Leprosy Mailing List – August 18th, 2007
Ref.:
Advice about treatment of ENL reaction
From:
Warren G., Sydney, Australia
Dear Dr Gajadeera,
Your patient (I refer to Dr Gajadeera’s request dated LML
July 24th, 2007) sounds suspiciously like the ones
I used to treat in Hong Kong. I
am afraid that a MB patient with a skin smear of 4+ is going to need
far more than the W.H.O. recommended 6 or 12 doses of MDT. The
fact that she is now hooked on steroids does make life very difficult.
There is the choice of using thalidomide and full MDT to
wean her off the steroids, but that is not always an option.
We did not have thalidomide in the 1970s, and I have rarely
used it in the last 30 years.
Then I found out the effectiveness of high clofazimine.
You do not say how much she weighs but if it is between 50 and 70 Kg
then I would start her on 300mfgms clofazimine daily, then continue
the steroid and once the clofazimine has stabilized her you
can start to slowly reduce the steroids maybe by using ACTH as a
stimulant to improve her own steroid function. Give the steroid only once
daily early a.m. with food and once you get a real drop in the steroid
level that she requires you can try giving it alternate days (yes
double the dose each time) so that this will help her adrenals
etc to produce their own steroids.
One grossly overweight Chinese who had been on steroids for
months when I got him requires 600mgms clofazimine daily; yet his skin
sure went dark but it eventually faded!
Now when you start the high clofazimine you must realize that
it will require 6-8 weeks for the clofazimine to build up its own
anti-reaction effect. As
she has already had anti-leprosy medication and in theory if she has
had rifampicin there ought to be very few whole live bacilli, I would
stop the rifampicin till you get the reaction under control. In the early days we gave
clofazimine alone as, mono-therapy for many years and I think there
are still no patients shown to have developed clofazimine resistant
bacilli.
Yes, get her haemoglobin up please and give her a good dose
of all the multivitamins especially Vit B1, Vit C and Calcium and
magnesium. Ensure good protein intake. Check the liver function. If it is satisfactory give a
good tranquiliser. I use
chlorpromazine for this in good high doses. Start with say 400mgms daily,
i.e. 100 tds and nocte. This
will make her very sleepy initially but after a few days she will
be able to feed and toilet herself and yet talk when spoken to and
will rest and sleep most of the rest of the time. Diazepam is not good for this. Amitriptyline e is ok but
not as good as chlorpromazine. Phenobarbital in very high doses
will help to cut the worry and stress levels; it is sedation she
needs.
There are lots of other drugs that can be given some rather
potent but I have found that if you start on the 300mgms clofazimine
daily and keep it at that level for many months you will hopefully be
able to reduce the steroids without return of the ENL.
I used to run a type of “yo yo” with the largactil and
steroids. E.g. I would
have the patient on Largactil 100 a.m. and noon and p.m. and and
say 20mgms steroid. The
every second day I would give one dose of largactil that was
smaller i.e. reduce 100 to 75 to 50 in the two earlier doses not the
evening, until she was on 50, 50, 100. Then next day “Turn
turkey” i.e. put the largactil back to 300 daily and reduce the
steroid on the same day. However
many of the patients are very clever and in order to do this well we
crushed all tablets with vitamin C so the patient tasted the Vit
c (or gave liquid largactil) plus crushed steroid with Vit
C. The nurse would crush
the tablets outside and literally put it on the patients tongue each
dose and watch it washed down. In
this way the patient did not know when the steroid was
reduced! I managed to get many patients who were hooked on
steroids, off them by this method with a tranquiliser like largactil
or amitriptyline.
I hope this makes sense.
Ah Yes, make sure you de-worm her and treat malaria and any
other parasite. They all
help continue the ENL!
I know
that what I have just written is rather radical! But it has saved many patients
from steroid problems. I hope it works for you; by all means
write back if I can help. In
my experience the severe MB patients with ENL reaction are going to
need years of MDT or at least Clofazimine; probably 5 years to get the
leprosy under control and keep it controlled!
All the best,
Grace Warren
(Previously in Hong Kong at Leprosy Mission Hospital
1959-75.)
