Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

new-onset or new flare: mild impairment

1st line – cognitive behavioral therapy (CBT) + educational and supportive therapy

Back
ACUTE
|
new-onset or new flare: mild impairment
1st line – 

cognitive behavioral therapy (CBT) + educational and supportive therapy

Mild impairment due to PANS may be defined as obsessive-compulsive symptoms that are significant but occur for only 1 or 2 hours a day and cause minor disruption at home or school.[51] Flares are defined as abrupt deteriorations in neuropsychiatric symptoms, lasting an average of 12 weeks.[1][3][4][5]

Refer the patient for CBT and provide other interventions, such as educational and supportive therapies.[86]

Psychotropic drugs are usually not required in this patient group.[86] However, psychotropic drugs may be considered on a case-by-case basis as an alternative to corticosteroids, for example, in children who do not tolerate corticosteroids.[86][87]

Consider – treatment of identified infection

Back
ACUTE
|
new-onset or new flare: mild impairment
Consider – 

treatment of identified infection

Treatment recommended for SOME patients in selected patient group

Following confirmation of the diagnosis of PANS, give antibiotics targeted at group A streptococcus (GAS) (e.g., penicillin or amoxicillin [or equivalent]) to any patient and their close contacts with laboratory-confirmed GAS infection (e.g., GAS pharyngitis, impetigo, perianal streptococcal infection).[33] For full details of treatment see Acute pharyngitis, Impetigo.

Consider an initial 2-week course of antibiotics for all patients while waiting for laboratory results.[33]

Many PANS cases are thought to be caused by GAS; however, the window of opportunity to diagnose GAS infection may be missed (as is true with many cases of Sydenham chorea). The PANS/PANDAS Consortium consensus guideline recommends an initial course of antibiotics for all newly diagnosed PANS patients, including those without documented GAS infection, as is done for patients with acute rheumatic fever.[33] However, due to the limited available evidence, the authors of this topic consider (based on their clinical experience) that the decision to give antibiotics in these cases should be made by the clinician and the family after a discussion of the risks and benefits. Scenarios where the benefits likely outweigh the risks include:

  • Families where recurrent streptococcus and/or poststreptococcal inflammatory diseases are common

  • Child has severely deteriorated, where the risk/harms of giving a 2-week course of antibiotics (with the possibility of dramatic benefit) is not as great as the risk of missing an opportunity to reverse a life-threatening situation (including suicide risk, starvation risk, risk of impulsive dangerous behavior). This recommendation is based on the clinical experience of the authors of this topic.

Carefully consider prophylactic antibiotics only in selected patients where benefits are deemed to outweigh the risks. The use of prophylactic antibiotics in patients with recurrent episodes of PANS triggered by GAS or in patients without documented infections is controversial.

  • The PANS/PANDAS Consortium consensus guideline recommends considering prophylactic antibiotics in patients with 2 or more recurrent episodes triggered by GAS infection and a severe course.[33]

  • However, European guidelines recommend against the use of prophylactic antibiotics in this scenario as it is not supported by high-quality evidence.[2]

Treat early any identified non-GAS bacterial infection, such as sinopulmonary infections (e.g., sinusitis, otitis media, mastoiditis, mycoplasma pneumonia), skin infections (abscesses), and Lyme disease as per standard of care for that infection.[33][86]

Viruses have been observed to be coincident with some presentations. These are generally self-limiting and are unlikely to need treatment.

Consider – nonsteroidal anti-inflammatory drug (NSAID)

Back
ACUTE
|
new-onset or new flare: mild impairment
Consider – 

nonsteroidal anti-inflammatory drug (NSAID)

Treatment recommended for SOME patients in selected patient group

Consider an NSAID if symptoms continue beyond 2 weeks (especially if symptoms are worsening and/or impairing function).[51] NSAIDs may shorten the episode to 8 weeks and minimize symptoms during this time.[23]

If the initial NSAID does not improve symptoms, consider switching to a different NSAID (e.g., switch from naproxen to ibuprofen).​[24][51]

Note that European guidelines recommend NSAIDs in patients with mild impairment only if symptoms persist following psychiatric interventions and elimination of infection.[2]

NSAIDs should be dosed frequently to maintain continuous anti-inflammatory action.[51]

Celecoxib (a cyclo-oxygenase [COX-2] inhibitor) may be useful in patients who develop gastritis on traditional NSAIDs.[51]

Discontinue treatment if the patient restricts fluids or is at risk of dehydration for other reasons.[51]

NSAIDs are associated with an increased risk of cardiovascular thrombotic events and gastrointestinal toxicity (bleeding, ulceration, perforation). Use caution in patients on corticosteroids (monitor for gastrointestinal toxicity). Consider gastroprotection (e.g., a proton-pump inhibitor). NSAIDs should be used at the lowest effective dose for the shortest effective treatment course.

Primary options

ibuprofen: 10 mg/kg orally every 6-8 hours, maximum 600 mg/dose and 2400 mg/day

OR

naproxen: children ≥2 years of age: 10 mg/kg orally every 12 hours, maximum 500 mg/dose

Secondary options

celecoxib: children ≥2 years of age and body weight 10-25 kg: 50 mg orally twice daily; children ≥2 years of age and body weight ≥25 kg: 100 mg orally twice daily

Consider – treatment of underlying conditions

Back
ACUTE
|
new-onset or new flare: mild impairment
Consider – 

treatment of underlying conditions

Treatment recommended for SOME patients in selected patient group

Consider evaluating patients with relapsing-remitting symptoms for underlying immunodeficiency and autoimmune/rheumatologic conditions and manage those conditions.[51]

2nd line – corticosteroid

Back
ACUTE
|
new-onset or new flare: mild impairment
2nd line – 

corticosteroid

If symptoms persist despite NSAID treatment or the patient has poor response to NSAIDs, consider a short burst (brief course) of an oral corticosteroid.[51] Continue CBT and educational and supportive therapies, and management of any identified infections or underlying conditions, as necessary.

  • The authors of this topic typically only use oral corticosteroids in patients with post-GAS infection PANS, using the same approach and rationale as for Sydenham chorea, and only after elimination of infection. Controlled trial data are lacking for the effectiveness of corticosteroids in both these conditions, and therefore other approaches (i.e., psychiatric interventions, elimination of infection) should be considered and preferred by clinicians.

  • Short bursts of an oral corticosteroid may shorten flares/episodes.[25]

Always make sure infection (e.g., low-grade sinusitis, perianal streptococcal infection) is cleared before starting corticosteroids. Corticosteroids may prolong elimination of triggering infections.

It is unclear whether corticosteroids are helpful in viral-triggered episodes and may prolong clearance of viruses.

Note that European guidelines only recommend corticosteroids if the patient has severe symptoms after treatment with an NSAID and there is a strong suspicion of inflammation.[2]

Monitor patients closely for adverse effects. Consider vitamin D and calcium supplementation.[51] Use caution in patients on NSAIDs (monitor for gastrointestinal toxicity).

Note that many patients have transient worsening of psychiatric symptoms after corticosteroid initiation.[51]​ This is almost always followed by improvement. If the patient does not improve, or only has a transient improvement, re-evaluate for underlying infection. Prepare families for worsening symptoms so that they can ensure adequate resources to manage the child.

Refer the patient for a full workup for other inflammatory diseases before giving immunomodulatory therapy.[51]

  • Starting corticosteroids before a complete inflammatory disease workup is complete may mask tell-tale signs of other autoimmune diseases (e.g., autoimmune encephalitis, arthritis).

Primary options

prednisone: 1-2 mg/kg/day orally given in 1-2 divided doses for 5 days, maximum 60-120 mg/day

new-onset or new flare: moderate to severe impairment

1st line – cognitive behavioral therapy (CBT) + educational and supportive therapy

Back
ACUTE
|
new-onset or new flare: moderate to severe impairment
1st line – 

cognitive behavioral therapy (CBT) + educational and supportive therapy

Moderate to severe impairing symptoms may be defined as symptoms that are distressing and impairing that interfere with daily life, but not overwhelming or incapacitating. The obsessive-compulsive symptoms may occupy 50% to 70% of waking hours, but there are periods of relief.[51] Flares are defined as abrupt deteriorations in neuropsychiatric symptoms, lasting an average of 12 weeks.[1][3][4][5]

Refer the patient for CBT and provide other interventions, such as educational and supportive therapies.[86]

Plus – management of psychiatric symptoms

Back
ACUTE
|
new-onset or new flare: moderate to severe impairment
Plus – 

management of psychiatric symptoms

Treatment recommended for ALL patients in selected patient group

Refer the patient to a pediatric psychiatrist. Management of the most impairing neuropsychiatric symptoms should be prioritized.[86]

For some children, PANS-related separation anxiety and obsessive thoughts create the most distress and interference. For others, the most troubling symptoms are emotional lability, rages, and impulsivity. The management of these symptoms should be the same as the treatment for those psychiatric conditions.[2][86] See Obsessive-compulsive disorder, Anorexia nervosa, Tic disorders, and Generalized anxiety disorder.

Standard evidence-based interventions for neuropsychiatric symptoms may include CBT, educational and supportive therapies, and the use of psychotropic drugs (e.g., selective serotonin-reuptake inhibitors [SSRIs], benzodiazepines, and alpha-2 agonists).[2][86]

  • As with other inflammatory brain conditions, patients may be sensitive to psychotropic drugs; starting at a lower than typical dose (e.g., up to one fourth to one half of the typical starting dose) should be considered. A slower and closely monitored dose escalation than typical should be employed to avoid activation, agitation, akathisia, and other adverse effects.[87]

  • Based on the experience of the authors of this topic, patients tolerate and have better responses to psychotropic drugs after addressing underlying infection and post-infectious inflammation.

Consider – treatment of identified infection

Back
ACUTE
|
new-onset or new flare: moderate to severe impairment
Consider – 

treatment of identified infection

Treatment recommended for SOME patients in selected patient group

Following confirmation of the diagnosis of PANS, give antibiotics targeted at group A streptococcus (GAS) (e.g., penicillin or amoxicillin [or equivalent]) to any patient and their close contacts with laboratory-confirmed GAS infection (e.g., GAS pharyngitis, impetigo, perianal streptococcal infection).[33] For full details of treatment see Acute pharyngitis, Impetigo.

Consider an initial 2-week course of antibiotics for all patients while waiting for laboratory results.[33]

Many PANS cases are thought to be caused by GAS; however, the window of opportunity to diagnose GAS infection may be missed (as is true with many cases of Sydenham chorea). The PANS/PANDAS Consortium consensus guideline recommends an initial course of antibiotics for all newly diagnosed PANS patients, including those without documented GAS infection, as is done for patients with acute rheumatic fever.[33] However, due to the limited available evidence, the authors of this topic consider (based on their clinical experience) that the decision to give antibiotics in these cases should be made by the clinician and the family after a discussion of the risks and benefits. Scenarios where the benefits likely outweigh the risks include:

  • Families where recurrent streptococcus and/or poststreptococcal inflammatory diseases are common

  • Child has severely deteriorated, where the risk/harms of giving a 2-week course of antibiotics (with the possibility of dramatic benefit) is not as great as the risk of missing an opportunity to reverse a life-threatening situation (including suicide risk, starvation risk, risk of impulsive dangerous behavior). This recommendation is based on the clinical experience of the authors of this topic.

Carefully consider prophylactic antibiotics only in selected patients where benefits are deemed to outweigh the risks. The use of prophylactic antibiotics in patients with recurrent episodes of PANS triggered by GAS or in patients without documented infections is controversial.

  • The PANS/PANDAS Consortium consensus guideline recommends considering prophylactic antibiotics in patients with 2 or more recurrent episodes triggered by GAS infection and a severe course.[33]

  • However, European guidelines recommend against the use of prophylactic antibiotics in this scenario as it is not supported by high-quality evidence.[2]

Treat early any identified non-GAS bacterial infection, such as sinopulmonary infections (e.g., sinusitis, otitis media, mastoiditis, mycoplasma pneumonia), skin infections (abscesses), and Lyme disease as per standard of care for that infection.[33][86]

Viruses have been observed to be coincident with some presentations. These are generally self-limiting and are unlikely to need treatment.

Consider – corticosteroid

Back
ACUTE
|
new-onset or new flare: moderate to severe impairment
Consider – 

corticosteroid

Treatment recommended for SOME patients in selected patient group

Consider a corticosteroid (oral bursts or pulse doses) to shorten flares/episodes in patients with moderate to severe impairment.[51] Corticosteroids are usually sufficient for this purpose, particularly if given within a few days of symptom onset.[51]

  • The authors of this topic suggest considering a 1-2 month course of an oral or intravenous corticosteroid in patients with post-GAS infection PANS, using the same approach and rationale as for Sydenham chorea. Controlled trial data are lacking for the effectiveness of corticosteroids in both these conditions, and therefore other approaches (i.e., psychiatric interventions, elimination of infection) should be considered and preferred by clinicians.

For more severe impairment, prolonged corticosteroid courses (with gradual taper) or repeated high doses of corticosteroids may be indicated.[51]

  • Temporary or permanent adverse effects can occur with prolonged courses, frequent oral bursts, and high doses (e.g., blurry vision, weight gain, Cushingoid appearance, altered glucose metabolism, dyslipidemia, hypertension, cataracts, glaucoma, osteoporosis, diabetes). The decision to give corticosteroids should be weighed against these potential toxicities. Monitor patients closely for adverse effects. Consider vitamin D and calcium supplementation.[51]

  • Note that many patients have transient worsening of psychiatric symptoms after initiation of corticosteroids.[51] This is almost always followed by improvement. If the patient does not improve, or only has a transient improvement, re-evaluate for underlying infection. Prepare families for worsening symptoms so that they can ensure adequate resources to manage the child.

It is important to address underlying infection before starting corticosteroids. Corticosteroids may prolong elimination of triggering infections.

It is unclear whether corticosteroids are helpful in viral-triggered episodes and may prolong clearance of viruses.

Examples of suitable regimens are provided here.[51] However, various corticosteroid regimens may be used, and you should consult your local guidelines for more information. Courses may need to be repeated.

Starting corticosteroids before a complete inflammatory disease workup is complete may mask tell-tale signs of other autoimmune diseases (e.g., autoimmune encephalitis, arthritis).

Primary options

Low-dose oral burst regimen

prednisone: 1-2 mg/kg/day orally given in 1-2 divided doses for 5 days, maximum 60-120 mg/day

More

OR

Prolonged oral course and taper regimen

prednisone: 1-2 mg/kg/day orally given in 1-2 divided doses for 5-10 days, then gradually taper over 4-8 weeks, maximum 60-120 mg/day

More

OR

Intermediate-dose pulse regimen

dexamethasone: 20 mg/square meter of body surface area/day orally given in 2 divided doses for 3 days, maximum 30 mg/day

More

OR

High-dose pulse regimen

methylprednisolone sodium succinate: 15-30 mg/kg intravenously every 24 hours for 3-5 days, maximum 1000 mg/day

More

Consider – intravenous immune globulin (IVIG)

Back
ACUTE
|
new-onset or new flare: moderate to severe impairment
Consider – 

intravenous immune globulin (IVIG)

Treatment recommended for SOME patients in selected patient group

High-dose IVIG may be considered instead of corticosteroids or if there is no long-term improvement in symptoms following cessation of corticosteroids.[2][51]

  • IVIG may be given alone or in combination with a corticosteroid for patients with moderate to severe PANS.[51]

  • IVIG is considered an experimental treatment for PANS; the decision to treat with IVIG should always rely on a highly specialized team after full consideration of the case, evaluation of autoimmune encephalitis and other inflammatory brain diseases, and demonstration of evidence for inflammation/autoimmunity.[2][51]

  • IVIG can address underlying infections; however, it is not readily available.[51]

  • One randomized controlled trial showed improvements in obsessive-compulsive symptoms, anxiety, and overall functioning in patients receiving IVIG compared with those receiving placebo after 1 month of treatment, but its effect was unclear in another trial.[26][88] An ongoing trial is evaluating the efficacy of IVIG (primary outcome: improvement of neuropsychiatric symptomatology and behavior) in patients with PANS.[89]

  • Note that many patients have transient worsening of psychiatric symptoms occasionally after initiation of immunomodulatory therapy.[51] If the patient has extreme symptoms such as rage/violence, life-threatening impulsivity, mood instability, or suicidality, ensure that a safe environment can be maintained in case the patient's behavior escalates.[51]

Refer the patient for a full workup for other inflammatory diseases before giving immunomodulatory therapy.[51]

  • Starting IVIG before a complete inflammatory disease workup is complete may mask tell-tale signs of other autoimmune diseases (e.g., autoimmune encephalitis, arthritis).

Renal dysfunction/acute renal failure and thrombosis have been reported with administration of IVIG. Use caution in patients predisposed to acute renal failure (e.g., renal impairment, diabetes). Infusion-related adverse effects may occur.

Primary options

immune globulin (human): induction: 1.5 to 2 g/kg intravenously initially, maximum 70 g/dose

More

Consider – treatment of underlying conditions

Back
ACUTE
|
new-onset or new flare: moderate to severe impairment
Consider – 

treatment of underlying conditions

Treatment recommended for SOME patients in selected patient group

Consider evaluating patients with relapsing-remitting symptoms for underlying immunodeficiency and autoimmune/rheumatologic conditions and manage those conditions.[51]

new-onset or new flare: extreme or life-threatening impairment

1st line – consider hospitalization

Back
ACUTE
|
new-onset or new flare: extreme or life-threatening impairment
1st line – 

consider hospitalization

Extreme or life-threatening impairing symptoms may be defined as obsessive-compulsive symptoms that occupy 90% to 100% of waking hours. Children experience profound distress from separation anxiety, generalized anxiety, depression, and emotional lability.[51] Flares are defined as abrupt deteriorations in neuropsychiatric symptoms, lasting an average of 12 weeks.[1][3][4][5]

Consider arranging admission to an inpatient psychiatric setting, particularly where the combination of escalated impulsivity, behavioral regression, mood lability, and irrational fears can lead to life-threatening impulsive actions.[51] If the child has severe separation anxiety, accommodations for a parent to stay with the child may be required.[51]

  • Crisis management in PANS is similar to that for other disorders presenting risk of self-harm. Impulsivity, physical violence, or aggression, refusal to eat or drink, suicidality, and sometimes acute psychosis, need to be carefully assessed and managed in a timely manner. An ideal inpatient unit for children with symptoms of PANS requires staff skilled in behavioral management and should be equipped to perform necessary medical procedures (e.g., lumbar puncture, intravenous fluid administration, tube feeding, ECG monitoring).[86]

Plus – management of psychiatric symptoms

Back
ACUTE
|
new-onset or new flare: extreme or life-threatening impairment
Plus – 

management of psychiatric symptoms

Treatment recommended for ALL patients in selected patient group

Treatment of extreme or life-threatening psychiatric symptoms, such as obsessive-compulsive disorder, restricted eating, and anxiety symptoms, should follow the usual standard of care for those conditions.[2][86] See Obsessive-compulsive disorder, Anorexia nervosa, Tic disorders, and Generalized anxiety disorder.

Plus – educational and supportive therapy

Back
ACUTE
|
new-onset or new flare: extreme or life-threatening impairment
Plus – 

educational and supportive therapy

Treatment recommended for ALL patients in selected patient group

Provide other interventions, such as educational and supportive therapies.[86]

Consider – treatment of identified infection

Back
ACUTE
|
new-onset or new flare: extreme or life-threatening impairment
Consider – 

treatment of identified infection

Treatment recommended for SOME patients in selected patient group

Following confirmation of the diagnosis of PANS, give antibiotics targeted at group A streptococcus (GAS) (e.g., penicillin or amoxicillin [or equivalent]) to any patient and their close contacts with laboratory-confirmed GAS infection (e.g., GAS pharyngitis, impetigo, perianal streptococcal infection).[33] For full details of treatment see Acute pharyngitis, Impetigo.

Consider an initial 2-week course of antibiotics for all patients while waiting for laboratory results.[33]

Many PANS cases are thought to be caused by GAS; however, the window of opportunity to diagnose GAS infection may be missed (as is true with many cases of Sydenham chorea). The PANS/PANDAS Consortium consensus guideline recommends an initial course of antibiotics for all newly diagnosed PANS patients, including those without documented GAS infection, as is done for patients with acute rheumatic fever.[33] However, due to the limited available evidence, the authors of this topic consider (based on their clinical experience) that the decision to give antibiotics in these cases should be made by the clinician and the family after a discussion of the risks and benefits. Scenarios where the benefits likely outweigh the risks include:

  • Families where recurrent streptococcus and/or poststreptococcal inflammatory diseases are common

  • Child has severely deteriorated, where the risk/harms of giving a 2-week course of antibiotics (with the possibility of dramatic benefit) is not as great as the risk of missing an opportunity to reverse a life-threatening situation (including suicide risk, starvation risk, risk of impulsive dangerous behavior). This recommendation is based on the clinical experience of the authors of this topic.

Carefully consider prophylactic antibiotics only in selected patients where benefits are deemed to outweigh the risks. The use of prophylactic antibiotics in patients with recurrent episodes of PANS triggered by GAS or in patients without documented infections is controversial.

  • The PANS/PANDAS Consortium consensus guideline recommends considering prophylactic antibiotics in patients with 2 or more recurrent episodes triggered by GAS infection and a severe course.[33]

  • However, European guidelines recommend against the use of prophylactic antibiotics in this scenario as it is not supported by high-quality evidence.[2]

Treat early any identified non-GAS bacterial infection, such as sinopulmonary infections (e.g., sinusitis, otitis media, mastoiditis, mycoplasma pneumonia), skin infections (abscesses), and Lyme disease as per standard of care for that infection.[33][86]

Viruses have been observed to be coincident with some presentations. These are generally self-limiting and are unlikely to need treatment.

Consider – plasmapheresis ± intravenous immune globulin (IVIG) ± corticosteroid ± rituximab

Back
ACUTE
|
new-onset or new flare: extreme or life-threatening impairment
Consider – 

plasmapheresis ± intravenous immune globulin (IVIG) ± corticosteroid ± rituximab

Treatment recommended for SOME patients in selected patient group

Plasmapheresis (therapeutic plasma exchange) as a first-line immunomodulatory therapy, given either alone or in combination with high-dose intravenous corticosteroids, IVIG, and/or rituximab may be considered.[51] Plasmapheresis removes autoantibodies triggering immune response leading to brain inflammation.[51]

  • Plasmapheresis followed by IVIG may be considered in life-threatening cases which are not responsive to psychotropic drugs since treatment response is typically rapid.[27] However, rebound worsening after apheresis is discontinued is not unusual (as is typical for many inflammatory conditions), hence, IVIG or other maintenance anti-inflammatory treatments should be considered.[51]

  • Note that European guidelines recommend plasmapheresis or rituximab only in patients with clinically probable or definite autoimmune encephalitis.[2]

  • This is an experimental treatment for PANS; the decision to treat should always rely on a highly specialized team after full consideration of the case, evaluation of autoimmune encephalitis and other inflammatory brain diseases, and demonstration of evidence for inflammation/autoimmunity.[2][51]

Refer the patient for a full workup for other inflammatory diseases before giving immunomodulatory therapy.[51]

  • Starting corticosteroids or IVIG before a complete inflammatory disease workup is complete may mask tell-tale signs of other autoimmune diseases (e.g., autoimmune encephalitis, arthritis).

Always make sure infection (e.g., low-grade sinusitis, perianal streptococcal infection) is cleared before starting corticosteroids.

It is unclear whether corticosteroids are helpful in viral-triggered episodes and may prolong clearance of viruses.

Note that many patients have transient worsening of psychiatric symptoms after corticosteroids, and occasionally after initiation of immunomodulators. If the patient has extreme symptoms such as rage/violence, life-threatening impulsivity, mood instability, or suicidality, ensure that a safe environment can be maintained in case the patient's behavior escalates.[51]

Temporary or permanent adverse effects can occur with prolonged courses, frequent oral bursts, and high doses (e.g., blurry vision, weight gain, Cushingoid appearance, altered glucose metabolism, dyslipidemia, hypertension, cataracts, glaucoma, osteoporosis, diabetes). The decision to give corticosteroids should be weighed against these potential toxicities. Monitor patients closely for adverse effects. Consider vitamin D and calcium supplementation.[51]

Renal dysfunction/acute renal failure and thrombosis have been reported with administration of IVIG; use caution in patients predisposed to acute renal failure (e.g., renal impairment, diabetes). The decision to give corticosteroids should be weighed against these potential toxicities. Infusion-related adverse effects may occur with IVIG and rituximab. Rituximab has been associated with severe mucocutaneous reactions and progressive multifocal leukoencephalopathy.

Primary options

methylprednisolone sodium succinate: 15-30 mg/kg intravenously every 24 hours for 3-5 days, maximum 1000 mg/day

-- AND / OR --

immune globulin (human): induction: 1.5 to 2 g/kg intravenously initially, maximum 70 g/dose

More

-- AND / OR --

rituximab: consult specialist for guidance on dose

Consider – treatment of underlying conditions

Back
ACUTE
|
new-onset or new flare: extreme or life-threatening impairment
Consider – 

treatment of underlying conditions

Treatment recommended for SOME patients in selected patient group

Consider evaluating patients with relapsing-remitting symptoms for underlying immunodeficiency and autoimmune/rheumatologic conditions and manage those conditions.[51]

ONGOING

chronic symptoms

1st line – multidisciplinary team management

Back
ONGOING
|
chronic symptoms
1st line – 

multidisciplinary team management

The vast majority of patients have relapsing-remitting symptoms with initial episodes lasting 4 weeks to 4 months. Although rare, some patients may progress to a chronic course.[51] The management of relapsing-remitting episodes is typically the same as for acute symptoms (new-onset or new flare) according to symptom severity.[51]

Patients with chronic symptoms and their families can benefit from a multidisciplinary team approach including psychiatrist with expertise in obsessive-compulsive disorder, and other behavior disorders, behavioral therapist, social work support, neurodevelopmental specialist, infectious disease expert, rheumatologist, immunologist, and geneticist with expertise in neurogenetics/neuroimmunogenetics.[3]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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