Anti-NMDA Receptor Encephalitis Clinical Pathway — Inpatient

Prophylactic Medication Dosing

All dosing is enteral unless otherwise stated.

Minimum titration interval based on tertiary recommendations and/or drug half-life. If in intensive care unit can consider faster titration interval based on the half-life of drug in discussion with clinical pharmacy and/or the rehab service.

Benzodiazepines and opioids are not agents of choice for long term management (i.e. prophylactic management), but may be used on a case-by-case basis given response in coordination with primary team, clinical pharmacy, and rehabilitation medicine.

Alpha² Adrenergic Agonist

Pediatric doses should not exceed adult dosing recommendations.

Medication	Age	Initial Dose	Titration Dose	Titration Interval	Side Effects and Considerations
Clonidine	Pediatric	0.005-0.01 mg/kg/DAY divided every 6-12 hrs	0.001-0.002 mg/kg/DOSE	3 days	Hypotension Bradycardia Sedation
Clonidine	Adult	0.1-0.2 mg/DAY divided every 8-12 hrs	0.1 mg/DAY	3 days	Hypotension Bradycardia Sedation
Dexmedetomidine ICU Only	Pediatric	0.2-0.5 mcg/kg/hr IV continuous	0.2 mcg/kg/hr	6 hrs	Bradycardia Hypertension Hypotension Nausea/vomiting
Dexmedetomidine ICU Only	Adult	0.2-0.5 mcg/kg/hr IV continuous	0.2 mcg/kg/hr	6 hrs	Bradycardia Hypertension Hypotension Nausea/vomiting

Beta-blocker (Non-selective)

Pediatric doses should not exceed adult dosing recommendations.

Medication	Age	Initial Dose	Titration Dose	Titration Interval	Side Effects and Considerations
Propranolol	Pediatric	0.5-1 mg/kg/DAY divided every 6-8 hours	0.5-1 mg/kg/DAY	7 days	Fatigue Dizziness Bronchospasm Bradycardia Hypotension Hypoglycemia
Propranolol	Adult	10 mg every 6-8 hours	10 mg/DOSE	7 days

Dopamine Agonists

Pediatric doses should not exceed adult dosing recommendations.

Medication	Age	Initial Dose	Titration Dose	Titration Interval	Side Effects and Considerations
Bromocriptine	Pediatric	1.25-2.5mg/DAY divided 1-2 times	1.25 mg/DAY	2 days	Diarrhea Irritability Dyskinesia Headache Fatigue
Bromocriptine	Adult	1.25-2.5mg/DAY divided 1-2 times	2.5 mg/DAY	2 days	Diarrhea Irritability Dyskinesia Headache Fatigue

GABA Agonists and Analogues

Pediatric doses should not exceed adult dosing recommendations.

Medication	Age	Initial Dose	Titration Dose	Titration Interval	Side Effects and Considerations
Baclofen	Pediatric	2.5-15 mg/DAY divided every 6-8 hrs	5-15 mg/DAY	3 days	Hypotension Constipation Vomiting Asthenia Dizziness Somnolence
Baclofen	Adult	5 mg every 8 hrs	5-15 mg/DAY	3 days
Gabapentin	Pediatric	5-15 mg/kg/DAY divided 1-3 times daily	5-10 mg/kg/DAY	3 days	Nausea Peripheral edema Fatigue Dizziness
Gabapentin	Adult	300-900 mg/DAY divided 1-3 times daily	300 mg/DAY	3 days	Nausea Peripheral edema Fatigue Dizziness

Ryanodine Receptor Antagonist

Pediatric doses should not exceed adult dosing recommendations.

Medication	Age	Initial Dose	Titration Dose	Titration Interval	Side Effects and Considerations
Dantrolene	Pediatric ≤ 50 kg	0.5 mg/kg/dose once daily	0.5 mg/kg/dose three times daily followed by 1 mg/kg/dose three times daily followed by 2 mg/kg/dose three times daily	7 days	Sedation Weakness Hepatotoxicity Respiratory depression
Dantrolene	Adult > 50 kg	25 mg once daily	50 mg three times daily followed by 100 mg three times daily	7 days	Sedation Weakness Hepatotoxicity Respiratory depression

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.