How to manage a patient with suspected Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD) on a tapering dose of oral prednisolone (corticosteroid) presenting with fever, headache, urinary retention (difficulty micturition), and leukocytosis (elevated White Blood Cell count)?

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Dosage of Prednisolone Oral Solution should be individualized according to the severity of the disease and the response of the patient. If a period of spontaneous remission occurs in a chronic condition, treatment should be discontinued. IT SHOULD BE EMPHASIZED THAT DOSAGE REQUIREMENTS ARE VARIABLE AND MUST BE INDIVIDUALIZED ON THE BASIS OF THE DISEASE UNDER TREATMENT AND THE RESPONSE OF THE PATIENT After a favorable response is noted, the proper maintenance dosage should be determined by decreasing the initial drug dosage in small decrements at appropriate time intervals until the lowest dosage which will maintain an adequate clinical response is reached. Included in the situations which may make dosage adjustments necessary are changes in clinical status secondary to remissions or exacerbations in the disease process, the patient’s individual drug responsiveness, and the effect of patient exposure to stressful situations not directly related to the disease entity under treatment In this latter situation it may be necessary to increase the dosage of Prednisolone Oral Solution for a period of time consistent with the patient’s condition.

The patient with suspected MOGAD on a tapering dose of oral prednisolone presenting with fever, headache, urinary retention, and leukocytosis may require adjustment of the prednisolone dosage. Given the clinical presentation, it is possible that the patient is experiencing an exacerbation of the disease process.

• The dosage of prednisolone may need to be increased temporarily to manage the exacerbation, as the current tapering dose may be insufficient to control the disease activity.
• Close monitoring of the patient's clinical status and laboratory parameters, including the white blood cell count, is necessary to determine the effectiveness of the adjusted dosage and to minimize the risk of adverse effects.
• The patient's individual drug responsiveness and exposure to stressful situations should also be taken into account when adjusting the dosage 1.

From the Research

Management of a patient with suspected MOGAD on tapering prednisolone who presents with fever, headache, urinary retention, and leukocytosis requires immediate evaluation for infection while considering disease relapse. First, obtain urgent neuroimaging (MRI brain and spine with contrast) and lumbar puncture to differentiate between infection and MOGAD relapse. Empiric broad-spectrum antibiotics should be started immediately after cultures are collected, without waiting for results. However, considering the potential for ceftriaxone to increase the risk of enterococcal re-infection and prolonged hospitalization 2, an alternative such as co-amoxiclav+gentamicin could be considered for urinary tract infections. Continue the current prednisolone dose rather than reducing it until infection is ruled out. If neuroimaging shows new demyelinating lesions and infection is excluded, increase prednisolone to 1mg/kg/day (maximum 60-80mg daily) for acute relapse management. For urinary retention, insert a urinary catheter and consider urological consultation. Once stabilized, transition to steroid-sparing immunosuppression such as rituximab (1000mg IV, repeated after 2 weeks, then every 6 months) or mycophenolate mofetil (starting at 500mg twice daily, increasing to 1000-1500mg twice daily as tolerated) for long-term management. This approach balances the need to treat potential infection while not compromising immune response to a possible MOGAD relapse, as these patients often require prolonged immunosuppression to prevent further relapses. It's also important to note that combination therapy with certain antibiotics and antivirals, such as ceftriaxone and acyclovir, may have an underestimated nephrotoxic potential 3, and therefore, monitoring of serum creatinine is crucial. Additionally, the use of fluoroquinolones, such as ciprofloxacin, may be effective for urinary tract infections, especially in areas with high resistance to other antimicrobials 4. Key considerations in managing this patient include:

• Urgent neuroimaging and lumbar puncture to rule out infection and MOGAD relapse
• Empiric broad-spectrum antibiotics, with consideration of alternatives to ceftriaxone for urinary tract infections
• Maintenance of current prednisolone dose until infection is ruled out
• Increase in prednisolone dose if neuroimaging indicates new demyelinating lesions and infection is excluded
• Urinary catheter insertion and urological consultation for urinary retention
• Transition to steroid-sparing immunosuppression for long-term management.