What is the recommended dose of methylprednisolone (corticosteroid) for the treatment of autoimmune encephalitis?

Methylprednisolone Dosing in Autoimmune Encephalitis

For the treatment of autoimmune encephalitis, methylprednisolone should be administered at a dose of 1 g IV daily for 3-5 days, followed by an oral corticosteroid taper. 1

Initial Treatment Approach

Mild to Moderate Autoimmune Encephalitis

• Initial treatment with methylprednisolone 1-2 mg/kg/day IV 1
• If symptoms are progressing or not improving, escalate to pulse dose therapy 1

Severe or Progressive Autoimmune Encephalitis

• Administer pulse dose methylprednisolone 1 g IV daily for 3-5 days 1
• This high-dose regimen is particularly indicated when:
  • Symptoms are severe or rapidly progressing 1
  • Oligoclonal bands are present in CSF 1
  • Patient has not responded to initial lower-dose steroid therapy 1

Adjunctive Therapies

• Consider adding intravenous immunoglobulin (IVIG) 2 g/kg divided over 5 days in severe cases 1
• For refractory cases or those with confirmed autoimmune encephalopathy antibodies, consider:
  • Rituximab or plasmapheresis in consultation with neurology 1
  • This is particularly important when there is limited or no improvement with initial therapies 1

Special Considerations

Transverse Myelitis Variant

• For autoimmune encephalitis with transverse myelitis features, consider:
  • Higher initial methylprednisolone dose of 2 mg/kg 1
  • Consider escalating to 1 g/day for 3-5 days 1
  • IVIG should be strongly considered as an adjunctive therapy 1

Post-Treatment Management

• Following high-dose IV methylprednisolone, transition to oral corticosteroid taper 1
• Typical taper duration is 4-6 weeks 2
• Monitor closely for symptom recurrence during taper 1

Administration Considerations

• High-dose methylprednisolone (>0.5 g) should be administered over at least 30 minutes to avoid cardiac arrhythmias 3
• For severe cases requiring repeated dosing, administration may be repeated every 4-6 hours for up to 48-72 hours 3

Monitoring and Follow-up

• Neurologic consultation should be obtained for all cases of autoimmune encephalitis 1
• Regular clinical assessment for treatment response is essential 1
• Be vigilant for relapse, particularly when tapering corticosteroids 1, 4

Pitfalls and Caveats

• Exclude infectious causes (particularly viral) before initiating high-dose corticosteroids 1
• Consider empiric antiviral therapy (IV acyclovir) until CSF results are available 1
• Rapid administration of high-dose methylprednisolone (>0.5 g over <10 minutes) has been associated with cardiac arrhythmias 3
• Prolonged corticosteroid therapy (≥3 months) without maintenance immunotherapy may be sufficient for some forms of autoimmune encephalitis (e.g., anti-LGI1), but this approach requires careful monitoring 4