Leprosy medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

The medical treatment of leprosy is made with a multiple drug regimen that must be followed rigorously during a long period of time, 6 to 12 months, depending on the class of disease. This drug regimen includes 2 to 3 different drugs, in order to minimize the risk of resistance.

Medical Therapy

Independently of the class of leprosy, every patient should receive multidrug therapy, and never be treated with a single drug. Multidrug therapy, or MDT, is a safe and effective combination of oral drugs to treat leprosy that, at the same time, aim to prevent drug resistance. In order to improve adherence to the treatment it is distributed for free. The drug combination is provided in blister packs, in order to facilitate the process.

This treatment regimen is identical, both in adults and children, simply with a change in dosage of the drugs, and is safe for pregnant women or those who are breastfeeding. This treatment does not interfere with the therapy for HIV, nor TB, however, in this last case, if a leprosy patient is also being treated for tuberculosis with rifampin, then rifampin should be omitted from the MDT regimen.

It is important to emphasize the importance of adherence to this regimen, in order to avoid development of resistance to the medication. For the monthly administered drugs, their administration should be supervised by an health care practitioner at a local clinic. During this visit, it is also important to evaluate the patient for potential complications of the disease, such as neuritis, or any possible reaction to the medication.

The MDT regimen will be slightly diferent, depending on the classification of leprosy:

• Paucibacillary patients - MDT consists of 2 drugs, taken for 6 months.

• Multibacillary patients - MDT consists of 3 drugs, taken for 12 months.

People who need MDT may be divided into:

• New cases:

• Those who have never received MDT in the past.

• Other cases:

• Relapsed cases - will repeat previous MDT regimen.
• Previous paucibacillary cases, now returning as multibacillary patients.
• Patients who did not complete the due MDT regimen, shall receive the same MDT regimen as new cases.
• Transfered patients - these should carry a record of the current treatment to date, in order for this to be continued.

In rare occasions, for patients with high bacterial index, it may be considered to treat the patient for more than 12 months yet, this decision should only be made by a specialist at referral units after careful evaluation of the clinical scenario.

Multidrug Therapy

According to the directions of the WHO, the multidrug treatment of leprosy should be:

Multibacillary Leprosy   ▸  Adults   ▸  Children <10 years old   ▸  Children >10 years old Paucibacillary Leprosy   ▸  Adults   ▸  Children <10 years old   ▸  Children >10 years old

Adults Preferred Regimen† ▸ Rifampicin 600 mg once a month PO PLUS ▸ Clofazimine 50 mg/day PO and 300 mg once a month PO PLUS ▸ Dapsone 100 mg/day PO † During 12 months. Children <10 years old Preferred Regimen† ▸ Rifampicin 10 mg/Kg once a month PO PLUS ▸ Clofazimine 1 mg/Kg/day PO and 6 mg/Kg once a month PO PLUS ▸ Dapsone 2 mg/Kg/day PO † During 12 months. Children >10 years old Preferred Regimen† ▸ Rifampicin 450 mg once a month PO PLUS ▸ Clofazimine 50 mg every other day PO and 150 mg once a month PO PLUS ▸ Dapsone 50 mg/day PO † During 12 months. Adults Preferred Regimen† ▸ Rifampicin 600 mg once a month PO PLUS ▸ Dapsone 100 mg/day PO † During 6 months. Children <10 years old Preferred Regimen† ▸ Rifampicin 10 mg/Kg once a month PO PLUS ▸ Dapsone 2 mg/Kg/day PO † During 6 months. Children >10 years old Preferred Regimen† ▸ Rifampicin 450 mg once a month PO PLUS ▸ Dapsone 50 mg/day PO † During 6 months.

Leprosy Drug Summary

Rifampicin

Rifampicin is typically used to treat Mycobacterium infections, including tuberculosis and Mycobacterium leprae; and also has a role in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) in combination with fusidic acid. It is used in prophylactic therapy against Neisseria meningitidis (meningococcal) infection. Rifampicin inhibits DNA-dependent RNA polymerase in bacterial cells by binding its beta-subunit, thus preventing transcription of messenger RNA (mRNA) and subsequent translation to proteins. Its lipophilic nature makes it a good candidate to treat the meningitis form of tuberculosis, which requires distribution to the central nervous system and penetration through the blood-brain barrier.

Clofazimine

Clofazimine is a fat-soluble riminophenazine dye used in combination with rifampicin and dapsone as multidrug therapy (MDT) for the treatment of leprosy. It has been used investigationally in combination with other antimycobacterial drugs to treat Mycobacterium avium infections in AIDS patients. Clofazimine also has a marked anti-inflammatory effect and is given to control the leprosy reaction, erythema nodosum leprosum (ENL). Clofazimine exerts a slow bactericidal effect on Mycobacterium leprae. It inhibits mycobacterial growth and binds preferentially to mycobacterial DNA. It also exerts anti-inflammatory properties in controlling erythema nodosum leprosum reactions. However, its precise mechanisms of action is unknown.

Dapsone

Dapsone (diamino-diphenyl sulphone) is an pharmacological medication most commonly used in combination with rifampicin and clofazimine as multidrug therapy (MDT) for the treatment of Mycobacterium leprae infections (leprosy). As an antibacterial, dapsone inhibits bacterial synthesis of dihydrofolic acid. Though structurally distinct from dapsone, the sulfonamide group of antibacterial drugs also work in this way. When used for the treatment of skin conditions in which bacteria do not have a role, the mechanism of action of dapsone is less well understood.

References

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