A 28-year-old woman with borderline tuberculoid leprosy (BT) is started on MDT. She develops severe hemolytic anemia and jaundice within 2 weeks of starting treatment. G6PD deficiency is confirmed. Which drug should be substituted in her regimen?

Explanation

## Drug Intolerance in MDT: Dapsone and G6PD Deficiency ### Clinical Context The patient has **borderline tuberculoid (BT) leprosy**, which is **paucibacillary (PB)**. The acute hemolytic anemia and jaundice triggered by Dapsone in the setting of **G6PD deficiency** is a classic adverse effect. **Key Point:** Dapsone causes oxidative hemolysis in G6PD-deficient patients. This is a **contraindication** to Dapsone use. ### Standard PB-MDT Regimen and Substitution Algorithm | Drug | Role | G6PD Deficiency Issue | Substitute | |---|---|---|---| | **Rifampicin** | Bactericidal | Safe | None needed | | **Dapsone** | Bacteriostatic | **CONTRAINDICATED** | **Ofloxacin 400 mg daily** | | **Clofazimine** | Bacteriostatic + anti-inflammatory | Safe | None needed | **High-Yield:** In G6PD deficiency with Dapsone-induced hemolysis: - **STOP Dapsone immediately** - **REPLACE with Ofloxacin 400 mg daily** (unsupervised) - Continue Rifampicin + Clofazimine as planned ### Why Ofloxacin? 1. Fluoroquinolone with proven anti-leprosy activity 2. No oxidative hemolysis risk 3. WHO-approved substitute for Dapsone intolerance 4. Dosing: 400 mg daily (unsupervised) ### Modified PB-MDT for Dapsone Intolerance **Rifampicin (monthly supervised) + Ofloxacin (daily unsupervised) + Clofazimine (daily unsupervised)** for 6 months. **Clinical Pearl:** Always screen for G6PD deficiency before starting Dapsone, especially in patients from high-risk populations (African, Mediterranean, Southeast Asian descent).