54
Treatment
Table 7. Nervous System Toxicities
7.7 Demyelinating diseases, including multiple sclerosis, transverse myelitis,
acute-disseminated encephalomyelitis (ADEM), optic neuritis (ON) and
neuromyelitis optica (NMO)
Workup/Evaluation
• Neurologic consultation.
• Ophthalmic or neuro-ophthalmic evaluation if ocular involvement
• MRI with contrast of brain, orbit, cervical, and thoracic spinal cord (tailor to exam
finding ).
• Lumbar puncture with CSF analysis including autoimmune encephalitis panel
and oligoclonal bands, CNS demyelinating disease antibodies (aquaporin 4 and
myelin oligodendrocyte glycoprotein), viral PCRs especially JCV PCR to exclude
progressive multifocal leukoencephalopathy.
• Serum studies: B12, HIV, rapid plasma reagin, ANA, Ro/La, TSH, aquaporin-4
immunoglobulin G (IgG), paraneoplastic panel or anti-HU and anti-CRMP5-
CV2, thyroid panel including TPO and thyroglobulin, am cortisol and ACTH,
paraneoplastic and autoimmune encephalitis panels.
• Evaluation for urinary retention, constipation.
• EEG to evaluate for subclinical seizures.
• Although less common, biopsy may provide definitive evidence of CNS
demyelination
Grading Management
G1: Asymptomatic or mild
symptoms; clinical or diagnostic
observations only
• Intervention not indicated.
• Continue immunotherapy unless symptoms
worsen or do not improve.
G2: Moderate symptoms;
minimal, limiting age-appropriate
instrumental ADL
• Stop ICPi.
• Neurolog y consultation.
• Start prednisone 1 mg/kg daily and taper over
1 month.
• Rule out infection.
G3–4: Severe or medically
significant symptoms but not
immediately life-threatening ;
limiting self-care ADL
• Permanently discontinue ICPi.
• Neurolog y consultation.
• Non opioid management of neuropathic
pain, for example, pregabalin, gabapentin, or
duloxetine.
• Admit patient for methylprednisolone
pulse dosing 1g/day and consider IVIG* or
plasmapheresis if no improvement or symptoms
worsen after 3 days.**
Footnotes:
*
IVIG 2 g/kg, administered in divided doses per package insert.
**
Plasmapheresis immediately aer IVIG will remove immunoglobulin.
(cont'd)
