Leprosy Mailing List – January 7, 2020
Ref.: (LML) MDT duration and ENL neuritis risk
From: Joel Almeida, London and Mumbai
Dear Pieter,
Front-line clues allow rapid improvements in the quality and efficacy of interventions. At the start of a new decade, we can focus on what demonstrably works and discard what does not. This reduces suffering for our patients and our people.
Happy New Year to all,
Joel Almeida
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MDT duration and ENL neuritis risk
Introduction
ENL (Erythema Nodosum Leprosum) is an extremely painful and distressing "reaction" condition often involving many organ systems. It occurs most commonly in highly bacillated types of HD (leprosy).
Does the duration of MDT (multi-drug therapy) affect the risk of ENL neuritis among LL (lepromatous) patients? More specifically, does withdrawing MDT after 12 months have any impact on the risk of ENL neuritis subsequently?
Methods
Comparison was made by Balagon, Gelber et al between one-year MDT and two-year MDT.(1) 58 LL patients given one-year MDT were compared to 139 LL patients given two-year MDT.
Months 13 to 24 after the start of MDT are of particular interest. The one-year MDT group had no MDT during months 13 to 24, but the two-year MDT group did.
Patients with signs of reaction were examined weekly or fortnightly. ENL reactions were considered severe if there were more than 20 ENL skin lesions or if papulonodules of ENL were associated with either severe joint pains, edema, high fever, other constitutional signs and symptoms of iritis, laryngitis, orchitis, and other organ involvement. Any neuritis was noted. Neuritis was defined as pain associated with swelling and tenderness of a nerve.
The incidence rate of ENL reactions with neuritis in the one-year MDT group during months 13 to 24 after the start of MDT can be compared to that in the two-year MDT group. The Incidence Rate Ratio is used.
Results
The results are shown in the Figure.
The Figure. (see attached file) The one-year MDT group showed a 600% increase in the risk of ENL with neuritis compared to the two-year MDT group, during months 13 to 24 after the start of MDT.
Discussion
It would be good to continue MDT beyond 12 months in LL patients. Otherwise they are needlessly subjected to a greatly multiplied risk of the painful, swollen and tender nerves found in the neuritis of ENL "reactions".
Reference
1. Balagon MVF, Gelber RH, Abalos RM, Cellona RV. Reactions following completion of 1 and 2 year multidrug therapy (MDT) Am J Trop Med Hyg 2010 Sep;83(3):637-44. doi: 10.4269/ajtmh.2010.09-0586
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
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