Leprosy Mailing List – December 30, 2013
Ref.: (LML) Thalidomide in treating kidney involvement in ENL
From: Grace Warren, Sidney, Australia
Dear Pieter,
I am very interested in the letters of Dr. Jingquan Wang and the progress of his patient. You ask why thalidomide and steroids are not recommended more for lepra reaction. I was working In Hong Kong for 15 years including all the 1960s when we started by using thalidomide to treat reaction but as the decade wore on the problems of foetal abnormality after use of thalidomide resulted in it being very difficult to obtain it anywhere except in S America. In fact it was banned in some countries.
We also realized the tendency for the patients with ENL to become dependent on steroids if they were used alone. So we tried using many variations of drugs available at that time and found some of them did produce undesirable side effects. However, I was also involved in the drug trials for clofazimine (we started in about 1966) and we soon found that clofazimine was excellent in treatment of ENL. In very heavy patients or when the reaction was very severe, we often went as high as 300mgms daily for the first month but usually 200mgms daily was enough. When initiating the antileprosy treatment we did not give, except clofazimine, the other anti-leprosy drugs for 4-6 weeks, during which time we treated other medical problems like anemia and parasites and malnutrition. We found that this was excellent in managing new patients with LL leprosy and a tendency to ENL before even starting antileprosy therapy. Of course by 1970 no one had even thought of MDT. We also regularly gave a good dose of multivitamins especially Vit. B 1 as many were short of that due to the maintenance on white rice in which of course most of the Vit. B1 is removed in preparation and milling. We were able to do well controlled pathology testing that showed that clofazimine certainly helped liver function and also did not usually produce the problems we saw with some other drugs that were used in those days.
In treating chronic ENL it was found that clofazamine was usually very effective. We would give 200mgms daily with some form of relaxant like valium or just phenobarb or amitriptyline as many of the patients went into reaction because of stress and worry about their families. Once it was known that a member of the family had leprosy, the rest of the family were excluded from the community. Clofazamine is of course bacteriostatic and also anti-inflammatory, and in some situations acts as an antibiotic. Once the patient’s condition was stabilized we would give the other antileprosy drugs and continue using it in lower dosage for the whole duration of treatment.
I have treated leprosy in 26 countries of the world and agree that of the many races that I have treated the Chinese do seem to be those who most frequently develop very chronic or long term ENL. I also found that in many countries the use of steroids may lead to unwanted problems as the patient can often purchase it themselves and continue it when the doctor concerned has tried to stop it. This can of course produce other problems that we do not want to have to treat. I could give many examples of patients who have died because of secondary problems they have developed because they were taking unsupervised steroids for prolonged periods . As I result I try as far as possible to only use steroids for acute neural deficit or for a very short term initially in a patient with severe reaction at initiation of therapy.
Yes, I am thoroughly convinced that clofazimine is an ideal drug in the treatment of lepra reaction especially ENL but when combined with other drugs can assist in the management of any lepra reaction.
Grace Warren.
Superintendent Hong Kong Leprosarium( 1960-1975)
Adviser on Leprosy, and Reconstructive surgery for The Leprosy Mission , 1975-1989)
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
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