Treatment of Autoimmune Encephalitis with IVIG or PLEX
First-Line Treatment Approach
- The American Academy of Neurology recommends high-dose corticosteroids as the first-line treatment for autoimmune encephalitis, but IVIG or PLEX should be used when steroids are contraindicated or ineffective 1, 2
- IVIG is administered at a dose of 0.4 g/kg/day for 5 days, while PLEX typically involves 5-10 sessions performed every other day 1
- Treatment should be initiated as soon as infection is ruled out based on cerebrospinal fluid results and when primary central nervous system lymphoma or neurosarcoidosis is not a consideration 4
Patient-Specific Considerations for IVIG vs. PLEX
- IVIG is preferred for patients who are agitated or combative, have bleeding disorders or coagulopathy, or have difficulty with central line placement 1, 3, 5
- PLEX is preferred for patients with severe hyponatremia, high thromboembolic risk, or associated brain or spinal demyelination 1, 3
Treatment Escalation
- If there is no clinical, radiological, or electrophysiological improvement after initial treatment with corticosteroids, add IVIG or PLEX as the next step 1, 2
- For severe initial presentations, consider combination therapy with steroids plus IVIG or steroids plus PLEX from the beginning 1, 6
Efficacy and Safety Considerations
- PLEX has shown effectiveness in autoimmune encephalitis, particularly in refractory cases 1, 7
- A small retrospective study showed that patients with NMDAR-antibody encephalitis treated with both corticosteroids and PLEX had better improvement in the modified Rankin score than those treated with corticosteroids alone 1, 5
- Major limitations of PLEX include increased bleeding risk, volume shifts, and the need for central line placement 1, 4