(LML) 2018 WHO Guidelines for the treatment of leprosy

Leprosy Mailing List –  April 3, 2019

Ref.:    (LML) 2018 WHO Guidelines for the treatment of leprosy

From:  Marco Andrey Cipriani Frade, Ribeirão Preto, Brazil

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Dear Pieter, 

Thank you for bringing this important topic issue in discussion.

The guidelines are clear about the current treatment of leprosy stating: 

"The guidelines recommend a 3-drug regimen of rifampicin, dapsone and clofazimine for all leprosy patients, with a duration of treatment of 6 months for PB leprosy and 12 months for MB leprosy."

This represents a change from the current standard treatment for PB leprosy (ONLY FOR PB LEPROSY). Therefore, NO EVIDENCE to support U-MDT, 6 month MB treatment for everyone.

In Brazil, one group of researchers wants to propose the implementation of U-MDT in the field in concordance with the National Leprosy Program. They state, that as it is similar to the 2018 guidelines by the WHO, the same unified treatment using only one pack (MB) not considering the classification (PB or MB) and consequently not considering the time differentiation (6 or 12 months treatment) respectively.  Their message is not in accordance the WHO 2018 guidelines and has brought unfortunately much confusion to the leprosy professionals.

I also hope this topic will be discussed seriously during the coming ILA Congress in the Philippines, because not always the value of "p" can be used as the only opinion-forming element for such a serious public policy considering the fearful risk of shortening the treatment of multibacillary patients for six months using only three or four studies with important limitations, especially the time of follow-up. About the relation of leprosy late relapses (after 10 years) and the time of follow up, there is a huge and consistent literature which should be considered before applying this proposal to the field. 

Although papers published pointing to increasing antibiotic resistance in leprosy, fortunately the leprosy drug treatment is not still our major concern to stop the disease. A major concern is that health professionals do not think and are not aware of leprosy any more. They should be trained continuously to recognize leprosy as earlier as possible avoiding disabilities (one terrible reality still present today) in a disease which everybody claims to be curable. 

New schemes with new drugs could be thought about, but no time should be spend proposing to halve traditional MDT (in use for around 40 years) and that U-MDT all at once should be better than complete 12 months MDT. 

Who will evaluate these MB-patients after 10-20 years after MDT? May be, none of us "responsible" for the implementation today? What do we actually know about the real impact of changing 24 doses MDT to 12 doses MDT in 1998?

Just my opinion for reflection!!!

Best regards,

Marco Andrey Cipriani Frade

National Reference Center of Sanitary Dermatology focused in Leprosy of Clinical Hospital Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil 

Note editor:

On March 26, 2019 we wrote a letter called "(LML) 2018 WHO Guidelines for the treatment of leprosy" in which we forgot to refer to the letters by Ruth Butlin of December 22, 2018 called "LML) New WHO guidelines on chemotherapy for PB leprosy" and the reactions to this letter by Diana Lockwood of December 23, 2018 and Jaison Barreto of December 25, 2018. I would strongly advise to reread these letters as they are very important for the right background information and the ongoing discussion.

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LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com