Leprosy Mailing List – November 1, 2017
Ref.: (LML) Steroid Dependency and the use of Methotrexate
From: Ben Naafs, Munnekeburen, the Netherlands
I am glad that MTX (Methotrexate) is mentioned again (LML, October 18 and 28, 2017). In 2005 we discussed this in LML. One of the reasons was an article from prof Kar. I wrote that time:
"I may have a suggestion for an alternative drug. It is recently published by Kar and Babu from Karigiri (Int. J. Lepr. 2004: 72; 480-2) that methotrexate (MTX) was of help. A 6 years ago, before I started to treat with high and short doses of steroids (pulse therapy) I used in desperation also MTX in a patient and that patient responded and did not get a new ENL after a few months of decreasing maintenance therapy. I was not sure whether I could attribute this to the MTX since ENL is basically a self-limiting disease, so I never mentioned it. And here in the Netherlands I have too few patients to do a controlled trial." Such trial is being done at the moment by the ENL consortium under Steve Walker.
The question is how to use MTX.
Type II leprosy reactions (ENL) last in the majority less than 1- 2 weeks. Severe reactions last untreated in over 95% one month or less.
- Mild ENL: I use in patients a NSAID often together with chloroquine or hydroxychloroquine.
- Severe ENL: I treat these the first time they occur with steroids starting
60- 120 mg once daily and tapering off quickly in one month to zero. If they reoccur during tapering off I double the dose again and taper off again.
I do not give maintenance therapy with steroid because I think that 20- 40 mg of steroids does not effectively prevent a immunocomplex disease which most of us still consider ENL to be. I hardly use thalidomide anymore because in other diseases
than leprosy I found that 20% develops sensory loss. Among my leprosy patients I had two in whom I for myself was sure that this occurred too.Thus I stopped using it.
When a patient develops recurrent attacks of ENL or chronic ENL than I start like dr Grace Warren and dr Pieter Schreuder and so many others, with Clofazimine, starting at 200 - 300 mg daily, then after 1 - 2 months tapering over 6 months to 0. At the same time I start MTX 10 - 15 mg once a week with folic acid after 3 days. When it has effect I start tapering. Usually it takes about 1 year. Each ENL attack occurring during that period I treat as written before.
Dr Ben Naafs
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << firstname.lastname@example.org