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Combination Versus Monotherapy in Acute Anti-LGI1 Encephalitis: A Real-World Dose Optimization Analysis.

Yao Tan1, Ming Sun2,3,4,5, Qinqin Liu6

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Summary

For anti-leucine-rich-glioma-inactivated 1 encephalitis (LGI1e), combined immunotherapy with intravenous immunoglobulin (IVIg) and intravenous methylprednisolone (IVMP) is more effective than monotherapy. A 500 mg IVMP dose is optimal, balancing efficacy and safety, with ongoing cognitive impairment management crucial.

Keywords:
anti‐LGI1 encephalitisefficacyimmunoglobulinmethylprednisolonesafety

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Area of Science:

  • Neuroimmunology
  • Clinical Neurology
  • Pharmacology

Background:

  • Anti-leucine-rich-glioma-inactivated 1 encephalitis (LGI1e) primarily affects older adults with comorbidities, necessitating optimized immunotherapy.
  • This population is at higher risk for adverse effects from standard treatments.

Purpose of the Study:

  • To compare the efficacy and safety of intravenous immunoglobulin (IVIg), intravenous methylprednisolone (IVMP) at 500 or 1000 mg/day, and combined IVIg with IVMP for LGI1e.
  • To define an optimal immunotherapy regimen balancing efficacy and safety for LGI1e patients.

Main Methods:

  • A cohort of 131 LGI1e patients was analyzed.
  • Efficacy was assessed via response rate, latency, and improvements in CASE, mRS, MMSE, and FBDS.
  • Safety was evaluated by incidence and severity of adverse events (AEs).

Main Results:

  • Combination IVIg+IVMP showed superior response rates, shorter latency, and greater improvements in CASE, mRS, and FBDS compared to monotherapy.
  • 1000 mg IVMP reduced latency and FBDS cessation time versus 500 mg, but response rates were similar.
  • IVMP-containing regimens increased AEs, particularly at 1000 mg; diabetes was the sole independent AE risk factor. Cognitive impairment persisted as a major disability.

Conclusions:

  • Combined IVIg and corticosteroid therapy is more effective than monotherapy for LGI1e.
  • A starting IVMP dose of 500 mg is considered optimal for balancing efficacy and safety.
  • Post-immunotherapy cognitive impairment requires sustained management, necessitating further validation in randomized trials.