Leprosy
mailing list – October 13th, 2006
Ref.: Treatment
of recurrent ENL reaction
From: Naafs
B., Winnekeburen, The Netherlands
Dear
Dr Strahm,
In some patients the
treatment of recurrent ENL is extremely difficult. A few years ago there was an
extensive non-conclusive discussion on this website.
I think you did the right things.
I would suggest the following approach, it is the one I use
myself. At present I do
not have to many recurrent ENL patients, in my own care, to try other
treatment regimens. There
are no evidence based treatments.
First check for intercurrent
diseases: TB, HIV, parasites, intestinal but also onchocerciasis,
filariasis. I suppose
since the patient had no nerve damage he has no ulcers. Check for anaemia and stress
factors.
I would continue the
clofazimine but would after the long period that you use it now
diminish to 100mg daily. If
he is quiescent now, go down with 2.5 mg every 2 weeks with the
steroids. Add
azathioprine 100mg daily. If
not available, you also may use 10mg methotrexate once weekly. In the days that he does not
take MTX you can supply extra folic acid.
When tapering off he develops an ENL give
high dose steroids up to 150 mg for 2 days and than taper down in one
month to the 10mg you are on now and diminish that again as indicated. If during tapering off he
develops a new bout of ENL than go up again to either the double
dosage he is on at that moment or preferable again to 150 mg. Continue
the azathioprine or MTX. If
after 4 attacks the strategy does not work than add thalidomide in the
silent period and taper off the steroids.
Thalidomide prevents new
reactions better than low dose prednisolone. In a combination of low dose
prednisolone and thalidomide the 2 drugs seem to counteract each
other. The 1 month
treatment is based on the observation that in over 95% of the attacks
of ENL last only one month. Chronic ENL
may last for 6-8 years but eventually will go on its own.
There is one other but experimental
approach if you are extremely rich which is promising that is a
biological. Please keep
me informed on the patient. Though it is not an experimental approach
for me, it has failed occasionally, if so I want to understand why. Than Dr Pieter Schreuder who
approached me about your problem, also comments you for your approach
and suggests to add largactil at night, it seems to help to prevent
the reoccurrence of ENL symptoms with the accompanying stress in the
morning, the patients also sleeps better and as such it may have a
positive effect. But it
also is able by it self immunologically to diminish the ENL reaction,
though it is week in this respect.
I hope to hear from you. With
kind regards,
Ben Naafs
