module 2: treatment module 2: treatment. what is mdt? multi-drug therapy (mdt) is the accepted...

Module 2:

TREATMENT

Module 2:

TREATMENT

WHAT IS MDT?WHAT IS MDT?

• Multi-Drug Therapy (MDT) is the accepted standard treatment for leprosy.

• Multi-Drug Therapy (MDT) is the accepted standard treatment for leprosy.

• Dapsone• Rifampicin• Clofazimine

• Dapsone• Rifampicin• Clofazimine

• Ofloxacin• Minocycline• Ofloxacin• Minocycline

• It is a combination of two (2) or more anti-leprosy drugs:

• It is a combination of two (2) or more anti-leprosy drugs:

Adult Multibacillary Regimen:Adult Multibacillary Regimen:(For MB leprosy patients above 15 years old)(For MB leprosy patients above 15 years old)

Day 1

(Monthly Dose)

Day 1

(Monthly Dose)Rifampicin – 600mg

Clofazimine – 300mg

Dapsone – 100mg

Rifampicin – 600mg

Clofazimine – 300mg

Dapsone – 100mg

Day 2-28

(Daily Doses)

Day 2-28

(Daily Doses)

Clofazimine – 50mgDapsone – 100mgClofazimine – 50mgDapsone – 100mg

Duration of TreatmentDuration of Treatment

Twelve (12) blister packs to be taken monthly within a maximum of 18 months

Twelve (12) blister packs to be taken monthly within a maximum of 18 months

Day 1

(Monthly Dose)

Day 1

(Monthly Dose)Rifampicin – 450mg

Clofazimine – 150mg

Dapsone – 50mg

Rifampicin – 450mg

Clofazimine – 150mg

Dapsone – 50mg

Day 2-28

(Daily Doses)

Day 2-28

(Daily Doses)

Clofazimine – 50mg(every other day)

Dapsone – 50mg

Clofazimine – 50mg(every other day)

Dapsone – 50mg

Duration of TreatmentDuration of Treatment

Twelve (12) blister packs to be taken monthly within a maximum of 18 months

Twelve (12) blister packs to be taken monthly within a maximum of 18 months

Pedia Multibacillary Regimen:Pedia Multibacillary Regimen:(For MB leprosy patients 10-15 years old)(For MB leprosy patients 10-15 years old)

Adult Paucibacillary Regimen:Adult Paucibacillary Regimen:(For PB leprosy patients above 15 years old)(For PB leprosy patients above 15 years old)

Day 1

(Monthly Dose)

Day 1

(Monthly Dose)Rifampicin – 600mg

Dapsone – 100mg

Rifampicin – 600mg

Dapsone – 100mg

Day 2-28

(Daily Doses)

Day 2-28

(Daily Doses)

Dapsone – 100mgDapsone – 100mg

Duration of TreatmentDuration of Treatment

Six (6) blister packs to be taken monthly within a maximum of nine (9) months

Six (6) blister packs to be taken monthly within a maximum of nine (9) months

Pedia Paucibacillary Regimen:Pedia Paucibacillary Regimen:(For PB leprosy patients 10-15 years old)(For PB leprosy patients 10-15 years old)

Day 1

(Monthly Dose)

Day 1

(Monthly Dose)Rifampicin – 450mg

Dapsone – 50mg

Rifampicin – 450mg

Dapsone – 50mg

Day 2-28

(Daily Doses)

Day 2-28

(Daily Doses)

Dapsone – 50mgDapsone – 50mg

Duration of TreatmentDuration of Treatment

Six (6) blister packs to be taken monthly within a maximum of nine (9) months

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.

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

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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:Single-Lesion Paucibacillary Regimen:(ROM for SLPB leprosy patients)(ROM for SLPB leprosy patients)

Rifampicin – 600mg (2 x 300mg)Rifampicin – 600mg (2 x 300mg)

Ofloxacin – 400mg (2 x 200mg)Ofloxacin – 400mg (2 x 200mg)

Minocycline – 100mg (2 x 50mg)Minocycline – 100mg (2 x 50mg)

Adult (2 blister packs)Adult (2 blister packs)

Rifampicin – 300mgRifampicin – 300mg

Ofloxacin – 200mgOfloxacin – 200mg

Minocycline – 50mgMinocycline – 50mg

Child (1 blister pack)Child (1 blister pack)

SIDE EFFECTS:SIDE EFFECTS:

Rifampicin:Rifampicin:

• May cause slightly reddish discoloration of urine within a few hours after intake.

• May cause slightly reddish discoloration of urine within a few hours after intake.

• Patient may experience body malaise, joint and muscle pains.

• Patient may experience body malaise, joint and muscle pains.

SIDE EFFECTS:SIDE EFFECTS:

Clofazimine:Clofazimine:

• Gastric irritation.• Gastric irritation.• Skin discoloration

(disappears a few months after stopping treatment).

• Skin discoloration (disappears a few months after stopping treatment).

• Dryness of skin.• Dryness of skin.

SIDE EFFECTS:SIDE EFFECTS:

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

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.

• 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.

• Patients who are allergic to any of the sulfa drugs should not be given Dapsone.

SIDE EFFECTS:SIDE EFFECTS:

Ofloxacin:Ofloxacin:

• Well absorbed, reaches peak serum concentration after 2 hours.

• Well absorbed, reaches peak serum concentration after 2 hours.

• May cause nausea, diarrhea, headache, dizziness and insomnia.

• May cause nausea, diarrhea, headache, dizziness and insomnia.

SIDE EFFECTS:SIDE EFFECTS:

Minocycline:Minocycline:

• Has significant bactericidal activity against M. leprae.

• Has significant bactericidal activity against M. leprae.

• May cause discoloration of teeth in children, occasional pigmentation of the skin, gastro-intestinal disturbance and dizziness.

• May cause discoloration of teeth in children, occasional pigmentation of the skin, gastro-intestinal disturbance and dizziness.

• Cases with severe liver and kidney disease.

• Cases with severe liver and kidney disease.

• Severe hypersensitivity to any of the MDT drugs.

• Severe hypersensitivity to any of the MDT drugs.

• Severe anemia.• Severe anemia.

• Ofloxacin & Minocycline are not recommended for use in pregnant women and children below five (5) years old.

• Ofloxacin & Minocycline are not recommended for use in pregnant women and children below five (5) years old.

CONTRA-INDICATIONS TO MDT:CONTRA-INDICATIONS TO MDT:

The success of MDT treatment is the joint responsibility of the doctor/health care provider and the leprosy patient.

The success of MDT treatment is the joint responsibility of the doctor/health care provider and the leprosy patient.

PATIENT EDUCATION:PATIENT EDUCATION:

Please educate your patient about the importance of treatment compliance and give corresponding instructions or advice.

Please educate your patient about the importance of treatment compliance and give corresponding instructions or advice.

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.

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.

Important Messages

About MDT

Important Messages

About MDTHealth Advice / InstructionHealth Advice / Instruction

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.

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.

2. A leprosy patient becomes non-infectious after starting MDT.

2. A leprosy patient becomes non-infectious after starting MDT.

Important Messages

About MDT

Important Messages

About MDTHealth Advice / InstructionHealth Advice / Instruction

Explain to the patient and his family that he becomes non-infectious one month after taking the initial dose of MDT drugs.

Explain to the patient and his family that he becomes non-infectious one month after taking the initial dose of MDT drugs.

3. During the course of treatment, leprosy reactions may occur.

3. During the course of treatment, leprosy reactions may occur.

Important Messages

About MDT

Important Messages

About MDTHealth Advice / InstructionHealth Advice / Instruction

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.

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.

4. Impairments of the eyes, hands and feet are preventable.

4. Impairments of the eyes, hands and feet are preventable.

Important Messages

About MDT

Important Messages

About MDTHealth Advice / InstructionHealth Advice / Instruction

Advise the patient to take care of his anesthetic eyes, hands and feet by using protective devices such as sunglasses, hats, gloves and shoes.

Advise the patient to take care of his anesthetic eyes, hands and feet by using protective devices such as sunglasses, hats, gloves and shoes.

5. MDT is available FREE of charge in Rural Health Units.

5. MDT is available FREE of charge in Rural Health Units.

Important Messages

About MDT

Important Messages

About MDTHealth Advice / InstructionHealth Advice / Instruction

Advise the patient to collect his MDT blister packs at the RHU until all the prescribed number of blister packs are taken.

Advise the patient to collect his MDT blister packs at the RHU until all the prescribed number of blister packs are taken.

Treatment is completed when:Treatment is completed when:

TREATMENT COMPLETION:TREATMENT COMPLETION:

• A PB patient has taken 6 MDT blister packs within 6-9 months.

• 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 MB patient has taken 12 MDT blister packs within 12-18 months.

• An SLPB patient has taken the single dose of ROM.

• An SLPB patient has taken the single dose of ROM.

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

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

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Upon completion of treatment:Upon completion of treatment:

TREATMENT COMPLETION:TREATMENT COMPLETION:

• Remind the patient about the early signs of a leprosy reaction.

• Remind the patient about the early signs of a leprosy reaction.

• Encourage him to continue self-care of the eyes, hands and feet to prevent injuries that may lead to deformities.

• Encourage him to continue self-care of the eyes, hands and feet to prevent injuries that may lead to deformities.

• Teach him the early signs of a relapse.• Teach him the early signs of a relapse.

A defaulter is a patient who has started treatment but who has not collected his MDT drugs for six (6) consecutive months.

A defaulter is a patient who has started treatment but who has not collected his MDT drugs for six (6) consecutive months.

DEFAULTERS:DEFAULTERS:

It is, however, important that adequate efforts are made to trace these patients and persuade them to return for assessment and re-treatment.

It is, however, important that adequate efforts are made to trace these patients and persuade them to return for assessment and re-treatment.

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

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

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Accompanied MDT:Accompanied MDT:

PATIENTS WITH SPECIAL NEEDS:PATIENTS WITH SPECIAL NEEDS:

Sometimes, patients have to interrupt their treatment for one reason or another:

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.

• 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.

Accompanied MDT:Accompanied MDT:

PATIENTS WITH SPECIAL NEEDS:PATIENTS WITH SPECIAL NEEDS:

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.

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.

Accompanied MDT:Accompanied MDT:

PATIENTS WITH SPECIAL NEEDS:PATIENTS WITH SPECIAL NEEDS:

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.

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.

Pregnancy:Pregnancy:

PATIENTS WITH SPECIAL NEEDS:PATIENTS WITH SPECIAL NEEDS:

The standard regimens are considered safe for both the mother and child.

The standard regimens are considered safe for both the mother and child.

If a woman becomes pregnant during the course of treatment, continue MDT.

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.

However, if a woman is 1-3 months pregnant, wait until the 2nd trimester before starting MDT.

Tuberculosis:Tuberculosis:

PATIENTS WITH SPECIAL NEEDS:PATIENTS WITH SPECIAL NEEDS:

Patients suffering from both leprosy and tuberculosis require appropriate anti-TB therapy in addition to MDT.

Patients suffering from both leprosy and tuberculosis require appropriate anti-TB therapy in addition to MDT.

Tuberculosis:Tuberculosis:

PATIENTS WITH SPECIAL NEEDS:PATIENTS WITH SPECIAL NEEDS:

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.

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.

Give the Clofazimine and Dapsone together with the TB regimen.

When the TB treatment is completed, resume the prescribed MDT regimen.

When the TB treatment is completed, resume the prescribed MDT regimen.

HIV Infection:HIV Infection:

PATIENTS WITH SPECIAL NEEDS:PATIENTS WITH SPECIAL NEEDS:

The management of a leprosy patient infected with HIV is the same as with any other leprosy patient.

The management of a leprosy patient infected with HIV is the same as with any other leprosy patient.

The management, including treatment of reactions, does not require modifications.

The management, including treatment of reactions, does not require modifications.

Information available so far indicate that their response to MDT is the same.

Information available so far indicate that their response to MDT is the same.

Relapse:Relapse:

PATIENTS WITH SPECIAL NEEDS:PATIENTS WITH SPECIAL NEEDS:

Relapse is the recurrence of leprosy after the successful completion of treatment.

Relapse is the recurrence of leprosy after the successful completion of treatment.

It is characterized by the occurrence of new lesions.

It is characterized by the occurrence of new lesions.

Relapse:Relapse:

PATIENTS WITH SPECIAL NEEDS:PATIENTS WITH SPECIAL NEEDS:

The probability of relapse after MDT is very rare.

The probability of relapse after MDT is very rare.

It is often confused with reactions which can also occur after cure.

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.

A Morphological Index is highly recommended when there is suspicion of a relapse.