Experts revise PANS/PANDAS treatment guidelines

A panel of clinicians and researchers recently published revised treatment recommendations for management of Pediatric Acute Onset Neuropsychiatric Syndrome and Pediatric Autoimmune Neuropsychiatric Syndrome Associated with Streptococcal Infection.

“Directly controlling or minimizing symptoms of [Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS)/Pediatric Autoimmune Neuropsychiatric Syndrome Associated with Streptococcal Infection (PANDAS)] is essential to decrease suffering, increase the child’s ability to receive other important treatments, and overall recovery. As is true in treatment of delirium, the instigating processes (which include infections and inflammatory diseases) and symptoms of PANS/PANDAS must be addressed simultaneously,” Margo Thienemann, MD, of Stanford University, and colleagues wrote. “Early research in other types of brain injury, including concussion, stroke, and multiple sclerosis, suggest that neural plasticity depends on use and that early rehabilitation has better outcome, supporting the prompt initiation of psychotherapy.”

The guidelines are categorized into three parts.

Part I addresses psychiatric and behavioral interventions for children with PANS/PANDAS.

Guidance included:

Individualizing treatment;
Considering safety, including use of a comprehensive diagnostic evaluation and school accommodations, such as excusing absences or being aware of urinary urgency/frequency and other illness flares;
Providing support and education to families;
Cognitive behavior therapy, specifically exposure/response prevention and minimizing family accommodation for OCD behaviors;
Psychoactive medications for management of PANS/PANDAS symptoms; and
Various recommendations regarding OCD, restricted food or fluid intake, tics, irritability and aggression, anxiety, ADHD symptoms, sleep problems, depression, psychosis, and pain.

Part II addresses the use of immunomodulatory therapies for PANS/PANDAS.

The researchers recommended:

For mildly impairing PANS, “tincture of time” combined with CBT and other supportive therapies, nonsteroidal anti-inflammatory drugs or short oral corticosteroid bursts if symptoms persist;
Oral or IV corticosteroids for moderate-to-severe PANS, however; IV immunoglobulin is often patient’s preferred treatment;
Prolonged corticosteroid courses with taper or repeated high-dose corticosteroids for severe or chronic PANS; and
For PANS with extreme and life-threatening impairment, therapeutic plasma exchange as first-line therapy alone or in combination with IV immunoglobulin, high-dose IV corticosteroids, or rituximab.

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Part III addresses treatment and prevention of infections in PANS/PANDAS.

Guidelines included:

An initial course of anti-streptococcal treatment for children newly diagnosed with PANS;
Chronic secondary antimicrobial prophylaxis for children with PANDAS with severe neuropsychiatric symptoms or recurrent group A Streptococcus-associated exacerbations;
Vigilance for streptococcal pharyngitis or dermatitis in children with non-streptococcal PANS and close contacts;
Closely monitor all children with PANS or PANDAS for other intercurrent infections, such as sinusitis and influenza; and more.

“Until further research informs clinicians about effective treatments for behavioral and psychiatric interventions for children with PANS and Pediatric Autoimmune Neuropsychiatric Syndrome Associated with Streptococcal Infection (PANDAS), current literature and clinical experience must guide clinicians treating these children,” Thienemann and colleagues wrote. “This article fills the gap between empiric therapy and current knowledge by conveying consensus guidelines for symptomatic treatment of children with PANS and PANDAS.” – by Amanda Oldt

Disclosure: Please see the studies for a full list of relevant financial disclosures.

Reference:

Cooperstock M, et al. J Child Adolesc Psychopharmacol. 2017;doi:10.1089/cap.2016.0151.

Frankovich J, et al. J Child Adolesc Psychopharmacol. 2017;doi:10.1089/cap.2016.0148.

Thienemann M, et al. J Child Adolesc Psychopharmacol. 2017;doi:10.1089/cap.2016.0145.