Leprosy Mailing List – May 14, 2015
Ref.: (LML) Parenteral treatment of leprosy reactions
From: Ben Naafs, Munnekesburen, the Netherlands
Dear Pieter,
Thanks for the reactions, comments and questions from Dr. Harun, Dr. Jingquan, Dr Van Brakel, Dr Kar and Dr. Theuvenet.
Concerning Wim van Brakel’s comment on the paper of Walker at all (LML 5 May 2015):
- This paper investigates the effects after only 16 weeks prednisolone treatment, which is shorter than I advise. The short treatment influences the outcome more than the initial treatment.
- Concerning his second comment: I think he cannot talk about not-ethical since the mentioned trial does not show any additive effect. And moreover this trial he referred to was not using parameters sensitive enough to detect an additive effect on the nerve.
Garbino et all (Arq. Neuropsiquiatr. 66 (2008) 861-866) showed that high dose prednisone at start has more effect than lower doses. However after long time follow-up with continuing treatment this difference disappears, at least with the evaluation methods used. High dose has thus an initial effect. Thus is worth as a short bolus dose to be investigated.
Dr Kar points to supposed evidence based studies that point to a 1mg/kg prednisone start dose for both the leprosy reactions with a gradual tapering and with a minimal maintenance dose for a certain period of time. He is right that this is done for T1R and shows clear results. However, not for T2R which is a definitive other type of reaction than T1R.
His remark about the anti-adrenal effect of a short high bolus dose is refuted by the actual effect observed in the treatment of many other diseases. The chronic long time maintenance dose may be more dangerous than the bolus dose.
This is also shown in the “fatal case from China”. I am glad that this patient is presented. His history shows clearly what can go wrong. Nevertheless, it may not be concluded that this is due to the initial bolus therapy.
I can fully agree with the summary of Dr. Harun. The bolus (125 mg methylprednisolone i.v.) for type 1 reaction will take care of an initial anti-edematous effect in nerves (Garbino et al). It may take some of the compression away. The initial extra effect in this way may diminish the nerve damage already at start of an anti-reaction treatment. Whether in the long run it will contribute to the total improvement after long term of anti-T1R reaction treatment should be studied in a double blind trial with sensitive parameters. I do not see any ethical constrains regarding this.
Concerning the T2R, a bolus steroïds is an excellent idea. It will work quickly on the intra-neural edema which leads to a conduction block in the nerves and moreover it may help to stop the T2R immunologically too.
Since a T2R is episodic and lasts in the majority of the patients only 1-4 weeks it may shorten the treatment and diminish the side effects of the usually practiced ENL treatment. Also here a trial is warranted.
I thank Dr. Harun for initiating this discussion.
dr Ben Naafs
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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