Leprosy Mailing List – January 8th, 2007
Ref.: Treatment
of type one reaction (reversal reaction) in HIV positive patients.
From: Warren
G., Sydney, Australia
Dear Dr Bhattarai,
I have received your request
via Salvatore’s letter (LML Jan. 5th, 2007). I have worked in Green Pasture
on and off since 1975 04 was it 76!!!
I appreciate your problems. As your patient is already on antiretroviral
drugs we can concentrate on treating the Type 1 reaction, Do Not stop
the antiviral medication. I took liberty today to ask a
friend who had done quite a bit of this in Africa and he confirms that the
management of the reaction should not significantly vary if he is
already on antiretroviral drugs.
You say he has commenced MDT. I assume:
1.
Rifampicin 600mgms once
monthly supervised please.
2.
Lamprene (clofazimine)
was it 50mgms daily - as he has positive skin smear I would give at
least 100mgms daily - If there is any evidence of Type 2 reaction as
well as type 1 (Oh yes, I have often seem both together) then give
Lamprene at 300mgms for 6-8 weeks and then reduce to 200mgms
daily (unless very heavy i.e. over 80KG which is not common for
Nepalis, in which case continue 250mgms till off all pred.)
Once all reaction controlled the clofazimine is reduced by 50 daily
about every 3 – 6 months till on the 50mg routine. The clofazimine helps in
killing M. leprae in nerves and controls the inflammation
swelling that is due to the reaction.
3.
Dapsone ideally 1mg / kg per
day- though if about 60 kg we usually only give the 50mgms when in
MDT.
If I had seen him at
commencement I would not have given the dapsone or rifampicin at
first visit but just high clofazimine and prednisolone to reduce
the swelling etc. The
rifampicin kills bacteria so effectively that there is a rapid rise in
the Antigen levels and this results in more anti-leprosy activity i.e.
inflammation. If the
swelling in the nerves is acutely increased there can be more
paralysis! The Lamprene
is relatively mildly bacteriostatic and bactericidal so prevents
bacilli multiplying and does not produce sudden rises in antigen (you
may have found acute increase in swelling after the first dose of
rifampicin)
If you are treating an LL who
has a history of ENL before you even see him to start MDT, do
the same thing, give just Lamprene initially with supportive
therapy and after 6-8 weeks introduce the rifampicin and Dapsone.
By giving the rifampicin and dapsone at first visit you produce
a very rapid kill of bacteria and this often results in a severe bout
of ENL at 5 days and the patient may say: “that medicine
produced more ENL I am not going to take it any more”!)
We want to instil confidence not undermine it by our treatment. Supportive treatment including
treatment of any intercurrent disease: has he TB also? Yes, deworm him and treat his
anaemia, check for diabetes?
Now back to your patient. You query starting him on
prednisolone. You state
he has foot drop for 3 months but has he got other nerves involved? Please get a detailed
voluntary muscle testing (VMT) of all muscles on arms and legs and
face and list every nerve that is palpable and if it is hard or soft. If it is already hard it could
be acutely swollen and may be paralysed and the chances of acute
recovery are very poor but hopefully with adequate care it may
recover. One foot drop I
dealt with, took 24 months for the first sign of returning function to
the anterior tibial muscle!
My recommendation would be
that you commence him on 40mgm prednisolone daily at 6am (or well
before first meal) for 1 week.
That ought to reduce any relatively acute swelling and
occasionally if given soon enough after the acute paralysis can result
in some reversal of the paralysis within a few weeks (not in your
patient). Check nerve
progress periodically; you ought to palpate yourself not just
rely on the PMW and Physio reports.
I would plan to give
your patient about 3 months steroid.
No, you do not continue it till muscle power returns it may
never return! And you do
not want the patient to become dependant on steroids. So, I
would recommend 40mgms x 7 days, 35mgms x 7 days, 30mgms x 7
days, 25mgms x 7 days, (I month).
Then 20mgm x 14 days, 15mgms x 14 days, 10mgms x 14 days
and then 5mgms x 14 days. Total
3 months.
If I the swelling starts to
increase as the steroid drops below 15 that is bad news and we may
have to continue steroid longer but do not increase it over one
5mgms and, contact me again.
You must not try and adjust the steroid level by any response
in the VMT or sensory perception.
You need to provide him with
a foot drop spring so that the nerve is kept at rest with no need for the
muscles to be stimulated and, he wears that till it fully recovers or
he has surgery to correct the drop.
He needs physiotherapy to maintain mobility in any limb with
evidence of muscle weakness. He
also needs the supplementary or supportive medications listed in the
paper that will follow with next message and that I rewrote a couple
of years ago.
Regarding the duration of
MDT: - steroids of any
type slow down the removal of AFB and the safest rule is that the
months on steroid should not be included in the total months of
MDT. So, if you must
adhere to the WHO recommendation of 12 months for MB leprosy I would
say a minimum of 15 months, providing he is only on prednisolone
for 3 months.
But for a case like yours he
needs MDT till his skin smear is negative for 6 sites, basically the
edges of lesions taken on 3 occasions at 4-6 week intervals.
To be safe I would recommend anti-leprosy medication for
one year above the highest skin smear result. I.e. if one site
is 4+ then he takes 5 years medication.
But after the full 24 months MDT I sometimes give just the
clofazimine.
WHO says we have removed the
bacilli by their recommendations of MDT duration; but I very much
doubt it, I have seen to many recurrences and M. leprae is the
cleverest bacillus we know and an expert at persisting. In Malaysia they recovered
viable bacilli fully SENSITIVE TO RIFAMPYCIN from the nerves of a
patient who had had supervised rifampicin daily for 6 years! Yes most of the drugs do not
get into the nerves and the bacilli hide in the basement membranes of
nerves! So they can survive!
If you need any more
explanations you can write to me.
All the best,
Grace Warren
