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Review of approved NMO therapies based on mechanism of action, efficacy and long-term effects. Mult Scler Relat Disord 2020 Nov;46:102538

Date

10/16/2020

Pubmed ID

33059216

Pubmed Central ID

PMC7539063

DOI

10.1016/j.msard.2020.102538

Scopus ID

2-s2.0-85092416377   8 Citations

Abstract

IMPORTANCE: Neuromyelitis optica (NMO - including NMO spectrum disorders [NMOSD]) is a devastating disease. Eighty-three percent of patients with transverse myelitic (TM) attacks and 67% of patients with optic neuritis (ON) attacks have no or a partial recovery.

OBSERVATIONS: Up until recently, there was no proven agent to treat to prevent relapses. The neuro-immunological community had a dearth of indicated agents for NMOSD. We now have three agents indicated for the treatment of NMO including (eculizumab [SolirisA?]), an anti-C5 complement inhibitor, satralizumab (ENSRYNGA?), a monoclonal antibody against the IL-6 receptor (IL-6R) that blocks B cell antibody production and inebilizumab (UplinzaA?), a monoclonal antibody that binds to the B-cell surface antigen CD19 with subsequent B and plasmablast cell lymphocytolysis with decreasing antibody production. Autologous hematopoietic stem cell bone marrow transplantation (AHSCBMT) has also been used. How do we sequence NMO therapies with the understanding of the acuteness and severity of the disease, the individual mechanism of action (MOA) and rapidity of onset of action, onset of efficacy and long-term safety of each agent?

CONCLUSIONS AND RELEVANCE: We might suggest the following sequence - 1st line using eculizumab for rapid efficacy and stabilization without effect on the acquired immune system followed by satrilizumab (long term immunomodulation). Reserve inebilizumab (immunosuppressant) for breakthrough disease and salvage the severe with AHSCBMT. In NMO, control the complement, transition to modulation, and reserve suppression - and salvage the severe with AHSCBMT.

Author List

Brod SA

Author

Staley A. Brod MD Professor in the Neurology department at Medical College of Wisconsin




MESH terms used to index this publication - Major topics in bold

Antibodies, Monoclonal, Humanized
Aquaporin 4
Humans
Neoplasm Recurrence, Local
Neuromyelitis Optica
Optic Neuritis