This protocol applies to children under 18 years of age who experience a relapse of anti-NMDA-receptor antibody encephalitis and who have not achieved adequate improvement following treatment with second-line immunotherapy. Relapse is defined as the return of previously resolved symptoms and signs, or the appearance of new symptoms or signs associated with a change in function.
The previous step in management involved a second-line immunosuppressive regimen — either rituximab or cyclophosphamide (or both, used sequentially). After that treatment, adequate clinical improvement was expected within approximately 1–3 months.
For children with NMDA-receptor antibody encephalitis relapse who remain refractory after the preceding second-line regimen, escalation to IV tocilizumab is considered. This is reserved for the most refractory patients and involves a sustained course of treatment.
The full eligibility criteria, weight-based dosing schedule, treatment duration, and monitoring guidance are available in the complete structured regimen below.
DOI: 10.1212/NXI.0000000000001052
Return of previous resolved symptoms and signs, or appearance of new symptoms or signs, associated with change in function, lasting more than 1 wk (or shorter if associated with change in safety), that cannot be explained by adverse reactions to current medications or intercurrent illness, after a period of stability or improvement of at least 1 mo.
In patients with NMDARE relapse, escalation to IV tocilizumab should be considered only in the most refractory patients who fail to improve adequately after about 1–3 mo of treatment with RTX and/or CYC.
12 mg/kg/dose (<30 kg), 8 mg/kg/dose (≥30 kg) (max 800 mg) given monthly over 6 mo or more (duration of required immunosuppression)
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