Module 2: TREATMENT

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 Rifampicin Clofazimine Ofloxacin Minocycline

Adult Multibacillary Regimen: (For MB leprosy patients above 15 years old) Day 1 (Monthly Dose) Rifampicin – 600mg Clofazimine – 300mg Dapsone – 100mg Day 2-28 (Daily Doses) Clofazimine – 50mg Dapsone – 100mg Duration of Treatment Twelve (12) blister packs to be taken monthly within a maximum of 18 months

Pedia Multibacillary Regimen: (For MB leprosy patients 10-15 years old) Day 1 (Monthly Dose) Rifampicin – 450mg Clofazimine – 150mg Dapsone – 50mg Day 2-28 (Daily Doses) Clofazimine – 50mg (every other day) Dapsone – 50mg Duration of Treatment Twelve (12) blister packs to be taken monthly within a maximum of 18 months

Adult Paucibacillary Regimen: (For PB leprosy patients above 15 years old) Day 1 (Monthly Dose) Rifampicin – 600mg Dapsone – 100mg Day 2-28 (Daily Doses) Dapsone – 100mg Duration of Treatment Six (6) blister packs to be taken monthly within a maximum of nine (9) months

Pedia Paucibacillary Regimen: (For PB leprosy patients 10-15 years old) Day 1 (Monthly Dose) Rifampicin – 450mg Dapsone – 50mg Day 2-28 (Daily Doses) Dapsone – 50mg Duration of Treatment Six (6) blister packs to be taken monthly within a maximum of nine (9) months

For children below ten (10) years old, the dose may be adjusted.

Children under 10 years of age Rifampicin: 10 mg/kgBW Clofazimine: 1 mg/kgBW daily 6 mg/kgBW monthly ** can be spaced out as required Dapsone: 2 mg/kgBW daily The Standard child blister pack may be broken up according to dose requirement

Special Considerations: Rarely, it may be considered advisable to treat a patient with a high bacillary index (BI) for more than 12 months. This is done by specialists at referral units after careful consideration & bacteriologic evidence.

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

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.

SIDE EFFECTS: Clofazimine: Gastric irritation. Skin discoloration (disappears a few months after stopping treatment). Dryness of skin.

SIDE EFFECTS: Dapsone: side effects are rare but…prolonged intake can cause anemia and dapsone psychosis 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.

SIDE EFFECTS: Ofloxacin: Well absorbed, reaches peak serum concentration after 2 hours. May cause nausea, diarrhea, headache, dizziness and insomnia.

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.

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.

PATIENT EDUCATION: The success of MDT treatment is the joint responsibility of the doctor/health care provider and the leprosy patient. Please educate your patient about the importance of treatment compliance and give corresponding instructions or advice.

Health Advice / Instruction Important Messages About MDT Health Advice / Instruction 1. Leprosy is curable with MDT if taken regularly and continuously, and if the prescribed number of blister packs are consumed within the prescribed period of 12- 18 months for MB and 6-9 months for PB. Advise the patient to take his monthly and daily doses of MDT drugs regularly, continuously and adequately to make sure that he gets cured of the disease.

Health Advice / Instruction Important Messages About MDT Health Advice / Instruction 2. A leprosy patient becomes non-infectious after starting MDT. Explain to the patient and his family that he becomes non-infectious one month after taking the initial dose of MDT drugs.

Health Advice / Instruction Important Messages About MDT Health Advice / Instruction 3. During the course of treatment, leprosy reactions may occur. Teach the patient to recognize the early signs of reaction and advise him to report immediately for appropriate intervention in case it occurs. Advise him to continue MDT intake even during reactions.

Health Advice / Instruction Important Messages About MDT Health Advice / Instruction 4. Impairments of the eyes, hands and feet are preventable. Advise the patient to take care of his anesthetic eyes, hands and feet by using protective devices such as sunglasses, hats, gloves and shoes.

Health Advice / Instruction Important Messages About MDT Health Advice / Instruction 5. MDT is available FREE of charge in Rural Health Units. Advise the patient to collect his MDT blister packs at the RHU until all the prescribed number of blister packs are taken.

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.

i Remember: A leprosy case who has completed a full course of treatment should no longer be regarded as a leprosy patient. i

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.

DEFAULTERS: A defaulter is a patient who has started treatment but who has not collected his MDT drugs for six (6) consecutive months. It is, however, important that adequate efforts are made to trace these patients and persuade them to return for assessment and re-treatment.

i A defaulter who returns for re-treatment should be given a new course of MDT. i

PATIENTS WITH SPECIAL NEEDS: Accompanied MDT: Sometimes, patients have to interrupt their 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.

PATIENTS WITH SPECIAL NEEDS: Accompanied MDT: With Accompanied MDT, they are given the first dose at the Health Center, and allowed to bring home the remaining blister packs to complete the treatment at home.

PATIENTS WITH SPECIAL NEEDS: Accompanied MDT: The treatment procedure is taught to the patient and, if possible, a home companion. They are then instructed to report to the Health Center if problems occur or when treatment is completed.

PATIENTS WITH SPECIAL NEEDS: Pregnancy: The standard regimens are considered safe for both the mother and child. If a woman becomes pregnant during the course of treatment, continue MDT. However, if a woman is 1-3 months pregnant, wait until the 2nd trimester before starting MDT.

PATIENTS WITH SPECIAL NEEDS: Tuberculosis: Patients suffering from both leprosy and tuberculosis require appropriate anti-TB therapy in addition to MDT.

PATIENTS WITH SPECIAL NEEDS: Tuberculosis: Since Rifampicin doses for TB are larger than those in MDT, remove the Rifampicin capsules from the MDT blister packs for the duration of the TB therapy. Give the Clofazimine and Dapsone together with the TB regimen. When the TB treatment is completed, resume the prescribed MDT regimen.

PATIENTS WITH SPECIAL NEEDS: HIV Infection: The management of a leprosy patient infected with HIV is the same as with any other leprosy patient. Information available so far indicate that their response to MDT is the same. The management, including treatment of reactions, does not require modifications.

PATIENTS WITH SPECIAL NEEDS: Relapse: Relapse is the recurrence of leprosy after the successful completion of treatment. It is characterized by the occurrence of new lesions.

PATIENTS WITH SPECIAL NEEDS: Relapse: The probability of relapse after MDT is very rare. It is often confused with reactions which can also occur after cure. A Morphological Index is highly recommended when there is suspicion of a relapse.