Clinical Neurology · Neuro-Immunology
Choosing an Immunomodulator
Selecting an immunomodulator depends on the underlying disease, the goal of chronic (maintenance) immunotherapy, and pregnancy considerations.
Preferred agents by disease
| Disease | Chronic (maintenance) immunotherapy |
|---|---|
| CIDP | Steroids, azathioprine, mycophenolate, cyclosporine |
| MMN | Monthly IVIG, rituximab, cyclophosphamide |
| Anti-Mag | Rituximab, cyclophosphamide |
| Polymyositis | Steroids, azathioprine, rituximab |
| Myasthenia | Steroids, azathioprine, mycophenolate, cyclosporine, tocilizumab, rituximab |
| NMO | Rituximab, mycophenolate, azathioprine, eculizumab (Mayo Clinic trial) |
| Paraneoplastic | Steroids, monthly IVIG, rituximab |
| GCA (arteritis) | Steroids, tocilizumab |
Rituximab
- Used for: CIDP, Anti-Mag, MMN, inflammatory myopathies, myasthenia gravis, RRMS, NMO & paraneoplastic syndromes.
- Phase I and II studies on rituximab for MS patients showed marked success; however the manufacturer didn't seek FDA approval.
- Infusion-related reactions are thought to be related to its cytolytic effect on CD20 cells with release of cytokines.
- Rituximab protocol is available at http://neurologyresidents.com/neuro-immunology
Pregnancy category
| Class | Agents |
|---|---|
| Class B | None |
| Class C | Rituximab, steroids, IVIG, cyclosporine, tacrolimus |
| Class D | Cyclophosphamide, azathioprine, mycophenolate |
| Class X | Methotrexate |
| Not assigned | Tocilizumab |
Ahmed Koriesh, MD