Frequently asked questions about treatment
What is the reason for shortening the duration of MDT to multibacillary or MB patients to 12 months?
Rifampicin is the major component of MDT. The majority of rifampicin-susceptible multibacterium leprae are killed by a few monthly doses of rifampicin. Recently it has been shown that a daily combination of dapsone and clofazimine is capable of eliminating any rifampicin-resistant mutants in an untreated MB leprosy patient within three to six months. Therefore, the Seventh WHO Expert Committee considered that the duration of treatment of MB leprosy could be reduced to 12 months without compromising the efficacy of the MDT regimen.
Is there any problem foreseen in treating MB patients with a high bacteriological index (BI) with a 12-month MDT regimen?
Multibacillary patients starting with a high bacterial index (BI) may have a higher risk of developing reactions and nerve damage during the second year than those patients starting with a low bacterial index. Secondly, this group of patients starting with high bacteriological index is likely to show clearance of skin lesions more slowly and is likely to have a significant level of bacterial index at the end of 12 months compared with those starting with lower BI. While most of the high BI patients will continue to improve even after stopping the 12 months of treatment, some may show evidence of deterioration and will need an additional 12 months of MDT for multibacillary leprosy.
Will shortening the duration of MDT for multibacillary leprosy increase the risk of multibacterium leprae developing resistance to rifampicin?
No, there is no risk, if the patient takes all the drugs prescribed in the MDT. Several studies have demonstrated that even a few doses of rifampicin kill all organisms susceptible to rifampicin. The naturally occurring rifampicin-resistant mutants are killed by the clofazimine/dapsone combination. Therefore, the chances of finding any live bacilli after 12 doses of MDT are extremely small.
How should we deal with MB leprosy patients who are currently on treatment and have completed 12 or more monthly doses of MDT?
According to the recommendation, all MB (multibacillary) patients who have completed 12 or more doses of WHO MDT for multibacillary leprosy should be regarded as cured and removed from the registers. However, as usual, all patients should be educated about the signs/symptoms of reactions and relapse and asked to report immediately to the nearest health centre should such problems arise.
In some control programmes, after completion of MDT, patients continue with a single drug, usually dapsone, for various lengths of time. Is this necessary?
The continuation of dapsone monotherapy after a course of MDT is totally unnecessary. Some control programmes may be using this to ensure regular follow-up; to satisfy patients who are not willing to discontinue treatment; or in situations where the physician may not be convinced of the efficacy of MDT. Whatever the reason, this approach puts an unnecessary burden on the patient and on the field workers and is not recommended.
Is post-MDT surveillance of patients essential?
Because the risk of relapses after completion of the WHO MDT regimens is negligible, it is no longer necessary to continue active post-MDT surveillance. Instead, patients should be taught at the time of release from treatment to recognize early signs of possible relapses or reactions and to report promptly for treatment.