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4. treatment


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4. treatment

  1. 1. TREATMENT OF LEPROSYSusana V. Caseria, MD
  2. 2. What is MDT?• Multi-Drug Therapy (MDT) is the accepted standard treatment for leprosy.• It is a combination of two (2) or more anti-leprosy drugs: • Dapsone • Ofloxacin • Rifampicin • Minocycline • Clofazimine
  3. 3. PB Blister Pack PB Blister Pack (Adult) (Child)
  4. 4. MB Blister Pack MB Blister Pack (Adult) (Child)
  5. 5. SIDE EFFECTS:Rifampicin:• May cause slightly reddish discoloration of urine within a few hours after intake.• Patient may experience body malaise, joint and muscle pains.
  6. 6. SIDE EFFECTS:Clofazimine:• Gastric irritation.• Skin discoloration (disappears a few months after stopping treatment).
  7. 7. SIDE EFFECTS:Clofazimine:• Gastric irritation.• Skin discoloration (disappears a few months after stopping treatment).• Dryness of skin.
  8. 8. SIDE EFFECTS:Dapsone:• Side effects are rare.• Some patients may develop allergic reactions causing itchy skin rashes and exfoliative dermatitis.• Patients who are allergic to any of the sulfa drugs should not be given Dapsone.
  9. 9. SIDE EFFECTSDAPSONE Hemolytic anemia – most common G6PD deficiency Psychosis DDS Syndrome - 1st 6 weeks  Fever  Exfoliative dermatitis  Hepatitis  Cholestatic jaundice  splenomegaly  lymphadenopathy
  10. 10. FLUOROQUINOLONES Inhibit DNA gyrase Basically vs. gram (-) bacteria In vivo & in vitro activity of Ofloxacin against M.leprae (Saito,et al, 1986) 3 commercial derivatives tested in mouse footpad system (Grosset, et al) -Ciprofloxacin was inactive -Pefloxacin had bactericidal activity at 150mg/KBNW/day -Ofloxacin at 50 mg/KBW/day had the same effect -Ofloxacin at 1500 mg/KBW/day had profound killing activity
  11. 11. SIDE EFFECTS:Ofloxacin:• Well absorbed, reaches peak serum concentration after 2 hours.• May cause nausea, diarrhea, headache, dizziness and insomnia.
  12. 12. MINOCYCLINE Activity of minocycline in M. leprae infected mice ( Dr. Gelber, 1987) Clinical trial of minocycline in lepromatous leprosy (Dr. Gelber et al) - 8 untreated lepromatous pts - 100 OD X 3 mos. - all were negative after 3 months - clearance :faster than dapsone &, clofazimine, slower than rifampicin & similar to pefloxacin, ofloxacin
  13. 13. SIDE EFFECTS:Minocycline:• Has significant bactericidal activity against M. leprae.• May cause discoloration of teeth in children, occasional pigmentation of the skin, gastro-intestinal disturbance and dizziness.
  14. 14. CONTRA-INDICATIONS TO MDT:• Cases with severe liver and kidney disease.• Severe hypersensitivity to any of the MDT drugs.• Severe anemia.• Ofloxacin & Minocycline are not recommended for use in pregnant women and children below five (5) years old.
  15. 15. TREATMENT: MULTIBACILLARY LEPROSY TRIPLE DRUG THERAPY 1. Dapsone 100 mg OD 2. Clofazimine 50 mg ODAND Supervised 3. Rifampicin 600 mg monthly 4. Clofazimine 300 mg monthly
  16. 16. TREATMENT: PAUCIBACILLARY LEPROSY DUAL DRUG THERAPY 1. Dapsone 100 mg ODAND Supervised 2. Rifampicin 600 mg monthly
  18. 18. Adult Multibacillary Regimen:(For MB leprosy patients above 15 years old) Day 1 Rifampicin – 600mg (Monthly Dose) Clofazimine – 300mg Dapsone – 100mg Day 2-28 Clofazimine – 50mg (Daily Doses) Dapsone – 100mg Duration of Twelve (12) blister Treatment packs to be taken monthly within a maximum of 18 months
  19. 19. Pedia Multibacillary Regimen:(For MB leprosy patients 10-15 years old) Day 1 Rifampicin – 450mg (Monthly Dose) Clofazimine – 150mg Dapsone – 50mg Day 2-28 Clofazimine – 50mg (Daily Doses) (every other day) Dapsone – 50mg Duration of Twelve (12) blister Treatment packs to be taken monthly within a maximum of 18 months
  20. 20. Adult Paucibacillary Regimen:(For PB leprosy patients above 15 years old) Day 1 Rifampicin – 600mg (Monthly Dose) Dapsone – 100mg Day 2-28 Dapsone – 100mg (Daily Doses) Duration of Six (6) blister packs Treatment to be taken monthly within a maximum of nine (9) months
  21. 21. Pedia Paucibacillary Regimen:(For PB leprosy patients 10-15 years old) Day 1 Rifampicin – 450mg (Monthly Dose) Dapsone – 50mg Day 2-28 Dapsone – 50mg (Daily Doses) Duration of Six (6) blister packs Treatment to be taken monthly within a maximum of nine (9) months
  22. 22. For children below ten(10) years old, the dosemay be adjusted. i
  23. 23. Single-Lesion Paucibacillary Regimen:(ROM for SLPB leprosy patients) Adult (2 blister packs) Rifampicin – 600mg (2 x 300mg) Ofloxacin – 400mg (2 x 200mg) Minocycline – 100mg (2 x 50mg) Child (1 blister pack) Rifampicin – 300mg Ofloxacin – 200mg Minocycline – 50mg
  24. 24. TREATMENT Leprosy can now be treated at home Health Education is an integral part of treatment To be effective, treatment should be adequate, regular and continuous
  25. 25. TREAT CORRECTLY THEN STOP TREATMENT Always treat with full doses Never reduce the dose If complications arise, may use a different drug
  26. 26. THE MAJOR PROBLEM IN LEPROSY CONTROL ISPATIENT COMPLIANCE Use every means to gain patient’s cooperation, so that they will take treatment as long as necessary
  27. 27. PATIENT EDUCATION: The success of MDT treatment is thejoint responsibility of the doctor and theleprosy patient. Please educate your patient about theimportance of treatment compliance and givecorresponding instructions or advice.
  28. 28. Important Messages Health Advice / Instruction About MDT1. Leprosy is curable with Advise the patient to MDT if taken regularly take his monthly and daily and continuously, and if doses of MDT drugs the prescribed number regularly, continuously of blister packs are and adequately to make consumed within the sure that he gets cured of prescribed period of 12- the disease. 18 months for MB and 6-9 months for PB.
  29. 29. Important Messages Health Advice / Instruction About MDT2. A leprosy patient Explain to the patient becomes non-infectious and his family that he after starting MDT. becomes non-infectious one month after taking the initial dose of MDT drugs.
  30. 30. Important Messages Health Advice / Instruction About MDT3. During the course of Teach the patient to treatment, leprosy recognize the early signs reactions may occur. of reaction and advise him to report immediately for appropriate intervention in case it occurs. Advise him to continue MDT intake even during reactions.
  31. 31. Important Messages Health Advice / Instruction About MDT4. Impairments of the eyes, Advise the patient to hands and feet are take care of his anesthetic preventable. eyes, hands and feet by using protective devices such as sunglasses, hats, gloves and shoes.
  32. 32. Important Messages Health Advice / Instruction About MDT5. MDT is available FREE Advise the patient to of charge in Rural collect his MDT blister Health Units. packs at the RHU until all the prescribed number of blister packs are taken.
  33. 33. TREATMENT COMPLETION:Treatment is completed when:• A PB patient has taken 6 MDT blister packs within 6-9 months.• An MB patient has taken 12 MDT blister packs within 12-18 months.• An SLPB patient has taken the single dose of ROM.
  34. 34. Remember: A leprosycase who has completed afull course of treatment ishould no longer be regarded as aleprosy patient.
  35. 35. TREATMENT COMPLETION:Upon completion of treatment:• Remind the patient about the early signs of a leprosy reaction.• Teach him the early signs of a relapse.• Encourage him to continue self-care of the eyes, hands and feet to prevent injuries that may lead to deformities.
  36. 36. DEFAULTERS: A defaulter is a patient who has startedtreatment but who has not collected hisMDT drugs for six (6) consecutive months. It is, however, important that adequateefforts are made to trace these patients andpersuade them to return for assessment andre-treatment.
  37. 37. A defaulter who returnsfor re-treatment shouldbe given a new course of iMDT.
  38. 38. PATIENTS WITH SPECIAL NEEDS:Accompanied MDT: Sometimes, patients have to interrupttheir treatment for one reason or another:• Poor access to the health service;• No one is at the Health Center when they come to collect their blister packs;• Nature of work (e.g. fisherman);• Insurgency.
  39. 39. PATIENTS WITH SPECIAL NEEDS:Accompanied MDT: With Accompanied MDT, they are giventhe first dose at the Health Center, andallowed to bring home the remaining blisterpacks to complete the treatment at home.
  40. 40. PATIENTS WITH SPECIAL NEEDS:Accompanied MDT: The treatment procedure is taught to thepatient and, if possible, a home companion.They are then instructed to report to theHealth Center if problems occur or whentreatment is completed.
  41. 41. PATIENTS WITH SPECIAL NEEDS:Pregnancy: The standard regimens are consideredsafe for both the mother and child. If a woman becomes pregnant during thecourse of treatment, continue MDT. However, if a woman is 1-3 monthspregnant, wait until the 2nd trimester beforestarting MDT.
  42. 42. PATIENTS WITH SPECIAL NEEDS:Tuberculosis: Patients suffering from both leprosy andtuberculosis require appropriate anti-TBtherapy in addition to MDT.
  43. 43. PATIENTS WITH SPECIAL NEEDS:Tuberculosis: Since Rifampicin doses for TB are largerthan those in MDT, remove the Rifampicincapsules from the MDT blister packs for theduration of the TB therapy. Give the Clofazimine and Dapsonetogether with the TB regimen. When the TB treatment is completed,resume the prescribed MDT regimen.
  44. 44. PATIENTS WITH SPECIAL NEEDS:HIV Infection: The management of a leprosy patientinfected with HIV is the same as with anyother leprosy patient. Information available so far indicate thattheir response to MDT is the same. The management, including treatment ofreactions, does not require modifications.
  45. 45. PATIENTS WITH SPECIAL NEEDS:Relapse: Relapse is the recurrence of leprosy afterthe successful completion of treatment. It is characterized by the occurrence ofnew lesions.
  46. 46. PATIENTS WITH SPECIAL NEEDS:Relapse: The probability of relapse after MDT isvery rare. It is often confused with reactions whichcan also occur after cure. A Morphological Index is highlyrecommended when there is suspicion of arelapse.
  48. 48. CLARITHROMYCIN Completely prevented the growth of M. leprae resistant & susceptible to dapsone & rifampicin (Walker,et al) No antagonistic drug interaction with rifampicin Less active than minocycline (Ji, et al) Minocycline and clarithromycin have additive effects
  49. 49. OTHER DRUGS Beta Lactam antibiotic -interfere with cell wall synthwesis -must be administered by injection Rifamycin derivatives -Rifabutin, Rifapertine, and R-76-1 -No difference in activity with Rifampicin -No report to support activity vs. rifampicin-resistant strains
  50. 50. OTHER DRUGSSTREPTOMYCIN -Bacteriostatic -Given by injectionFUSIDIC ACID -Highly active against intra/extracellular M. leprae (Franzblau, et al)
  51. 51. Thank You!