Multisystem Inflammatory Syndrome (MIS-C) Clinical Pathway — Emergency, ICU and Inpatient

Steroids

Treatment to be determined by primary team and subspecialty consultants (e.g., infectious diseases/rheumatology). Consults
These discussions will be expedited in the setting of critical illness
Monitor Clinical Response
- Resolution of fever, other clinical features and improving markers of inflammation
Lack of clinical response: Further recommendations surrounding immunomodulation in discussion with Rheumatology and DIRT
- Ongoing Laboratory Monitoring

Steroids should be considered in addition to IVIG for patients with MIS-C with shock, given their illness severity.

Dose and Adverse Effects
Dose	Initial Treatment IV methylprednisolone 1 mg/kg/dose BID (max 30 mg BID) x 5 days, then taper as below OR Oral prednisolone/prednisone 1 mg/kg/dose BID (max 30 mg BID) x 5 days, then taper as below Can transition from IV methylprednisolone to PO prednisolone/prednisone when clinically stable and able to tolerate PO Suggested Taper (review with rheumatology for each individual patient): After the initial 5 days outlined above, taper steroids as follows: Oral prednisolone/prednisone 0.5 mg/kg/dose BID x 5 days (max 15 mg BID) Then oral prednisolone/prednisone 0.5 mg/kg/dose daily x 5 days (max 15 mg daily) Then off The total steroid course is typically 15 days Consider a longer taper in patients with prolonged illness
Adverse Effects	Gastritis/Abdominal pain (consider famotidine while on steroids) Hypertension Bradycardia Behavioral irritability, insomnia, hallucinations (consider morning dosing or re-timing medication to give earlier in day)

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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