While all patients are treated as individuals and each case is different, the following are possible treatments that patients may encounter in the management of acute TM.
Although there are no clinical trials that support a unique approach to treat patients experiencing TM, it is well recognized as a standard of care that patients suspected to have acute myelitis receive high-dose intravenous methyl-prednisolone for 3-5 days, unless there are compelling reasons not to. The decision to offer continued steroids or add a new treatment is often based on the clinical course and MRI appearance at the end of 5 days of steroids.
Plasma Exchange (PLEX):
This is often used for those patients with moderate to aggressive forms of TM who don’t show much improvement after being treated with intravenous and oral steroids. Again, there has not been a clinical trial that proves PLEX effectiveness in TM but retrospective studies of patients with TM treated with IV steroids followed by PLEX showed a beneficial outcome. PLEX also has been shown to be effective in some patients with other autoimmune or inflammatory central nervous system disorders. Patients particularly benefit from early treatment, and will typically be started on PLEX within days of starting steroids. Particular benefit has been shown if started within the acute or subacute stage of the myelitis or in those patients who exhibit active inflammation on MRI. However, because of the risks implied by this procedure this intervention is determined by the treating physician on a case-by-case basis.
Other treatments for transverse myelitis:
For those patients who do not respond to either steroids or PLEX who continue to exhibit active inflammation in the spinal cord, other forms of immune-based interventions may be required. The use of immunosupressants or immunomodulatory agents may be required. One of those approaches may include the use of intravenous cyclophosphamide (a chemotherapy drug often used for lymphomas or leukemia). Patients who initially presented with aggressive forms of myelitis or those that are particularly refractory to treatment with steroids and/or PLEX may benefit from aggressive immunosupression with cyclophosphamide. It is very important that an experienced oncology team be involved in the administration of this drug, and patients should be monitored carefully as potential complications may arise from immunosuppression. As with all medications, risks versus benefits of aggressive immunosuppression need to be considered and discussed with your doctor.
The use of other immune-based therapies such as B-cell modulators, anti-TNFα inhibitors or IV immunoglobulins (IVIG) have not been tested and their use in the management of acute or subacute TM is not supported.
Transverse myelitis may be idiopathic in nature, such that a definite cause is not identified. In these cases, it is rare for patients to have a recurrence. For others, TM may be a manifestation of another disorder, such as neuromyelitis optica, multiple sclerosis, sarcoidosis, lupus, to name a few. In these cases, ongoing treatment with medications that modulate or suppress your immune system may be necessary. Either way, aggressive rehabilitation and long-term symptom management are an integral part of the healthcare plan.
Learn more about long-term care for transverse myelitis and further information about rehabilitative care and other ways to increase comfort.