title: [Treatment of pemphigus vulgaris by azathioprine and low doses of prednisone (Lever scheme)].
abstract: BACKGROUND
  The so-called "Lever scheme" therapeutic regimen has been proposed in the borderline forms of pemphigus to reduce the side effects of systemic corticosteroids.
  
  
  METHODS
  A retrospective study was conducted in 8 hospital centers. The criteria for inclusion were the clinical diagnosis of pemphigus, confirmed by histological examination and direct immunofluorescence and first line therapy using the "Lever scheme" protocol, combining 40 mg of prednisone on alternate days and 100 mg/day of azathioprine.
  
  
  RESULTS
  Twenty-two patients, seen between January 1990 and December 2000 were included in the study. Eighteen patients (82 p. 100) exhibited complete healing of their cutaneous-buccal lesions after a mean delay of 4.3 months. The lesions of 4 patients did not heal. Three of these patients died: a bed-ridden patient, a patient exhibiting a metastatic bronchial carcinoma and a hypertensive patient who died following a hemorrhagic cerebral vascular accident. Twelve patients (54 p. 100) were weaned off treatment after a mean duration of 2.9 years. Five severe adverse events were observed: one pneumonia, 2 unbalanced diabetes, one hepatitis and one pulmonary embolism.
  
  
  CONCLUSIONS
  This study showed that the healing of the cutaneous-buccal lesions was obtained using the "Lever scheme" in 18 cases out of 22 (82 p. 100). The delay to healing was relatively long in view of the delayed effect of azathioprine. This limits the use of the "Lever scheme" protocol to non-extensive and/or early stage pemphigus. The severe adverse events occurred in low-weight patients in whom the dose related to weight was the highest. Hence the doses of azathioprine and prednisone should be adapted to patients' body weight.
authors.affiliation: Service de Dermatologie, Hôpital Charles Nicolle, INSERM U519, Rouen.
authors.forename: C
authors.initials: C
authors.lastname: Benoit Corven
authors.forename: P
authors.initials: P
authors.lastname: Carvalho
authors.forename: C
authors.initials: C
authors.lastname: Prost
authors.forename: J-L
authors.initials: JL
authors.lastname: Verret
authors.forename: P
authors.initials: P
authors.lastname: Saiag
authors.forename: I
authors.initials: I
authors.lastname: Noblesse
authors.forename: C
authors.initials: C
authors.lastname: Bedane
authors.forename: O
authors.initials: O
authors.lastname: Chosidow
authors.forename: P
authors.initials: P
authors.lastname: Young
authors.forename: J-C
authors.initials: JC
authors.lastname: Roujeau
authors.forename: P
authors.initials: P
authors.lastname: Joly
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001379:Azathioprine / Q000008:administration & dosage*; D004359:Drug Therapy, Combination; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage*; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D010392:Pemphigus / Q000188:drug therapy*; D011241:Prednisone / Q000008:administration & dosage*; D012189:Retrospective Studies
chemical_list: D005938:Glucocorticoids; D007166:Immunosuppressive Agents; D001379:Azathioprine; D011241:Prednisone