Should we consider another prednisone burst for my child's OCD and intrusive thoughts due to PANS/PANDAS?

Prednisone Treatment for PANS/PANDAS in a Child with Recurring Symptoms

A third prednisone burst is appropriate for your child with PANS/PANDAS, as corticosteroids have been shown to shorten flare durations and improve symptoms more quickly when given early in disease flares. 1

Evidence for Corticosteroid Use in PANS/PANDAS

Corticosteroids appear to be one of the most effective treatments for PANS/PANDAS flares. A study by Brown et al. found that patients experienced significantly shorter flares when treated with oral corticosteroids (6.4 ± 5.0 weeks) compared to when not treated (11.4 ± 8.6 weeks) (p < 0.001) 1. This benefit remained significant even after controlling for multiple variables including age, antibiotic treatment, and psychiatric medications.

Key findings supporting corticosteroid use:

• Earlier use of corticosteroids was associated with shorter flare durations (p < 0.001) 1
• Longer courses of corticosteroids were associated with more enduring improvement (p = 0.014) 1
• Parents rate inflammation/infection mitigation interventions (including corticosteroids) as among the most appropriate treatments for PANS/PANDAS 2

Treatment Recommendations

Prednisone Dosing

• Recommended dose: 1-2 mg/kg/day (maximum 60 mg/day) 3
• Duration: Consider a 5-day burst similar to your previous effective treatment, with the option to extend to a longer course (1-2 weeks with taper) if symptoms are severe 1
• Administration: Give as a single morning dose to minimize hypothalamic-pituitary-adrenal axis suppression 3

Important Considerations

1. Timing is critical: Since your child showed improvement with previous prednisone bursts, administering the treatment early in this flare may lead to faster resolution 1
2. Spacing of treatments: The timing of your child's treatments (September 2024, July 2025, September 2025) provides adequate spacing between courses
3. Combination therapy: Continue the current course of cefdinir as antibiotics are also considered appropriate treatment for PANS/PANDAS 2, 4

Monitoring and Follow-up

During and after prednisone treatment:

• Monitor for common side effects: increased appetite, mood changes, sleep disturbances
• Watch for signs of infection as corticosteroids can mask infection symptoms 5
• Consider tapering the dose rather than abrupt discontinuation to prevent rebound symptoms 5
• Evaluate the need for longer-term anti-inflammatory treatment if flares continue to recur

Alternative and Adjunctive Treatments

If prednisone bursts become less effective or side effects become problematic:

• NSAIDs: Continue naproxen (Aleve) if helpful, as NSAIDs are rated favorably by parents of children with PANS/PANDAS 2, 4
• Antibiotics: Complete the full course of cefdinir as antibiotics are considered one of the most appropriate treatments 2, 4
• Consider IVIG: For refractory cases, intravenous immunoglobulin has been rated as effective by patients 4
• Family counseling: Rated as appropriate by parents and can help manage the psychological impact 2

Potential Pitfalls and Caveats

• Avoid frequent, repeated short bursts: While effective in the short term, repeated courses without addressing underlying triggers may lead to steroid dependency
• Don't ignore psychological support: While focusing on medical treatment, ensure appropriate psychological support continues
• Be aware of long-term steroid risks: If frequent courses become necessary, consider steroid-sparing agents 6
• Don't expect immediate complete resolution: While prednisone can provide significant improvement, some symptoms may persist and require ongoing management

Given your child's positive response to previous prednisone treatment and the timing between courses, a third burst is reasonable to help manage this flare of PANS/PANDAS symptoms.