›Divided daily infusions to reduce adverse effects
›Indications
›Alternative second-line when PLEX not feasible
›Preferred in pediatric patients or those with poor venous access
›Particularly useful when infectious etiology cannot be fully excluded (safer than PLEX in some cases)
›Monitoring
›Renal function before and during infusion
›Headache and aseptic meningitis risk
›Cyclophosphamide
›Reserved for SLE-associated TM or refractory cases
›750 to 1000 mg/m2 IV as pulse therapy
›Requires hematology or rheumatology co-management
›Bladder protection with adequate hydration and mesna
Long-term disease-modifying therapy
›NMOSD (AQP4-IgG positive)
›Rituximab
›Anti-CD20 B cell depletion
›375 mg/m2 weekly for 4 doses or 1000 mg twice 2 weeks apart
›Eculizumab (complement C5 inhibitor)
›900 mg IV weekly for 4 doses then 1200 mg every 2 weeks
›Requires meningococcal vaccination before initiation
›Satralizumab or inebilizumab
›IL-6 receptor antagonist or anti-CD19 options per specialist guidance
›MS-associated myelitis
›Disease-modifying therapies per MS guidelines
›High-efficacy therapy preferred for relapsing-remitting MS with severe relapse
›Neurologist-directed selection
›Idiopathic TM
›Observation with close follow-up; no established long-term immunotherapy
›Risk of relapse approximately 34% over follow-up; relapse rate 5.9% per year
›Repeat antibody testing at 3 to 6 months if initially negative
›Neuropathic pain
›Gabapentin
›Start 300 mg PO at night, titrate to 900-3600 mg per day in 3 divided doses
›Renal dose adjustment required
›Pregabalin
›Start 75 mg PO twice daily, titrate to 150-600 mg per day
›Faster titration than gabapentin
›Tricyclic antidepressants (amitriptyline) for mixed neuropathic/spasticity pain
›Start 10-25 mg PO at night
›Anticholinergic effects may worsen bladder retention
›Spasticity
›Baclofen PO
›Start 5 mg three times daily, titrate by 5 mg every 3 days
›Maximum 80 mg per day
›Abrupt discontinuation risk of withdrawal seizures
›Tizanidine PO
›Start 2 mg at night, titrate to 8 mg three times daily
›Hepatotoxicity monitoring with LFTs
›Bladder dysfunction
›Intermittent self-catheterization
›Preferred long-term management over indwelling catheter
›Reduces UTI risk
›Anticholinergic agents for overactive bladder (if retention excluded)
›Oxybutynin 5 mg PO twice to three times daily
›Tolterodine 2 mg PO twice daily
›Indwelling Foley catheter for acute urinary retention
›Bridge until intermittent catheterization training feasible
›Deep vein thrombosis prophylaxis
›Low molecular weight heparin (enoxaparin)
›40 mg SC daily for non-ambulatory patients
›Initiate after hemorrhagic cord lesion excluded
›Sequential compression devices
›Applied to both legs while non-ambulatory
›Early physical and occupational therapy consultation
›Mobility and transfer training
›Wheelchair assessment if ambulation impaired
›Fall prevention strategies
›Upper extremity function for cervical cord lesions
›Bowel regimen
›Scheduled toileting program
›High-fiber diet and adequate hydration
›Stool softeners (docusate sodium 100-200 mg PO daily)
›Glycerin or bisacodyl suppository for bowel initiation
›Psychological support
›Depression and anxiety common in TM
›Screening with validated tool (PHQ-9)
›Referral to neuropsychology or psychiatry if indicated