Extended Abstract Management of leprosy reactions : facing the realities
The clinical course of leprosy is altered by
to August, 2009. Type 1 reaction was recorded in
episodes of type 1 and type 2 reactions. This adds
32 patients among 127 (BT, BB, BL and pure
significantly to the disease morbidity and
neuritic) cases (25.19%). Type 2 reaction was
occasional mortality. Continuing episodes of
recorded in 10 patients among 67 (BL and LL)
reactions even after 'release from treatment' and
cases (14.92%). Recurrent type 1 reaction was recorded in 20 patients and late reaction in 8
nerve impairment related deformities are
patients. All 10 patients had recurrent episodes of
challenges in management of these patients.
ENL, 6 beyond 2 years of completion of MDT. Most
Recurrent leprosy reactions necessitate long-
of these patients were daily wagers, status below
term treatment, often for indefinite period.
Following elimination of leprosy in India, our
Patients with type 1 reaction were treated
focus is to improve health related quality of life
with 40-60 mg of prednisolone at gradually
(HRQL) of the patients suffering from the disease
at present and those who had it in the past. Lepra
Patients with type 2 reaction were treated with
reactions and their sequelae are the principal
determinants of HRQL in them. Several obstacles
prednisolone (40-60 mg) + clofazimine (300 mg),
are there on the way to effective management of
prednisolone + azathioprine / cyclophosphamide
/ pentoxifylline or thalidomide (200-300 mg) +
In an Indian study on leprosy reactions, 31% of the
prednisolone. MDT and general measures were
patients had reactions as the presenting feature
continued as appropriate. Regimes containing
(Kumar 2004). Of these, 21% had type 1 and
azathioprine and cyclophosphamide were slowly
11.8% had type 2 reactions. Recurrent episodes of
effective with erratic results and needed close
ENL were as high as 64%. Hence, effective
monitoring. Pentoxifylline was effective in reducing the constitutional symptoms associated
management of reactions should be emphasized
with type 2 reaction but did not prevent
as an integral part of leprosy control programme
In a tertiary care hospital in south India, 148 new
reactions in these patients has been presented in
cases of leprosy (excluding indeterminate and
Figure 1. The principal causes of failure in
histoid leprosy) were examined from March, 2006
A Palit, MD, Associate Professor, Department of Dermatology, Venereology and Leprosy, Sri B M Patil Medical College, Hospital and Research Center, BLDE University, Bijapur- 586103, Karnataka, India Correspondence to : A Palit Email : aparnapalit@rediffmail.com
effective management of reactions were found to
required. While tapering the dosage below 25-20
necessitating continuation of prednisolone at this
minimum required dose to control the disease. This gives rise to Cushingoid features which is
Lack of ample facilities for corrective /
patients. The alternative drug thalidomide is not
The various factors leading to non-compliance to
affordable by most patients as it is costly and not
Clofazimine is used at a dosage of 300 mg / day as
an adjuvant to prednisolone in the treatment of
iii. Severe side effects, leading to mortality in
type 2 reaction. In recurrent type 2 reactions,
clofazimine may have to be used for nearly a year (Sehgal 2007) resulting in intense red color of the
skin and conjunctiva, causing great resentment to
recurrence of reactions in spite of regular
the patient. Moreover, such high dosage of the
treatment, leading to loss of faith on treating
drug for prolonged period increases the risk of
enteropathy. Long term use of prednisolone
Lack of free supply of drugs used for reaction
increases the risk of widespread pulmonary
vi. Difficulties in availability of thalidomide
tuberculosis, septicemia, osteoporosis and
In the management of recurrent reactions,
related complications like avascular necrosis of
prolonged treatment with prednisolone is
the head of the femur and compression fracture
Doctor shopping Non-compliance to drug intake Non-compliance Immense psychological impact resulting in loss Treatment failure High cumulative cost of treatment No free supply Difficulties in availability of Severe side effects Lack of facilities and high cost involved in Mortality corrective surgeries for deformities Figure 1 : Difficulties encountered in management of reactions.
of vertebrae resulting in quadriplegia or
necessary formalities which is a time-taking
process. Inconvenient and patient un-friendly
Cumulative cost of the drugs like prednisolone
system averts many patients to approach these.
and clofazimine is high for long-term treatment,
Such circumstances force them to approach
this is more so with thalidomide which is a costly
private set ups for devices like MCR footwear,
drug and the treatment duration required is
splints and for corrective surgeries which turns
Among the drugs available in rural set up, there
are not many to choose. Physicians have to deal
vention at different levels. At individual level, all
physicians must gradually sensitize the leprosy
occasional combination with other drugs. In
patients about reactions through counseling. This
recurrent cases, some observant patients may
should be at the initiation of MDT during each
note that he is being prescribed the same
monthly visit and also during release from
medication in different doses. In such situation,
treatment. Such counseling must highlight the
they learn and practice self medication with
cause, natural course and probable complications
related to it and available treatment modalities.
symptoms. Moreover, as their expectation for
At the level of government, arrangements may be
'a better or newer drug prescribed by the doctor'
made for free supply of drugs for reaction at
remains un-fulfilled, they lose faith on the 'same
hospitals. Drugs like thalidomide may be made
prednisolone' and also on 'the doctor' and go for
available at select referral centers at a reduced
cost. Establishment of more zonal and regional
The psychological impact of reactions on the
centers for reconstructive surgery of deformities
patient is quite severe. Type 1 reaction involving
related to leprosy is the need of the hour where
lesions on face and other exposed body parts
these patients can approach directly for free of
gives patient a socially unacceptable look, making
cost and hassle-free management. Recurrent
them unable go around to school, common water
reactions remind us that even after 'cure' of
sources and at other public gatherings. Recurrent
leprosy, 'the disease' is 'not cured'. Perhaps 'cure'
debilitating episodes of ENL make the patient
of this debilitating disease lies in effective
bed-ridden for several days causing loss of daily
References
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Management of complications following leprosy:
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Walker SL, Waters MFR and Lockwood DNJ (2007).
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only through proper channel after fulfilling
The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list,you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. 2009 Express Scripts PLEAS
Case 1:07-cv-12153-RWZ Document 100 Filed 02/28/11 Page 1 of 3 ex rel. James Banigan and Richard Templin, et al. Relators bring this lawsuit under the federal False Claims Act (“FCA”), 31 U.S.C. § 3730, and several state false claims acts against a number of pharmaceuticalcompanies alleging that they participated in a scheme to offer unlawful enticements tothird parties to prescribe a d