OTHER TREATMENT OPTIONS
Clinicians and parents have reported improvement of patients’ symptoms with non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen. The medications appear to be particularly useful for exacerbations (or “mini-flares”) which occur in the weeks following immunotherapy. Assuming that the PANS and PANDAS condition is the result of an immune system disorder, reducing inflammation would have a beneficial effect for patients. Follow dosing level provided by the manufacturer’s label. The cyclo-oxygenase inhibitor, celecoxib, is another NSAID that has been reported to be helpful. Mechanisms of action are unknown. All the NSAIDS carry risks of GI bleeding and other side effects, so they should be used with caution, following manufacturers’ guidelines for dosage and duration of therapy.
Case reports to PPN include PANDAS and PANS children who have symptom exacerbations related to Candida albicans (yeast) infections. Even if the child takes probiotics, children on antibiotic therapy or prophylaxis are susceptible to candida overgrowth. Most physicians do not think to check for candida albicans in the oral cavity or other mucosal surfaces (vagina, rectum and urethra). Examining patients for yeast infections is imperative for all children whose PANS symptoms exacerbate during antibiotic treatment or prophylaxis, as well as for those with urinary frequency or other UTI-related symptoms. In young women, they are typically not yet at the age of gynecologic exams, and pediatricians rarely include yeast as a possible issue, even when urinary frequency or other urinary issues are present. If yeast is present, azole antifungals such as fluconazole (Diflucan) or nystatin may help alleviate the PANDAS exacerbation.
Antihistamines (H1 and H2 Blockers):
Antihistamines block effects of histamine and include H1 and H2 blockers. The H1 blockers include diphenhydramine, fexofenadine, loratadine, cetirizine and others; H2 blockers include cimetidine, ranitidine and nizatidine, among others. These drugs have a variety of anti-inflammatory and immunomodulatory activities. In addition to their immunologic properties, the H1 blockers (such as diphenhydramine or Benadryl) are “soporific” drugs which produce sleepiness; this side effect can be useful for PANDAS children with initial insomnia. However, paradoxical behavioral adverse events can occur with antihistamines, and instead of getting sleepy, the children become agitated, “wild” or out-of-control. These idiosyncratic reactions cannot be predicted, so initial doses of antihistamines should be administered with close parental supervision.