Leprosy Mailing List – May 29, 2015
Ref.: (LML) Alternative MDT drugs and treatment duration
From: Paul Saunderson, Älesund, Norway
Dear Pieter,
The problem raised by Grace Warren(LML, May 29, 2015) is interesting and it is one that some of us have been discussing recently: a person who has had adequate MDT (according to WHO guidelines) but still appears to have active disease.
From the description given by Grace Warren, it appears that this patient has had about 2 years of treatment with a multi-drug regimen containing rifampicin and clofazimine; it is thought that he has taken the treatment properly because of his skin discoloration and the BI has declined as expected. The problem is that "......so far, his progress is slow." It would be interesting to have a fuller description of this lack of progress: for example, is it slow resolution of the old skin lesions, or new skin lesions, or is it the development of reactions and/or nerve damage?
My view, and I think it is shared by several others, is that 24 months and even 12 months of a rifampicin containing multi-drug regimen has proved to be adequate treatment for multibacillary leprosy whatever the BI (from what we hear about the U-MDT trials, 6 months may also be adequate). A small number of patients relapse after these courses of treatment, but relapses are late (generally occurring more than 7 to 10 years after completing treatment), and seem to be due to persisters or to re-infection, neither of which can be prevented by longer courses of MDT.
There are, however, quite a number of cases like the one described by Grace Warren, in whom the skin lesions remain active and inflamed in the early years after completion of adequate chemotherapy. I do not think the answer is simply a matter of more chemotherapy, or different antibiotics. In discussion with Diana Lockwood and others this week, we concluded that there is ongoing inflammation in many patients, due to residual antigen in the tissues, but not related to a leprosy reaction, nor to ongoing infection with live bacilli.
This phenomenon leads many people to give more antibiotics, but a more nuanced approach would be to look more directly at reducing the inflammation. Clearly one would not advocate steroids if there is no recent nerve damage, but perhaps NSAIDs may be of benefit?
Paul
Paul Saunderson
Medical Director American Leprosy Missions
Greenville, USA
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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