
If it is not clear if Lyme and tick-borne infection or mold toxins are the cause of your illness, then you can treat both problems at the same time.
For more information, read Mold and Lyme Toxin Illness and Positive Lyme Test, No Symptoms, Don't Treat.
Chronic infections can trigger excessive allergic reactions to food, prescription and natural medicines, and the environment. If this is your problem, consider using supplements, diet, and medicines for Mast Cell Activation Syndrome. For more information, read Mast Cell Activation Syndrome & Lyme.
Sleep is often disturbed in chronic Lyme disease and tick-borne infections. Lack of adequate sleep worsens pain, increases fatigue, and suppresses the immune system. It appears that in response to infection, the excess inflammatory cytokines produced by the immune system decrease the output of sleep-inducing hormones to the sleep centers of the brain. Since lack of sleep increases cytokines, a restorative amount of sleep should ideally be 7-9 hours of sleep per night. Sleep in the few hours before midnight is most restorative.
You can either take these two supplements together or use in combination with the following prescription medicines, if needed.
For more information about these sleep supplements and prescriptions, or for additional options about sleep hygiene, see Sleep in Lyme Disease: The Basic Steps. For information about sleep herbs and supplements, see Sleep: The Natural Medicines. For more information and sleep prescriptions options, see Sleep: The Prescription Medicines.
Eat Plants. A healthy diet is one that lowers inflammation and supports a healthy intestinal microbiome. In general, plant-based (with limited animal protein) and plant-exclusive diets are much less inflammatory than the Standard American Diet (SAD) made up of processed foods, inflammatory fats, and immune suppressing sugars. Plant-based diets include prebiotic fibers and polyphenols that promote healthy bacteria in the intestines—even on antibiotics.
Short Term Elimination Diet. An elimination diet helps a person find which foods trigger allergies or inflammation reactions. If you are reacting to foods, consider trying an elimination diet first. Removing allergic and inflammatory foods from your diet also leads to decreased pain and improved energy.
Eat a plant-based diet that uses either plant-based proteins or animal proteins with low levels of inflammatory fats.
An elimination diet is another diet to consider starting if you are very reactive to a number of foods. For detailed information, see Elimination Diet to Find Food Problems.
There is a growing body of science stressing the important role of a healthy intestinal microbiome. The healthy bacteria and other germs living in your intestines make up the intestinal microbiome. The microbiome directs the immune system, brain, heart, bones, hormones, mental health systems and more.
Herbal and prescription antibiotics can hurt the function of the intestinal microbiome. Fortunately—even on herbal or prescription antibiotics, there are steps you can take to promote and maintain health of your intestinal microbiome.
Option 1. Use Supplements
Option 2. Eat a Plant-forward Whole Food Diet
Option 1. No Leaky Gut Syndrome Symptoms
If you do not have any intestinal symptoms of leaky gut, this option is for you.
Symptoms suggesting leaky gut can include intestinal gassines, bloating, or cramping, or multiple food sensitivities. The general probiotics I recommend here support and promote the health and growth of most healthy intestinal bacteria.
Comment. In my experience, probiotic supplement products deliver more probiotics than fermented food sources. I chose a spore-forming probiotic because they are easier to use as they do not require refrigeration. They also do a great job of microbiome rehab and may work even when a person is on antibiotics.
Substitution Consideration. If you have diabetes or are overweight, consider substituting Akermansia mucinphila for the Bacillus spp spore forming probiotic. Akkermansia may raise GLP-1 leading to weight loss and better sugar control. It also supports other intestinal microbiome bacteria like Bacillus spp. Its major drawback is that it is better refrigerated.
Option 2. Leaky Gut Symptoms with or without Intestinal Yeast Overgrowth or Dysbiotic Bacteria Overgrowth.
If you have intestinal symptoms, this option is for you.
If you have intestinal symptoms like gassiness, bloating, or cramping; or multiple food sensitivities, work to rebuild the intestinal lining and mucin layers while promoting the health and growth of good intestinal bacteria. Use this probiotic option regardless of whether you are treating yeast or bacterial intestinal dysbiosis with targeted antimicrobials.
Comment. With leaky gut there is injury to the mucin layer of the intestines that covers intestinal cells. Additionally, the intestinal lining develops gaps between the cells. Akkermansia builds the mucin layer. Bifidobacterium, Anaerobutyricum hallii, Clostridium beijerinckii, and Clostridium butyricum produce butyrate which is the leading fuel source for intestinal cells. Mucin in combination with butyrate helps heal the gaps between the intestinal cells.
Regulating the intestinal microbiome is complex. For more information and additional probiotic choices see Your Guide to a Healthy Intestinal Microbiome—Even on Antibiotics.
Exercise improves blood flow to all tissues. This improves the penetration of antibiotics and helps with detox. Exercise also releases various chemicals like endorphins and enkephalins that produce healing effects and improve immune function. Finally, exercise promotes a healthy intestinal microbiome.
Exercise to tolerance. Find a level you can do that does not make you worse the next day. This may mean you can only walk half a block at the beginning. Furthermore, overexercising—an amount that makes a person feel worse—may suppress the immune system and impair healing. Be careful. At the beginning of treatment, you may have to wait to begin exercise until you have some improvements.
Cytokines are inflammatory chemicals made by the immune system in chronic Lyme disease. Nutritional supports like curcumin, resveratrol, black tea extract, NAC, and antioxidants found in a good multivitamin (see Part 6 of this protocol below) may lower cytokines. This can
On the one hand, cytokines are good because they turn on the immune system. They perform several functions that include:
On the other hand, in chronic Lyme disease and tick-borne infections the immune system makes too many cytokines, which is bad. Too many cytokines
At the beginning of treatment or when antibiotics are changed, the cytokines are made in even greater amounts, which causes a person to feel much worse. This is called a Herxheimer die-off reaction.
See Control Cytokines: A Guide to Fix Lyme Symptoms & The Immune System for more information and additional herbal medicine options to use in a Lyme disease treatment.
There are no effective and safe options.
An adaptogen is a substance that helps the body deal with the harmful medical and emotional stress of being ill. Adaptogens have been used for centuries in Ayurvedic and Chinese medicine with greatly observed benefits. Based on animal experiments, ashwagandha may improve
It likely has additional benefits that have not been researched.
Fixing low adrenals and/or low thyroid can help the immune system work better and possibly improve energy. A person could have normal range testing for each of the hormones, but still have clinically low hormones. Because of the unreliability of testing, treatment for low hormones should occur if there are clinical symptoms of low hormones as long as the treatment does not increase hormone levels above the upper end of normal.
If you have a number of these symptoms, consider using the natural medicine approaches for each respective problem.
For adrenal insufficiency, start with the supplement or prescription medicine. It is possible to use both together if the symptoms of low adrenals persist.
In my practice, I rarely use prescription medicine for adrenal insufficiency because there is a very small risk of immune suppression using prescription hydrocortisone. However, the doses I recommend are the normal amounts the adrenal glands should make. I prefer ashwagandha because it is a supportive herb that does not suppress the immune system.
Use these nutritional supports first for one to two months before adding or trying the prescription medicine option below. Often, working with these supplements corrects the thyroid so you do not need to take thyroid prescription medicines.
For more information about how to manage thyroid, even if your tests are normal, read my comprehensive article, Hypothyroidism. The Best Tests, Meds, & Vitamins.
In my opinion, to heal and feel better requires a multivitamin with an essential set of vitamins, minerals, amino acids, and antioxidants. A good multivitamin can improve functioning of the immune system; muscles; brain and nerves; hormones; organs, including the kidney and liver; and detoxification, in addition to decreasing inflammation. A multivitamin also may protect the body from the toxic effect of prescriptive antibiotics.
Lyme produces toxins that lead to inflammation from cytokines, which suppress the immune system and manifests into many of the Lyme symptoms. In addition, many of the natural and prescription medicines can have toxic effects. These detoxification steps may protect against and fix toxin issues.
Reduce the total load of negative environmental influences on your health by
Support liver detoxification.
See The Basic Lyme Detox Steps for more detailed information.
The Ross Lyme & Tick-borne Diseases Protocol is entirely designed to support and boost your immune system. Because of this, most people do not need to take specific immune system boosters. The Ross Lyme & Tick-borne Diseases Protocol supports the immune system through:
In addition to these steps, there are additional supplements you can take. To read more about these options, see How to Boost the Immune System in Lyme. I do not recommend these additional supplements at first. Consider adding them 6-9 months into treatment or during antibiotic holiday periods.
Too many yeasts in the intestines (yeast overgrowth) is a common problem that occurs in those with chronic Lyme disease or tick-borne infections either during or prior to beginning treatment.
Antibiotics used to treat Lyme and tick-borne infections can lead to too many yeasts. Immune suppression prior to starting antibiotics can also cause yeast overgrowth. Yeast overgrowth can result in an ongoing systemic allergic reaction that can suppress the immune system. Yeast overgrowth also leads to inflammatory cytokine excess that causes many of the Lyme disease symptoms and pain. Food allergies and sensitivities can be the result of yeast overgrowth, too.
A reliable test for yeast overgrowth does not exist. While some physicians may test for antibodies to intestinal yeast in the blood, antibodies are common even when yeasts are in balance. In addition, it is normal to have stool cultures grow yeast, therefore, a culture does not indicate if yeasts are in excess. For this reason, yeast is diagnosed using my yeast screening questionnaire. This questionnaire evaluates the possibility of yeast overgrowth based on risk factors and intensity of symptoms. In general, I find people benefit from treatment for yeast overgrowth if the score is 140 or higher.
At the beginning of a Lyme disease treatment, often before antibiotics are started, it is essential to treat yeast. Doing so can limit the severity of Herxheimer die-off reactions from treating Lyme because removing yeast removes one source of inflammatory cytokine excess.
For yeast overgrowth prevention, use probiotics and antifungals in A & B. For current intestinal yeast overgrowth treatment, use probiotics and antifungals in A & C.
Use either the supplement or prescription medicine antifungals for prevention. You do not need to use both together.
Do the following if you have a yeast screening score of 140 or higher. When you complete treatment for antifungals, then start yeast prevention antifungals as described above. Use either the supplement or prescription medicine antifungals for overgrowth, but not both together.
Use both of the following together:
Some have great difficulty getting rid of intestinal yeast overgrowth. See Kills & Prevents Yeast: A Brief Guide for more herbal and prescription medicine options.
These action steps address the different forms and growth states of the Lyme germ.
Lab experiments suggest the great majority of spirochetes and cysts are in a growth phase. However, persisters generally do not respond to regular antimicrobials. In my experience, the best outcomes with my patients occur when I address spirochetes and cysts in the growth phase and persister phase at the same time. The Action Plan options below both do this.
Otoba parvifolia extract and Cat’s Claw are supplements that reach all forms of Lyme inside and outside of cells. Because these herbs are dosed using drops, they are more easily regulated to manage a die-off reaction by not increasing the dose until the reaction lessens.
Likewise, in my experience, any oral antibiotic combination works as well as the Otoba parvifolia extract and Cat’s Claw combination, which is 85-90 percent of the time.
Doxycycline or clarithromycin treat the spirochete. They also treat Lyme in and out of cells. Rifampin, rifabutin, tinidazole, and grapefruit seed extract treat the cyst form.
I include liposomal cinnamon, clove, and oregano oil because they are shown in laboratory experiments to eliminate persisters and growth phase Lyme and Bartonella. They also appear to remove biofilm slime layers that cover germs and can block out antimicrobials and immune cells.
More recent lab experiments show Cryptolepis and Japanese Knotweed are effective at killing growing and persister Borrelia and Bartonella.
About Disulfiram. Disulfiram has gotten a lot of press due to its effect on persisters. I do not include it in this protocol, but some of you may want to consider trying it. Disulfiram is a very hard drug to take due to its side effects and dietary restrictions. While it appears effective against persisters in the laboratory, it is only moderately effective against the growth phase of Lyme infection. If you are new to treating Lyme disease, I do not recommend starting with disulfiram alone due to common treatment difficulty and the fact it may miss growing forms of Lyme.
Read More About Persisters. To read more about all persister options, including when it might be okay to try disulfiram, see How to Treat Persister Lyme & Bartonella.
Take the supplements below together for a complete treatment.
When a Lyme infection exists, I generally start with oral antibiotics. For considerations about IV antibiotics, see A Lyme Disease Antibiotic Guide.
Take one item from each of the three parts for a complete treatment.
Part 1.
Choose doxycycline if you have an Anaplasma or Ehrlichia coinfection.
Part 2.
Part 3.
Comment: I include the oil combination to break up Borrelia and Bartonella biofilm. In addition, it treats growing and persister forms of these two germs. The research says the clove oil in this combination may help with Babesia as well.
Based on my experience, a person will not recover from Lyme if Bartonella and Babesia are not treated when they are present. It is as though they protect Lyme. Conversely, Lyme seems to protect them, as well, which is why it takes months to get rid of Bartonella and Babesia infections.
Recent research from Johns Hopkins University shows Bartonella, like Lyme, has persisters, too. I include liposomal cinnamon, clove, and oregano oil capsules to address this issue. For more information about persister options, see How to Treat Persister Lyme & Bartonella.
Generally, I do not recommend that a person start supplements or prescription medicines that target Bartonella or Babesia coinfections at the initial visit. Wait one month or longer to adjust to the Herxheimer die-off reaction from treating the Lyme infection and to stabilize on the supportive supplements.
If you have both Bartonella and Babesia coinfections, support or treat one first before adding a support or treatment for the other. When both are present, my preference is to address Bartonella first for two to three months and then add support or treatment to address Babesia. You can address these coinfections at the same time you treat or support the Lyme infection.
In my experience, the following supplements work 70-75 percent of the time and take four to six months. If you do not have improvement in Bartonella symptoms by two months, then change to prescription medicines. For best results use all three of these supplements at the same time.
In my experience, this prescription antibiotic-based option has a 10 percent better chance of working than the supplement-only option above. For best results, use the two prescription medicines and the supplement combination at the same time. Note: This option is also a full Lyme infection support and treatment.
In my experience, the following supplements work 75-80 percent of the time and take four to five months. If you do not have improvement in Babesia symptoms by two months, then change to prescription medicines. Any of my recommended prescription options works about 80-85 percent of the time.
Comment: I include the oil combination to break up Borrelia and Bartonella biofilm. In addition, it treats growing and persister forms of these two germs. The research says the clove oil in this combination may help with Babesia as well.
Many other supplements or prescription medicines can help manage symptoms and problems existing in Lyme disease and chronic tick-borne infections. Wait one month after beginning a treatment to start these. For additional treatment ideas based on your specific medical problems, see articles in the following medical problem chapters. For instance, if you have severe brain fog or numbness, find helpful articles in the Brain & Nerves chapter.
One of the strongest Lyme infection persister medications or supplements is Disulfiram. Clinical experience shows it can get over 36 percent of people who have been on extensive antibiotic regimens in the past into enduring remission. This is a repurposed prescription medication that is used to treat alcoholism. Laboratory and human research publications show Disulfiram is helpful for Lyme infection. However, laboratory experiments and my own experience show this is not an effective medication for Bartonella.
As I noted in the Lyme Infection section, I do not suggest a person new to chronic Lyme treatment start with a Disulfiram-only regimen because of the potential for severe side effects and the fact we do not know if it also effectively treats growth phase Lyme. However, in people who do not have active Bartonella or Babesia coinfections that have already tried a year or more of prescription antibiotics, I do think it is worth a try as stand-alone antimicrobial. For more information about the potential benefit, risks, dietary restrictions, and how to take the medication see: Disulfiram for Lyme Update. For additional supplement and prescription medication persister options see: How to Treat Persister Lyme. What Works?
Chronic infections can trigger excessive allergic reactions to food, prescription and natural medicines, and to the environment. If this is your problem, consider using supplements, diet, and medicines for Mast Cell Activation Syndrome. For more information, read Mast Cell Activation Syndrome & Lyme.
On an effective Bartonella or Babesia antimicrobial regimen, improvements in symptoms that come from the respective infection should start to improve by one to two months of treatment and support. If there is no improvement, then change the antimicrobials to another option.
Another reason the symptoms may not improve by two months is fibrin-germ plaques (also called fibrin nests) that form on blood vessel walls. These include babesia woven into fibrin protein or bartonella woven into fibrin protein. Fibrin is a protein found in blood to help with blood clotting. In plaques, fibrin can block out antimicrobials and the immune system. Lumbrokinase is a nutritional support composed of enzymes that may break down fibrin. Consider adding Lumbrokinase at two months.
There are additional support and treatment steps to consider by six to nine months of Lyme disease treatment if you are not having adequate improvement. Read these articles online at Treat Lyme (treatlyme.net) for more information.
Continually review your symptoms to see if you have a coinfection that was missed. Treating Lyme is like peeling the layers of an onion. As you treat, it sometimes becomes more apparent which coinfections are present. In addition, it is possible to have coinfection relapses.
If you have a number of these symptoms—such as increased sugar cravings, intestinal gassiness or bloating, recent vaginal yeast infection, oral yeast, and/or vaginal or rectal itching—consider treating for yeast overgrowth in the intestines.
It is common to have ups and downs during a Lyme disease or chronic tick-borne infection treatment. In some cases, there can be a significant decline after a person is doing better. In these cases, consider yeast overgrowth of the intestines or relapse of a Bartonella or Babesia coinfection. In my experience, most major health declines are due to yeast overgrowth in the intestines. This is true even if significant symptoms of yeast do not exist.
Excessive yeast in the intestines lead to increased levels of cytokines. Because excess cytokines cause many of the chronic Lyme disease or tick-borne infections symptoms, it could seem like your Lyme disease or tick-borne infection is getting worse.
Yeast could be the cause of your decline if you have a number of these symptoms: increased sugar cravings, intestinal gassiness or bloating, recent vaginal yeast infection, oral yeast, and/or vaginal or rectal itching. For information on diagnosing yeast, see A Silent Problem: Do You Have Yeast? For yeast treatment information, see Kills & Prevents Yeast: A Brief Guide.
See the references sections for The Best Brain, Inflammation, Pain, Energy & Detox Diet Ever and Elimination Diet to Find Food Problems.
Marty Ross, MD is a passionate Lyme disease educator and clinical expert. He helps Lyme sufferers and their physicians see what really works based on his review of the science and extensive real-world experience. Dr. Ross is licensed to practice medicine in Washington State (License: MD00033296) where he has treated thousands of Lyme disease patients in his Seattle practice.
Marty Ross, MD is a graduate of Indiana University School of Medicine and Georgetown University Family Medicine Residency. He is a member of the International Lyme and Associated Disease Society (ILADS), The Institute for Functional Medicine, and The American Academy of Anti-Aging Medicine (A4M).
Subscribe to receive our FREE pdf download book: How to Successfully Treat Lyme: Key Info before You Treat or Treat Again & The Ross Lyme Support Protocol; health tips; updates; special offers; and more.
