High-dose methotrexate with leucovorin rescue: For monumentally severe CNS inflammatory syndromes

Background At sufficiently high doses, methotrexate (HDMTX) achieves substantial CNS penetration, whereas other tissues can be rescued from the effects of HDMTX by leucovorin rescue (LR), which does not penetrate the blood-brain barrier. Objectives To report on the efficacy and safety of HDMTX with LR (HDMTX-LR), in the treatment of acute demyelinating inflammatory CNS syndromes refractory to conventional immunotherapy. Methods We performed a retrospective chart review of 12 patients treated (6 multiple sclerosis [MS], 4 neuromyelitis optica [NMO], and 2 Sjogren's syndrome myelopathy [SSM]) with HDMTX-LR after failing to improve, or exhibiting worsening following conventional immunotherapy. 11 patients were followed for a total of 6 months following HDMTX-LR (one was lost to follow up after 1 month); and clinical findings were documented at 1 month, 3 months, and 6 months following HDMTX-LR therapy. Results Ten patients demonstrated both clinical and radiologic evidence of near, if not complete, abolishment of disease activity, in conjunction with impressive reconstitution of neurologic function in the 6-month period following HDMTX-LR. Mean Kurtzke Expanded Disability Status Scale (EDSS) prior to HDMTX-LR was 8.1 (± 1.4). Following HDMTX-LR, mean EDSS was 6.6 (± 2.4) at 1 month, 5.8 (± 2.3) at 3 months, and 5.7 (± 2.3) at 6 months. Conclusions In this retrospective assessment of treatment-recalcitrant fulminant inflammatory CNS syndromes, HDMTX-LR was observed to be a safe and highly effective treatment, producing the rapid and near complete cessation of disease activity, in conjunction with an important corresponding and ‘durable remission’ in the majority of our small treatment cohort.