Long-term immunosuppressive therapy is suitable for patients with NMOSD

Long-term immunosuppression in patients with neuromyelitis optica spectrum disorder (NMOSD) is generally appropriate, although those with extensive transverse myelitis appear more likely to relapse after discontinuation, study results show in the European Journal of Neurology.1

Altogether, study investigator Wei Qiu, MD, PhD, Vice Chief of Department of Neurology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China, and colleagues reported that among In a cohort of 343 people, the duration of immunosuppression treatment showed strong associations with a reduced risk of relapse (HR, 0.53; P <.001 additionally continued use of immunosuppressive therapy resulted in decreased rrs relapse within years treatment with a rebound beginning after years.>

After discontinuation of immunosuppressive therapy, the relapse rate was 77.5% in this single-center evaluation. Longitudinal extensive transverse myelitis was associated with a higher risk of relapse after discontinuation, which was significant (HR, 2.023; P = 0.006).

Qiu et al wrote that “future studies should explore individualized rituximab maintenance treatment strategies” because treatment with rituximab (Rituxan; Genentech/Biogen) reduced the risk of NMOSD relapse to almost zero within 3 years. , which contrasts with other immunosuppressive treatments. Currently, the treatment is used off-label in the United States to treat NMOSD, but has been shown in a variety of data sets to improve relapse rates among this patient population.2.3

READ MORE: Features of Bilateral Parafalcian Cortical Leptomeningeal Deficiency in NMOSD, MOGAD Identified to Avoid Misdiagnosis

“Relapse prevention with immunosuppressants is critical for the prognosis of neuromyelitis optica spectrum disorder (NMOSD); however, the optimal duration of IS treatment is still under discussion. The aim was to explore the optimal duration of IS treatment and the risk of IS discontinuation for NMOSD,” wrote Qiu et al. The group conducted their study at the Third Affiliated Hospital of Sun Yat-sen University, which they said housed the largest NMOSD database in southern China. Patients included were those with NMOSD who were on immunosuppression therapy, with a primary outcome of changes in risk of relapse based on duration of therapy, as well as clinical outcomes and predictors of relapse after discontinuation.

A similar study by Su-Hyun Kim, MD, et al, published in Neurology in 2021, suggested parallel results. The retrospective review indicated that discontinuation of immunosuppressive therapy led to an increased risk of relapse in HIV-positive patients with NMOSD despite long relapse-free periods. In this study, Kim et al noted that people with a history of a severe attack before immunosuppression should be cautious because of the risk of irreversible disability even from a single attack.4

Kim et al reported that immunosuppression was discontinued after a median relapse-free period of 62 months (interquartile range [IQR], 48-73), with the most common reasons for discontinuation being the patient’s decision (n = 8; 47%) and provider advice (n = 8; 47%). Preparing for pregnancy (n = 1; 6%) was also among the reasons given. No significant safety issues were identified among the 17 patients included in the review, all of whom had been relapse-free for at least 3 years.

After discontinuation of immunosuppressive therapy, 14 patients (82%) relapsed at a median interval of 6 months (IQR, 4-34). The median interval was 4 months (IQR, 3-18) for patients (n=12) who discontinued azathioprine (Imuran; Prometheus Laboratories) or mycophenolate mofetil (CellCept; Genentech). Among the 2 patients who discontinued ritixumab, the median interval to relapse was 54 and 85 months, respectively.4

1. Li R, Li C, Huang Q, et al. Immunosuppressants and neuromyelitis optica spectrum disorder: optimal duration of treatment and risk of discontinuation. Eur J Neurol. 2022;29(9):2792-2800. doi:10.1111/ene.15425
2. Kim SH, Huh SY, Lee SJ, et al. A 5-year follow-up of rituximab treatment in patients with neuromyelitis optica spectrum disorder. JAMA Neurol. 2013;70(9):1110-1117. doi:10.1001/jamaneurol.2013.3071
3. Etemadifar M, Salari M, Mirmosayyeb O, Serati M, Nikkhah R, Askari M, Fayyazi E. Efficacy and safety of rituximab in neuromyelitis optica: review of the evidence. J Res Med Sci. 2017;22:18. doi:10.4103/1735-1995.200275
4. Kim S, Jang H, Park NY, et al. Discontinuation of immunosuppressive therapy in patients with neuromyelitis optica spectrum disorder with aquaporin-4 antibodies. Neurology. 2021;8(2). doi:10.1212/NXI.0000000000000947

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