Leprosy Mailing List – November 7, 2017
Ref.: (LML) Steroid Dependency and the use of Methotrexate
From: Tarun Narang, Chandigarh, India
Dear Dr. Schreuder,
I like to refer to the discussion about steroid dependency and the use of methotrexate by Barbara M. Stryjewska and John F. Prestigiacomo, Grace Warren, Ben Naafs and José Augusto (LML, October and November 2017).
Severe and recurrent type 2 reactions are still a cause of morbidity and mortality. We recently lost two young patients who had become steroid dependent and who also start abusing systemic steroids, sometimes they don't come for follow up and increase and decrease the dose of prednisolone themselves.
One was a young female who developed severe hepatitis and then hepatorenal syndrome. Another patient was admitted for management of severe and recurrent ENL. On examination he had genital warts which he had never disclosed and further investigations revealed that he was HIV positive, with one week he deteriorated and developed disseminated CMV .
Shortening the duration of MDT will increase post treatment reactions and most of the leprosy centres in India only give prednisolone for management of T2 R which predisposes these patients to severe adverse effects and sometimes they also abuse NSAIDS, all of which may prove detrimental to the health of the patient.
I think Methotrexate is a good option as Dr Ben mentioned but I am worried about the immunosuppression it will cause and which may reactivate the persisters if we are giving 12 months FDT (FIXED DURATION THERAPY).
We have been using Minocycline in some of these patients of recurrent and chronic type 2 reactions with good results and have published a report of 10 patients treated with minocycline. I am attaching the report. I think we need to study minocycline in this subset of patients as it is bactericidal with immunomodulatory properties.
Dr Tarun Narang MD MNAMS
Department of Dermatology, Venereology and Leprology,
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << email@example.com