Anti-NMDA Receptor Encephalitis — Pharmacological Management of Behavior/Agitation — Clinical Pathway: Inpatient

Anti-NMDA Receptor Encephalitis Clinical Pathway — Inpatient

Pharmacological Management of Behavior/Agitation

Given antipsychotic medications can worsen the course of Anti-NMDARE, they should only be considered after consultation with Psychiatry and interdisciplinary treatment team members.

If no response within 1-2 days, consider another regimen.

Pediatric doses should not exceed adult dosing recommendations (initial or maximum). Please contact pharmacy with questions or concerns.

First Line — Benzodiazepines

Medication Age Initial Dose Side Effects and Considerations
Lorazepam
PO/IM/IV		 Pediatric 0.5-2 mg q4-6 hrs
Max 4 mg daily
  • If catatonia or unclear case of psychosis/aggression, then benzodiazepines are considered strongly.
  • If higher doses considered, discuss with Psychiatry.
  • May need to discontinue antipsychotics.
Adult 0.5-2 mg
Max 6-8 mg daily

Second Line — Alpha2-Adrenergic Agonist

Medication Weight Initial Dose Side Effects and Considerations
Clonidine
(Immediate release)
≥ 4 yrs
PO		 ≤ 20 kg 0.05-0.1 mg
Max 0.2 mg daily
  • Sedation
  • Hypotension
  • Bradycardia
20-45 kg 0.05-0.1 mg
Max 0.3 mg daily
> 45 0.05-0.1 mg
Max 0.4 mg daily

If Sleep Difficulties

Medication Age Initial Dose Side Effects and Considerations
Melatonin
PO		 2-5 yrs 0.75-3 mg at bedtime
Max 3 mg
  • Daytime drowsiness
  • Headache
  • Dizziness
  • Precautions for Use
    • Liver disease
    • History of seizures
    • Depression
≥ 6 yrs 0.75-6 mg at bedtime
Max 6 mg

If no response within 1-2 days, consider another regimen.