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Indian Journal of Dermatology, Venereology and Leprology
Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL)
ISSN: 0378-6323 EISSN: 0973-3922
Vol. 69, Num. 5, 2003, pp. 323-328
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Untitled Document
Indian Journal of Dermatology, Venerelogy & Leprology, Vol 69, No.
5 ,Sept-Oct, 2003, pp. 323-328
Viewpoint
Pulse therapy as a cure for autoimmune diseases
J. S. Pasricha
Retd. Professor and Head, Department of Dermatology and Venereology, AIIMS,
New Delhi - 110029, India.
Address for correspondence: Dr. J. S. Pasricha, Skin Diseases Centre,
1-A, Masjid Moth, DDA Flats, Phase-1, Outer Ring Road, Near Chirag Delhi Flyover,
New Delhi - 110048, India. E-mail: j_s_pasricha@hotmail.com
Code Number: dv03050
Pulse therapy means the administration of large (supra-pharmacologic) doses
of drugs in an intermittent manner to enhance the therapeutic effect and reduce
the side effects.1-3
The first reported use of pulse administration of corticosteroids
is attributed to Kountz and Cohn4 who used it to successfully prevent
renal graft rejection. Subsequently, pulse doses of corticosteroids were used
for several other diseases such as lupus nephritis, rheumatoid arthritis and
pyoderma gangrenosum,5-7 but usually to deal with emergency situations
only
and not as a preferred method of treatment. Methylprednisolone
was the commonest drug used, in a dose of 1 g per dose for a variable number
of days.
We first used pulse therapy in a patient having Reiter's
disease and could save him from an almost certain death.8 Continued
use of pulses at 1 month intervals led him to a remarkable recovery and a
fairly useful life for the next 10 years. For pemphigus, the pulse therapy
was first used by us in 1982,9 for systemic sclerosis in 1989,10 for
pyoderma gangrenosum in 1990,11 and other diseases in subsequent
years.1 However, we used 100 mg dexamethasone on three consecutive
days at 4 week intervals and continued to use the pulses for a specified period
even after the patient had recovered from the disease completely. This was
done to ensure that the patient would not develop a relapse in future. By
now we have used pulse therapy for more than 1000 patients having pemphigus,
100 cases of systemic sclerosis, 25 patients having systemic lupus erythematosus,
20 patients having dermatomyositis, 10 patients having pyoderma gangrenosum
and fewer cases of other
diseases including extensive lichen planus, prurigo nodularis,
generalized morphea, DLE, scleredema, recurrent alopecia universalis, extensive
vitiligo, allergic vasculitis, disseminated porokeratosis, Darier's disease,
Hailey-Hailey disease, multiple keloids, sarcoidosis, multicentric histiocytosis,
and Peyronie's disease with similar success. With this experience over the
last nearly 20 years, it seems logical to claim that it is now possible to
cure almost all the autoimmune and several other corticosteroid responsive
dermatoses and avoid the side effects commonly associated with the conventional
daily-dose regimens of corticosteroid administration. To achieve optimum results
it is important to strictly follow the regimen recommended by us in all its
details. Any compromises have produced inferior results.
The regimen
The pulse therapy regimen designed by us is called the
DCP regimen or the dexamethasone-cyclophosphamide pulse (DCP) therapy regimen.
In its present form,1 it consists of giving 100 mg dexamethasone
dissolved in 500 ml of 5% glucose as a slow intravenous drip over 2 hours
repeated on 3 consecutive days. On the second day, the patient is also given
500 mg cyclophosphamide in the same drip. This constitutes one DCP. Such
DCPs are repeated at exactly 28 day intervals counted from the first day
of the pulse. In between the DCPs the patient receives only 50 mg cyclophosphamide
orally per day. The DCP regimen is administered in four phases. During the
first few months (phase I) the patient may continue to develop recurrences
of clinical lesions in between the DCPs and can therefore be given additional
treatment (conventional daily doses of oral corticosteroids or additional
dexamethasone pulses) to achieve quicker clinical recovery, and these are
as a rule withdrawn step-wise
during the subsequent DCPs. After the skin and the mucous membrane lesions
have subsided completely and the additional medication has been withdrawn,
the patient is considered to have entered phase II. During this phase,
the patient remains completely alright clinically but receives 9 more DCPs
at exactly 28 day cycles along with 50 mg cyclophosphamide orally per day.
During the next phase (phase III), the DCPs are stopped and the patient
receives only 50 mg cyclophosphamide orally per day for the next 9 months.
After this, the treatment for pemphigus is withdrawn completely and the
patient is followed up for the next 10 years to look for a relapse if any
(phase IV).
During the earlier part of our project, we used to
give 6 DCPs during phase II and the duration of phase III was 12 months.
Indications and contraindications
Since
the pulse therapy regimen virtually cures every pemphigus patient
for the rest of his life and there are almost no side
effects, all pemphigus patients deserve to be treated with this regimen
irrespective of whether they are having severe or mild disease. Even
those patients who are in clinical remission but have totake maintenance
doses of corticosteroids/immunosuppressive drugs, can be made to
give up the maintenance doses by administering
them a course of the DCP regimen.
There are almost no contraindications. DCP therapy can
be given to patients of all ages but the doses have to be reduced to
half for children below the age of 12 years. It can also be given to
patients having diabetes mellitus, hypertension, hyperacidity, osteoporosis,
tuberculosis, etc., but each patient must receive additional appropriate
treatment for the concomitant disease whenever necessary. Diabetic
patients need to be given 10 units of soluble insulin for every 500
ml bottle
of 5% glucose dissolved in the same drip in addition to the routine
treatment for diabetes. Hypertensive patients must monitor the blood
pressure regularly
and adjust the treatment for hypertension if necessary. Patients having
hyperacidity can continue to take antacids or H2 blockers as required and
even those having active
tuberculosis can continue the pulse therapy along with the anti-tubercular
treatment. Viral warts and molluscum contagiosum can also be treated concomitantly
along with the pulse therapy.
If a patient has severely infected lesions
or there is a serious infection elsewhere, the start of the pulse therapy
can
be delayed for a week or two till the infection has been brought under
control. Similarly patients having herpes zoster, herpes simplex or
even chicken pox can be given concomitant treatment with acyclovir
and the pulse therapy can be continued except under exceptional circumstances
when the viral infection is very severe.
The only contraindication for
pulse therapy is pregnancy or if the patient is a lactating mother and
feeding her infant. This
is also not an absolute contra-indication; the pulse therapy is only
to be postponed till the patient has delivered her baby and stopped
feeding the child. Till that time, the patient is to be maintained
on a regular dose of corticosteroid just sufficient to keep the disease
under control or even given a shot or two of dexamethasone alone in
consultation with the obstetrician.
Patients who are unmarried or those
who have not yet completed their family and want to have more children,
have to be given
only dexamethasone pulses (DPs) and not DCPs. Cyclophosphamide in
the pulses has to be avoided because it can lead to amenorrhea or azoospermia
in a significant proportion of patients. The low dose daily cyclophosphamide
can be continued.
The AIIMS experience
During the first few
years, pulse therapy was given to only a few selected patients, especially
those with severe disease.9 however,
the dosage schedule was haphazard and arbitrary as we were not sure
of the total regimen. The patients were also irregular in follow
up; they
reported for the pulses at their own convenience and tended to stop
the treatment by themselves. After about 2 years, a review revealed
that
several of the patients treated with the pulse therapy
had not developed any relapse for long periods
without any maintenance treatment, and thus we realized
that pemphigus could possibly be cured.12
Subsequently, we formulated an arbitrary regimen divided
into 4 phases which was used to treat almost all pemphigus patients.13-17 Several
patients still did not complete the course and/or received the pulses at
irregular intervals.1 The relapse rates during follow up (recurrence
of the disease after having completely recovered from the disease) were
53.8% in the patients who had received incomplete treatment and 18.2% in
the patients who had received their DCPs at irregular intervals. Subsequently,
we tried two modifications of the regimen. In the first modification, we
increased the number of the mandatory DCPs during phase II from 6 in the
original regimen to 9, and correspondingly reduced the duration of phase
III from 12 months to 9 months. The relapse rate in the group who received
the pulses at irregular intervals was 18.7% compared to 8% in the group
who received their pulses at exactly 28 day cycles. In the second modification,
we used only cyclophosphamide for the pulses during phase II of the regimen.
The relapse rate in this group was 23.5%.1
All patients who developed a relapse were given the second
course of the DCP regimen ensuring better compliance of the regimen. There
were only a few patients who were persistent defaulters and needed more
than 2 courses. The relapses in all cases were mild and responded easily
to the next course.
Between 1982 and 1998, 500 pemphigus patients (pemphigus
vulgaris 444, pemphigus foliaceus 33, pemphigus erythematosus 18, and pemphigus
vegetans 5), with an almost equal sex ratio (251 males, 249 females) were
enrolled for the DCP regimen. There were 44 patients younger than 20 years,
246 patients aged 20-40 years, 190 patients aged 40-60 years and 20 patients
older than 60 years. Of these, 97 patients could not complete the treatment,
and 19 patients died due to a variety of causes which were mostly unrelated
to the disease or its treatment, or causes that were preventable with better
patient management. The remaining 384 patients recovered from the disease
and are living without any disease and without any maintenance treatment.
Most of them have already
crossed the 5 year post-treatment follow up period.1
This experience led us to conclude that pemphigus can be
controlled in almost every patient and if the patient strictly follows
the DCP regimen, he can be cured for the rest of his life. The treatment administered
during phase II and III is necessary for ultimate cure; during phase
II the
most effective treatment consists of 9 DCPs taken at exactly 28 day intervals,
with a daily oral dose of cyclophosphamide, followed by 9 months of daily
cyclophosphamide during phase III. Compromises of any kind lead to inferior
results and increase the chances of a relapse.
It is also important to
remember that although the DCP regimen cures pemphigus, this does not
mean that the patient has been protected from
developing other diseases. The patient is as prone to develop other
cutaneous or mucosal diseases as any other normal individual. Therefore
subsequent
lesions such as dermatophytosis, scabies, pyoderma or even lichen
planus or aphthous ulcers in the mouth should not cause apprehension in
the
patient or the dermatologist that pemphigus has recurred. Several patients
continue
to develop aphthous ulcers in the mouth even during pulse therapy
and this has often led some dermatologists to consider the DCP regimen
as a
failure
in a small percentage of the patients. One should be able to distinguish
aphthous ulcers from pemphigus ulcers because aphthous ulcers are
far more painful, have a necrotic circular centre and an inflamed red periphery,
and
most ulcers heal within a few days, whereas pemphigus ulcers are
far
more persistent.
Clinic experience
During the earlier experience at AIIMS, although
almost every pemphigus patient recovered from the disease, in some patients
the duration of phase I was very long as oral ulcers would persist
for
several months-years. After my retirement from AIIMS therefore, the
DCP regimen was modified as follows:
Treatment in all patients with active
disease
was started with betamethasone 2-3 mg/day orally, ketoconazole 200 mg/day
orally
and 500 mg ciprofloxacin or cefadroxil twice daily, in addition to
the DCPs and the daily dose of 50 mg cyclophosphamide. The patients were
also encouraged to clean the oral cavity with regular brushing of the teeth,
and ignore the pain, the bleeding or the risk of peeling the oral mucosa.
They were also advised to massage a topical corticosteroid gel on the oral
ulcers 3-4 times a day especially after every meal.
This change in the regimen generally led to healing
of all the skin lesions within 1-2 months and the oral lesions within
2-3 months. The antibiotic was withdrawn after all the skin lesions
had healed and ketoconazole was withdrawn after the oral ulcers had
healed, while the dose of betamethasone was reduced step-wise by
1 mg at the time of each subsequent DCP.
With this modification, the duration of phase I in
almost all the patients was reduced to around 3-6 months, with the
result that all the 20 patients enrolled during the year 1998 have
already completed the treatment and are now in phase IV. Patients enrolled
during the subsequent years are also following the same pattern.
Side effects
During the initial stages of the project,
we had to evaluate the side effects of the large doses of corticosteroids
and immunosuppressive
drugs used. As a routine, we would admit every patient enrolled for
pulse therapy and undertake a complete clinical and laboratory
evaluation before
starting the pulse and again after completing the pulse to look for
side effects. Special care was taken to monitor the effects of
the pulse on
the total leukocyte counts, electrolyte levels, blood sugar levels
(in normal individuals as well as in diabetic patients) and blood
pressure
values (in normotensive as well as hypertensive patients). The changes
in all these parameters were found to be infrequent, insignificant
and random, and possibly not related to the pulse administration.
The admission
period of the patients was therefore reduced to 3 days from the initial
5 days and the laboratory monitoring of the patient was restricted
to the prepulse evaluation only.
Monitoring of the toxicity/safety on a long-term basis
revealed that pulse therapy is extremely safe, it does not lead to
an increase in the body weight unless the patient was receiving daily corticosteroids,
and if
the patient had already developed cushingoid obesity
due to previous treatment the body weight and
appearance would actually return to normal during the
pulse therapy. There was also almost no risk of
developing diabetes, hypertension, peptic ulceration,
osteoporosis, striae, acne, hirsutism or other side effects
commonly associated with corticosteroids unless the patient
was receiving or had received conventional daily doses
of corticosteroids. The risk of increased pyogenic infections on the skin,
and
candidiasis in the mouth persisted only as long as the patient had
ulcers on
the skin and oral cavity, and therefore vigorous
treatment with systemic antibiotics and antifungal agents
during this period was very helpful. Subsequently there
was almost no risk. Similarly, viral or
dermatophyte infections also needed to be treated on their own
merit without interrupting the pulse therapy regimen. A few patients did develop
reactivation of tuberculosis for which anti-tubercular treatment
was given concomitantly without interrupting
the schedule of the DCP therapy.
Similarly, side effects associated with cyclophosphamide
were also generally very infrequent. Leukopenia, thrombocytopenia and anemia
were rarely seen. Generalized hyperpigmentation was observed in 5 patients
and hemorrhagic cystitis in another 5 patients, especially those who were
irregular in their treatment and needed too many DCPs for effectively controlling
the disease. Malignancy as a side effect of cyclophosphamide was not seen
in any patient. The major side effects of cyclophosphamide in our patients
were diffuse hair loss (which was reversible in all cases) and amenorrhea
(and possibly azoospermia) in a significant proportion of patients. Subsequently
therefore, for the patients who had not yet completed their family and
wanted to have more children, we used only dexamethasone for the pulses
(DPs), though the low dose daily cyclophosphamide was continued.1
The other side effects of DCP therapy included a feeling
of weakness and tiredness due to corticosteroid withdrawal for 2-3 days
after the pulse, bad taste in the mouth and loose motions coinciding with
the pulses (both of which would respond to a 7 day course
of ciprofloxacin for 2-3 consecutive pulses), recurrent
hiccup after the pulse (observed in a few patients), cataract (which was
observed only in the elderly and could be coincidental), and bone pains
and aseptic necrosis of the bones which were attributable more to the conventional
daily dose treatment received earlier rather than the pulse therapy.
It was thus obvious that the pulse mode of administration
was far safer than the daily dose regimens in spite of the high doses
used, and considering its curative effect on the disease there is no
justification for persisting with the conventional daily dose mode
of treatment.
After having gained experience with the administration
of pulse therapy, it also became clear that there was no need to
hospitalize the patient (and no need to have continuous cardiac monitoring during
the pulse, as practiced in the West). Slow administration of the
dose
over approximately 2 hours given in the same manner as any glucose
drip in a day-care unit (at the AIIMS) or in a private clinic (post-retirement)
is all that is necessary. The patients are, as a rule, sent back
home after receiving the pulse. Patients having renal, hepatic or cardiac
disease (especially arrhythmias) would certainly require clearance
and appropriate treatment from the respective specialists.
Immunofluorescence tests
Two types of immunofluorescence tests were undertaken
in our patients: direct immunofluorescence (DIF) on the perilesional/normal-looking
skin (to look for autoantibodies deposited at the intercellular areas),
and indirect immunofluorescence (IIF) on the blood (to look for circulating
intercellular autoantibodies). These tests were positive in almost all
patients and helped confirm the diagnosis and monitor the response to
the treatment, but occasionally they were negative even when the clinical
diagnosis was undisputed and the titer of the autoantibodies was higher
after treatment even when the patient had clinically recovered completely.
We have encountered patients who continued to show positive DIF and/or
IIF even 5 years after treatment without their disease relapsing. Thus,
in our opinion the amount of treatment to be given should depend
upon the clinical state and not the DIF/IIF results.
Other regimens and drugs
The selection of drugs and their dosages was completely
arbitrary and based upon intuition and convenience. Whereas people in
the West had used methylprednisolone, we preferred to use dexamethasone
which was nearly 200 times cheaper. The dose of dexamethasone was fixed
at 100 mg because it was easily available commercially. Three doses per
pulse were considered to be adequate and convenient and found to be effective.
The dose of cyclophosphamide for the pulse was also fixed at 500 mg for
the sake of convenience and effectiveness without producing any serious
side effects. It was however given only on one day of the pulse and not
repeated earlier than 4 weeks. More frequent administration or using
higher doses per pulse can lead to more frequent side effects. The oral
dose of 50 mg cyclophosphamide per day had also been found to be safe
because it does not lead to leukopenia and does not need any monitoring.
The interval between the two pulses was fixed at 4 weeks for the sake
of convenience, but later on it was realized that patients who did not
follow the 28 day cycle had an increased risk of developing a relapse
during the follow up, and it is necessary to administer the next pulse
before the cells responsible for autoimmunity start proliferating again.
The most important decision made by us to achieve ultimate
cure in pemphigus was to administer a standard dose of the treatment
after clinical remission (the treatment given during phase II and phase
III). If the treatment is stopped after completing phase I, almost
every patient is expected to develop a relapse.
On learning about the
success of our regimen, several
dermatologists in other towns/institutions and even other countries
have used the pulse therapy approach for treating pemphigus and other
autoimmune
diseases and many workers have introduced their own modifications.
Some people have used methylprednisolone instead of dexamethasone,
others
have used larger or smaller doses of the corticosteroid, some have
not bothered about the 28 day cycle for repeating the pulses and
some have used the oral route for administering the corticosteroid.
Similarly, some workers have used only cyclophosphamide
for the pulses while others have used azathioprine instead of cyclophosphamide.
Basically, we believe that any combination of a corticosteroid and an immunosuppressive
drug in comparable doses should produce similar results. Comparative
studies may be undertaken but they are really not necessary. The combination
of
dexamethasone and cyclophosphamide is the cheapest and the safest. Methotrexate,
azathioprine and cyclosporine are potentially more hazardous than cyclophosphamide.
Similarly, placebo-controlled trials are also not necessary because each
patient has acted as his own control whenever he has received treatment
from other sources before starting the pulse therapy regimen, and the
differences in the results are too obvious. Most patients treated with
conventional
regimens have died, while almost all the patients treated with the DCP
regimen are alive (or have died due to unrelated causes).
Recently some workers have also used mycophenolate mofetil
or intravenous immunoglobulin (IVIg) for pemphigus. These drugs/regimens
have no doubt been successful in inducing remissions in pemphigus, but
there is a tremendous difference between a remission and a cure/prolonged
remission without maintainence treatment.
References
- Pasricha JS. Pulse therapy in pemphigus and other
diseases. 2nd ed. New Delhi: Pulse Therapy and Pemphigus Foundation;
2000.
- Bell PR, Briggs JD, Calman KC, Paton AM, Wood RF,
Macpherson SG, et al. Reversal of acute clinical and experimental
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1971;i:876-80.
- Feduska NJ, Turcotte JG, Gikas PW, Bacon GE, Penner JA. Reversal of
renal
allograft rejection with intravenous methylprednisolone "pulse" therapy.
J Surg Res 1972;12: 208-15.
- Kountz SL, Cohn R. Initial treatment of renal allografts with large
intrarenal doses of immunosuppressive drugs. Lancet 1969;i:338-40.
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MR, Leib E, McLaughlin K, Blocka K, Furst
DE, Nyman K, et al. Pulse methylprednisolone in rheumatoid arthritis.
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WG. Beneficial effects of methylprednisolone "pulse" therapy
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RB, Lazarus GS. Pulse therapy. Arch Dermatol
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in pemphigus. Indian J Dermatol Venereol Leprol 1984;50:199-203.
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Reddy R, Nandakishore Th, Khera V. Pyoderma
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pemphigus. Br
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