What is the treatment for transverse myelitis?

From the Guidelines

Treatment for transverse myelitis should prioritize reducing inflammation with high-dose intravenous corticosteroids, such as methylprednisolone 1000mg daily for 3-5 days, as the initial step. This approach is crucial in managing the condition, which is characterized by acute or subacute weakness or sensory changes that are bilateral, often with increased deep tendon reflexes, as defined in the management guidelines for immune-related adverse events 1. The use of corticosteroids aims to minimize neurological damage and improve outcomes in terms of morbidity, mortality, and quality of life.

In terms of specific treatment protocols, the following steps are considered:

• Initial treatment with high-dose intravenous corticosteroids, usually methylprednisolone 1000mg daily for 3-5 days, followed by an oral prednisone taper.
• For patients who do not respond to steroids, plasma exchange therapy (5-7 exchanges over 1-2 weeks) may be considered as a next step.
• In cases where autoimmune processes are suspected, immunosuppressive medications like cyclophosphamide, azathioprine, or rituximab might be prescribed to manage the underlying condition.
• Pain management is also a critical component, often including medications like gabapentin (300-1200mg three times daily), pregabalin (75-300mg twice daily), or amitriptyline (10-75mg at bedtime) to control neuropathic pain.
• Bladder dysfunction, a common complication, may require anticholinergics like oxybutynin (5mg 2-3 times daily) or intermittent catheterization to manage symptoms effectively.

Rehabilitation therapies, including physical and occupational therapy, are essential for recovery and should commence as soon as the patient is medically stable. These therapies play a vital role in maintaining muscle strength, preventing complications from immobility, and improving functional independence, thereby directly impacting the patient's quality of life and long-term outcomes 1. Given the variability in recovery, with some patients experiencing complete recovery while others have permanent disabilities, early aggressive treatment is paramount to minimize long-term neurological damage.

From the FDA Drug Label

Although controlled clinical trials have shown corticosteroids to be effective in speeding the resolution of acute exacerbations of multiple sclerosis, they do not show that corticosteroids affect the ultimate outcome or natural history of the disease

The treatment for transverse myelitis may involve the use of corticosteroids, such as methylprednisolone, to reduce inflammation and speed up recovery. However, the FDA drug label does not provide direct information on the treatment of transverse myelitis. Key points:

• Corticosteroids may be used to treat transverse myelitis
• Methylprednisolone is a type of corticosteroid that may be used
• The FDA drug label does not provide direct information on the treatment of transverse myelitis 2

From the Research

Treatment Options for Transverse Myelitis

The treatment for transverse myelitis typically involves a combination of therapies aimed at reducing inflammation and managing symptoms. Some of the treatment options include:

• Corticosteroids: High-dose glucocorticoids are often used as first-line therapy to reduce inflammation and swelling in the spinal cord 3.
• Plasma exchange: This treatment involves removing the plasma portion of the blood, which contains antibodies that may be contributing to the inflammation, and replacing it with a substitute solution 4, 5.
• IV immunoglobulin (IVIg): This treatment involves infusing antibodies into the bloodstream to help reduce inflammation and modulate the immune system 3.
• Chemotherapeutic agents: In some cases, chemotherapeutic agents such as cyclophosphamide may be used to treat transverse myelitis, particularly in patients with underlying conditions such as systemic lupus erythematosus 4, 6.
• Immunomodulation: Escalation of immunomodulation with either induction IVIg or plasmapheresis may be necessary for patients who relapse or have a refractory state despite initial treatment 3.

Specific Treatment Approaches

Different studies have proposed various treatment approaches for transverse myelitis, including:

• IV methylprednisolone (IVMP) and induction IVIg for patients with immune checkpoint inhibitor-induced transverse myelitis 3.
• Pulse methylprednisolone followed by pulse cyclophosphamide for patients with transverse myelitis complicating systemic lupus erythematosus 6.
• Methylprednisolone therapy for acute transverse myelitis, although its effectiveness has been questioned by some studies 7.

Considerations for Treatment

When treating transverse myelitis, it is essential to consider the underlying cause and the patient's individual needs. Some factors to consider include:

• The severity of symptoms and the extent of spinal cord damage.
• The presence of underlying conditions, such as systemic lupus erythematosus or cancer.
• The patient's response to initial treatment and the need for escalation of immunomodulation.
• The potential risks and benefits of different treatment options, including the risk of relapse and the potential for significant morbidity and mortality 3.