Effectiveness of Methotrexate in prednisolone and thalidomide resistant cases of Type 2 lepra reaction: report on three cases

Abstract

Type 2 lepra reactions, and its cutaneous manifestation, Erythema Nodosum Leprosum (ENL) are an immune complex mediated systemic condition, often complicating the disease and/or its treatment in cases of the lepromatous spectrum of leprosy. Prednisolone and thalidomide are the mainstay for the treatment of Type 2 lepra reactions. According to the guidelines set out by the WHO and the National Leprosy Elimination Programme (NLEP) of India cases of Type 2 lepra reaction should be managed with prednisolone, cofazimine and thalidomide. NLEP guidelines suggest that prednisolone at 1 mg/kg body wt/day is given to start with as a single morning dose after breakfast, and after the reaction/inflammation is controlled, to taper the prednisolone by 10 mg fortnightly till the dose of 20 mg/day is reached. Thereafter prednisolone is tapered by 5 mg/day, fortnightly till withdrawal. Clofazimine is given with corticosteroids in every case, starting with 100 mgs three times a day, tapering to 100 mgs after every 12 weeks. It is recommended not to exceed clofazimine beyond 12 months. Thalidomide can be used in resistant cases of ENL under strict supervision in tertiary care centres only. During the years 2009 and 2010, thalidomide was made available to our department through the kind donation of the NGO Lepra Society, India. This thalidomide was used for prednisolone/clofazimine non-responsive patients of Type 2 lepra reaction. The thalidomide schedule that we followed was, to start 100 mgs three times a day, tapered fortnightly