Leprosy mailing list - 17 December
2003
Ccn: all;
Ref.:
"Fitzpatrick's Dermatology in General
Medicine" - treatment of leprosy;
From: C Bendick, Phnom
Penh, Cambodia.
Dear Salvatore,
I just got the 2003 edition of one of the world's
most renown textbooks on dermatology: "Fitzpatrick's
Dermatology in General Medicine". Sad to see that the opus
magnum (2600 pages) devotes only ten pages to leprosy -
authors Thomas Rea and Robert Modlin. However, what amazes me truly
are their statements concerning treatment:
"For paucibacillary disease (TT or BT) the
WHO recommends the combination of unsupervised dapsone (bacteriostatic)
100mg daily and supervised rifampin (bactericidal) 600mg monthly for
a duration of 6 months. We prefer dapsone 100mg daily for 2 to 3
years with or without rifampin 600mg monthly...
For multibacillary disease (BB, BL and LL) the
WHO recommends unsupervised dapsone 100mg daily,supervised rifampin
600mg monthly and clofazimine 50mg daily, unsupervised, and 300mg
monthly supervised for a routine duration of 2 years. ...
The report of a 20% relapse rate within 8 years
after completion of this regimen suggests a need for alternative
approaches...
...we often use the combination of rifampin 600mg
daily and dapsone 100mg daily for 3 years followed by dapsone 100mg
daily indefinitely or cessation of treatment. Alternative regimens
of rifampin 600mg daily in combination with either minocycline
(bactericidal) 100mg daily or clarithromycine (bactericidal) 500mg
daily for 2 to 3 years, followed by monotherapy, has been well
tolerated, ..."
Assuming that a major textbook should give
guidelines and not (or to a lesser extent) personal views I would
like to ask:
-
Are the days of dapsone monotherapy over or
is this still a valid treatment regimen?
-
"with or without rifampin" is not
really a helpful statement.
-
Does the WHO recommend a routine treatment
duration for MB leprosy of 2 years or 1 year?
-
Can the report of a 20% relapse rate within 8
years (source: Jamet P et al.: Relapse of long term follow up of
MB patients treated by WHO multidrug regimeen. Int J Lepr Other
Mycobact Dis 63: 195, 1995) be confirmed by other authors?
-
What means:"we often use..."? Is
this a recommendation, a personal opinion, an alternative to
standard MDT?
-
Is it justified to treat a patient lifelong
when other treatment regimens of short duration have been proven
to be successful?
-
When a drug is "well tolerated" it
must not necessarily mean that it is efficient. The authors do
not further comment on that.
-
Living in Cambodia, the idea of providing a
patient for 2-3 years with clarithromycine and minocycline is
out of reach. So do the author's statements reflect the practice
of treating leprosy in industrialized nations, whereas treatment
of patients in the third world has to follow (WHO-recommended)
regimens, which are less efficient and less well tolerated?
I would appreciate the comments of
your readers.
Thank you,
Christoph Bendick, MD, PhD
University of Health Sciences
Phnom Penh, Cambodia
