Can steroids be initiated concurrently with antilepra (antileprosy) drugs for leprosy neuritis?

Concurrent Administration of Steroids with Antilepra Drugs for Leprosy Neuritis

Steroids should be initiated concurrently with antilepra drugs for leprosy neuritis to prevent further nerve damage and improve outcomes. 1

Rationale for Concurrent Administration

• Leprosy reactions and neuritis cause significant nerve damage that can lead to irreversible disability if not promptly treated 1
• Early administration of steroids along with antilepra therapy helps prevent active inflammation and fibrosis of nerves, significantly reducing the prevalence of nerve damage 1
• The inflammatory process in leprosy neuritis can cause intraneural caseous necrosis in tuberculoid disease and microabscesses in lepromatous disease, leading to irreversible nerve damage if not promptly addressed 1

Evidence Supporting Concurrent Administration

• Studies have shown that administering steroids along with antilepra therapy helps to stop further nerve damage, although damage already done may not always be reversible 1
• Prophylactic steroid administration during the initial 8 months of multidrug therapy (MDT) has been shown to prevent deterioration of nerve function in multibacillary leprosy patients 2
• A comparative study found that patients receiving MDT with prednisolone (20 mg/day for 6 months followed by tapering) showed significant improvement in nerve function compared to those receiving MDT alone 2

Recommended Steroid Regimens

• For leprosy reactions with neuritis, high-dose glucocorticoids should be used, especially if severe or if neuritis is present 3
• A high-dose regimen (starting with 60 mg prednisolone) tapered over 28 weeks has been shown to be more effective than a low-dose regimen (40 mg) tapered over 22 weeks, with lower recurrence rates of reactions (16% vs 48.3%) 4
• For reversal reactions (Type 1), which often occur soon after chemotherapy is started, large doses of steroids should always be used if severe or if neuritis is present 3

Clinical Approach to Leprosy Neuritis

1. Start antilepra drugs immediately upon diagnosis

2. Concurrently initiate steroid therapy:

   • For severe neuritis: Prednisolone 60 mg daily, tapered over 28 weeks 4
   • For moderate neuritis: Prednisolone 40 mg daily, tapered over 22 weeks 4
   • For mild sensory impairment: Lower doses may be considered, but evidence suggests better outcomes with higher initial doses 5

3. Monitor nerve function regularly during treatment to assess response and adjust therapy as needed

Important Considerations and Caveats

• While steroids are effective in preventing further nerve damage during reactions, they may not reverse damage that has already occurred 1
• Cochrane reviews have found limited evidence for long-term benefit of corticosteroids for longstanding nerve function impairment, emphasizing the importance of early intervention 5, 6
• A 5-month corticosteroid regimen has been shown to be significantly more beneficial than a 3-month regimen, suggesting that adequate duration of therapy is important 6
• Preventive measures like detecting the disease before nerve trunks are infected and offering prompt combined therapy (antilepra drugs plus steroids) as early as possible have helped reduce the prevalence of deformities 1

In conclusion, the evidence strongly supports initiating steroids concurrently with antilepra drugs for leprosy neuritis, rather than waiting for antilepra drugs to act first. This approach provides the best chance of preventing irreversible nerve damage and associated disabilities.