Leprosy Mailing List – October 8, 2019
Ref.: (LML) (LML) Request advice on a lepromatous patient treatment
From: Francisco Almeida, Recifi, Brazil
Dear Dr. Pieter,
I would like to thank you for the opportunity to have expressed my opinion earlier and would like to collaborate once again on the case of Dr. Juan Periche Fernandez.
When patients develop dapsone intolerance and refuse to use clofazimine, the most commonly used association is the replacement of these two drugs with ofloxacin and minocycline1.
Some authors in some trials do not recommend the use of minocycline for more than 06 months2. Initially patients may experience side effects including nausea, vertigo and mild dizziness. These side effects occur mainly early after its administration and disappear shortly following adaptation or therapy discontinuation3.
However, treatment of anergic and bacilliferous patients requires a treatment period of more than 6 months. In this case, laboratory testing is recommended at least every 3 months due to the increased risk of hepatotoxicity, pigmentation and the development of systemic lupus erythematosus or pre-existing systemic lupus erythematosus worsens3.
If necessary, minocycline may be substituted for clarithromycin, or clarithromycin may be used from the outset if minocycline is not chosen4.
In cases not responsive to MDT-MB, I usually maintain the supervised dose of rifampicin, combining ofloxacin 400mg / day and minocycline 100mg / day for up to 24 months. I never had to discontinue minocycline after six months of use. Other colleagues in my country prefer to keep these three drugs beyond the initial six months, in the form of monthly-supervised doses up to 24 doses.
Finally, there is the possibility of using other quinolones for combination, such as moxifoxacin and levofloxacin5,6. Despite the recent stir due to prolonged use of quinolones, I have never had a problem with my patients, including the use of moxifloxacin, always being cautious about their laboratory monitoring. I have no experience using levofloxacin.
I particularly have many caveats about monthly dosing, including rifampicin, despite being advocated by the WHO. Nevertheless, this question is reason for another discussion.
Best regards,
Francisco Almeida
Bibliography:
1. Narang T, Bishnoi A, Dogra S, Saikia UN, Kavita. Alternate Anti-Leprosy Regimen for Multidrug Therapy Refractory Leprosy: A Retrospective Study from a Tertiary Care Center in North India. Am J Trop Med Hyg. 2019 Jan;100(1):24-30.
2. Gelber RH, Fukuda K, Byrd S, et al. A clinical trial of minocycline in lepromatous leprosy. BMJ. 1992;304(6819):91–92.
3. Garrido-Mesa N, Zarzuelo A, Gálvez J. Minocycline: far beyond an antibiotic. Br J Pharmacol. 2013;169(2):337–352.
4. Chan GP, Garcia-Ignacio BY, Chavez VE, et al. Clinical trial of clarithromycin for lepromatous leprosy. Antimicrob Agents Chemother. 1994;38(3):515–517.
5. Pardillo FE, Burgos J, Fajardo TT, et al. Powerful bactericidal activity of moxifloxacin in human leprosy. Antimicrob Agents Chemother. 2008;52(9):3113–3117. doi:10.1128/AAC.01162-07.
6. Dhople AM, Ibanez MA. In vitro activity of levofloxacin, singly and in combination with rifamycin analogs, against Mycobacterium leprae. Antimicrob Agents Chemother. 1995;39(9):2116–2119.
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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