8_abst (management of leprosy)211-213

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
economic strata, who have to manage the daily household chores, suffer similar illness, familial Epidemiological characteristics of leprosy disharmony arises and occasionally results in reactions: 15 years experience from north India. Int J Lepr Other Mycobact Dis. 72: 125-133.
Deformities developing from reactions are Sehgal VN, Sardana K and Dogra S (2007). stigmatizing. There are few referral centers all Management of complications following leprosy: over India for free reconstructive surgery of an evolving scenario. J Dermatol Treat. 18: 366-
deformities resulting from leprosy. However, these specialized centers are not easily accessible Walker SL, Waters MFR and Lockwood DNJ (2007). by most of the patients because of distance. The role of thalidomide in the management of Moreover, facilities can be availed at such centers erythema nodosum leprosum. Lepr Rev. 78: 197-
only through proper channel after fulfilling

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