Clinical Neurology · Neuro-Immunology
Immunomodulators
Immunomodulating therapies used in neuro-immunology, organized by route of administration. For each agent: dose, mechanism of effect, principal side effects, and recommended monitoring.
| Drug | Dose | Effect | Side effects | Monitoring |
|---|---|---|---|---|
| Injections | ||||
| Rituximab (Rituxan) | IV infusion: 2 doses of 1 gm 2 weeks apart, repeated every 6 months | Ab against CD20 | Infusion reaction: fatal arrhythmia, angina, hypotension, nausea, flushing. PML, HBV reactivation.
|
Screening: Hepatitis panel, CBC, HCG, creatinine. Premedication: Tylenol 650, Benadryl 50, solumedrol 100 mg IV. Monitoring: Monthly CD19 level by flow cytometry (target <5%) & IgG level (target to keep 30% above LLN) |
| Cyclophosphamide (Cytoxan) | PO (daily): 1–2 mg/kg/day. IV (pulse): 1 gm/m² then 600 mg/m² every 2 months |
Alkylating agent (interferes with DNA duplication) | Hemorrhagic cystitis, alopecia, infertility. Infusion reaction: headache, nausea | Monthly CBC, UA. Daily CBC, UA (with IV pulse) |
| Methyl-prednisone (Solumedrol) | IV: 1 gm/day for 3–5 days | Anxiety, insomnia, psychosis. Hyperglycemia, hypokalemia, gastritis | BP, FSBS, K | |
| IVIG (Gammagard, Carimune) | IV: 2 gm/kg over 3–5 days then 1 gm/kg every 1–2 months | Infusion reaction: hypotension, arrhythmia, flushing. Nephrotoxicity, aseptic meningitis, blood clots. Avoid Carimune in low GFR patients | Creatinine – BUN | |
| Tocilizumab (Actemra) | SC: 162 mg weekly with steroid taper | IL-6 Rc blocker | Avoid with active infections, live vaccines | CBC, LFT after 4 Wks then Q3 months. ANC: hold if <1000 – Dc if <500. Plat: hold if <100k – Dc if <50K |
| Eculizumab (Soliris) | Infusion weekly then biweekly | C5 (complement) Ab | High risk for meningococcal infections. Vaccinate for meningococcus before starting Soliris. Risk for encapsulated bacterial infection | |
| Oral | ||||
| Azathioprine (Imuran) | PO: 2–3 mg/kg/day (QD) | Inhibits purine synthesis | Hepato-toxicity, pancreatitis, leukopenia, anemia, risk of malignancy.
|
Pre: test for TPMT activity assay first. Monthly CBC, LFT |
| Cyclosporin (Sandimmune) | PO: 4–6 mg/kg/day (BID) | Calcineurin inhibitor, ↓ cytokines | Nephrotoxicity, hepatotoxicity, hypertension, hirsutism, tremors, gum hyperplasia, malignancy.
|
Monthly LFT, BUN/Cr, cyclosporine trough level (70–120 µg/l). BP monitoring |
| Mycophenolate (Cellcept) | PO: 1–1.5 gm BID | Inosine-1P-dehydrogenase inhibitor. Inhibits lymphocyte proliferation & migration | Nausea, vomiting, abdominal pain, diarrhea. Fever, peripheral edema, malignancy (lower risk).
|
Monthly CBC |
| Tacrolimus (Prograf, Protopic) | PO: 0.1–0.2 mg/kg/day (BID) | Calcineurin inhibitor, ↓ cytokines | Nausea, vomiting, abdominal pain, diarrhea. Nephrotoxicity, hepatotoxicity, hypertension. Electrolyte imbalance (↓Mg), tremors.
|
Monthly BUN/Cr, electrolytes, trough level (weekly ×4 then q3months). BP monitoring |
| Prednisolone | PO: 100 mg daily for 2 weeks then EOD for 4 weeks then gradual taper every 4 weeks | Anxiety, insomnia, psychosis. Hyperglycemia, hypokalemia, gastritis | BP, FSBS, K, body weight, Dexa scan, monitor for cataract formation | |
| Methotrexate | PO/IM: 7.5 mg weekly ×4 Wks then 10 mg weekly ×4 Wks then 15–20 mg weekly, taper steroids after 4 months of MTX | Dihydrofolate inhibitor | Hepato-toxicity, pulmonary fibrosis, gastritis, stomatitis, alopecia, infertility. Give daily folate (4 mg) to reduce side effects | Monthly LFT, CBC. Liver biopsy at 2 gm accumulative dose |
Ahmed Koriesh, MD