Treatment for Subsequent Episodes
Treatment for recurrences of PANDAS involves targeting what Dr. Swedo calls the three S’s: “the symptoms, the source, and the system.”
- The treatment for the symptoms — OCD and other forms of severe anxiety — is cognitive behavioral therapy (specifically, exposure and response prevention) and anti-depressant (also called anti-obsessional) medication, a selective serotonin reuptake inhibitor or SSRI. These treatments have been shown to be effective in reducing the symptoms, but they do not target the source of the problem.
- The treatment for the source — the infection — is another course of antibiotics.
- The system refers to the immune system, which is attacking the brain and generating these neuropsychiatric symptoms. The first-line treatment for the misfiring immune system is with IVIG, or intravenous immunoglobulin. IVIG is made from healthy blood plasma and is thought to balance the immune system. IVIG is recommended only for severe cases in which repeated courses of antibiotics combined with CBT and SSRIs were not successful in stopping the flare-up of symptoms.
- If IVIG, in turn, is not successful, children are treated with plasmapheresis (the removal, filtering and return of blood plasma). A review of 40 patients treated with plasmapheresis, published last year, showed an average improvement of 65% at 6 months following treatment, and 78% at longer-term follow-up.
Dr. Swedo notes that these three targets for treatment — symptoms, source, and system — are exactly the same if you were treating a child with asthmatic childhood pneumonia. “You treat the source — this is the pneumonia part — with antibiotics. You treat the symptoms with cough syrup – you don’t ask the child to cough for the next month, until the pneumonia resolves. And you treat the immune system with the inhaled steroid, the Singulair, and all the rest.”