Leprosy Mailing List – December 30, 2013
Ref.: (LML) Thalidomide in treating kidney involvement in ENL
From: Dr. HK Kar, New Delhi, India
Dear Dr Pieter,
I would like to refer to the discussion Dr. Jingquan Wang started in LML: Thalidomide in treating kidney involvement in ENL. It is an interesting letter on management of chronic/recurrent ENL. As you observed in China, in India also, we encounter more number of recurrent ENL rather than chronic ENL. This could be either due to inadequate or short course of anti-reactional therapy using conventional available anti-leprosy drugs. Recently we presented a paper in 18th Int. leprosy congress, Brussels, Sept. 2013(0-069).
Treatment of Chronic and recurrent type 2 reaction (T2R)
A combination of prednisolone plus thalidomide or clofazimine is preferable for management of chronic and recurrent T2R. The ideal duration and dose of steroid and other drug combinations is still a matter of debate. An open prospective single centre study in our institute was conducted to assess the comparative efficacy of combination of prednisolone plus thalidomide in one group v/s prednisolone with clofazimine in another group in chronic and recurrent T2R
Prednisolone was given in the dose of 1 mg/kg/day to start with, then gradually tapered as (10 mg every 2 weeks up to 30 mg, than 5 mg every 2 weeks up to 5 mg, then 2.5mg for 2weeks -for a total of 20 weeks) plus either Thalidomide (400 mg daily x 7days and then tapered by 100mg every month to a dose of 100mg daily, then every alternate day for a total period of 20 weeks) or Clofazamine (300 mg/day to start and then 300 mg x 12 wks, 200 mg/day x 4 wks, then 100 mg/day x 4 wks given over 20 wks).
Patients were followed up for 6 months after 20 weeks course of treatment to note any further recurrence of T2R. The response rate based on the clinical outcome was 82.35% in thalidomide plus prednisolone group and 60% in clofazimine and prednisolone group. In the follow up period of 6 months, 2 of 16 patients in prednisolone plus clofazimine group developed fresh episode of T2R where as none (0/17) in the prednisolone plus thalidomide group had recurrence. It was concluded that thalidomide has good efficacy when administered in combination with prednisolone for chronic and recurrent T2R. Clofazamine has a definite role when thalidomide cannot be administered (women in child bearing age). The duration of combination treatment should be judged depending on the frequency of recurrence of lesions.
A few individual cases of chronic ENL may need more than 20 weeks anti-reactional treatment to control the reaction fully.
A recent study from Bangladesh showed that nine cases of recurrent/chronic ENL not controlled by a combination of prednisolone with clofazimine could be managed with a combination of prednisolone with methotrexate (prednisolone dose: 40 mg/day x 3 months, reduced to 20 mg/day x 3 months, then reduced by 5mg/wk x 3 months, reduced by 5mg a/d, then weekly twice, then weekly once: 30 to 36 months (total) and methotrexate dose: 7.5 mg/wk: 24-30 months).
The treatment regimen is individualized depending on the complications associated with Type 2 reaction (ENL) like kidney complications, diabetes, pregnancy, steroid side effects. We also encountered a case of DVT in one case under prednisolone with thalidomide. This type case report has already been publishes earlier.
Dr (Prof.) H K Kar\
Professor in Dermatology and Leprosy
Director and Med. Superintendent
P.G.I.M.E.R. and Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
LML - S Deepak, B Naafs, S Noto and P Schreuder
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