Escalation therapy for neuromyelitis attacks improves remission rates

By Lucy Piper, Senior medwireNews Reporter

Researchers recommend escalating patients’ therapy in the event of continuing attacks of neuromyelitis optica (NMO), basing sequential treatment on the type of attack and prior treatment response.

Among 185 patients who experienced a total of 871 NMO attacks, the complete response rate after a first course of treatment, most frequently high-dose intravenous steroids, was just 19.1% with 16.4% of patients failing to respond.

But with each escalation of treatment, remission rates improved and the proportion of non-responders decreased significantly, so that by the last treatment course, up to five in some cases, the rates were 21.6% and 6.0%, respectively.

“Therapy escalation was clearly effective, particularly in decreasing the proportion of non-responders”, the researchers report in the Annals of Neurology.

“Escalation of therapy is therefore strongly recommended when first or second treatment courses of NMO attacks do not induce satisfactory recovery.”

Lead researcher Ingo Kleiter (Ruhr University Bochum, Germany) and colleagues note that the greatest increase in remission rates occurred with a second treatment course. Rates continued to improve with further escalation of treatment but the effects were less dramatic.

“This is in line with current recommendations and underlines the importance of close follow-up of NMO patients with acute attacks”, they say.

In all, 1153 treatment courses were reviewed; high-dose intravenous steroids were the most commonly used, in 70.3% of patients, followed by apheresis therapies such as plasma exchange and immunoadsorption in 19.9%.

The majority of NMO attacks were treated at least once, but only 28.2% of attacks were treated with a second treatment course and the rate dropped to 7.1% for a third treatment course and to 0.5% for a fifth treatment course.

Isolated myelitis attacks were more common than isolated optic neuritis attacks or simultaneous with myelitis and, irrespective of treatment regimen, complete remission rates were highest for isolated optic neuritis, particularly unilateral versus bilateral.

Treatment outcomes after a first attack showed an advantage for apheresis as a first-line therapy over high-dose steroids but only for isolated myelitis attacks, with complete remission rates of 30.6% versus 10.7%.

The use of apheresis therapies as first-line treatment versus high-dose steroids independently predicted complete remission of NMO, increasing the likelihood 4.38-fold. Complete response from a previous NMO attack increased the likelihood 6.85-fold while the presence of myelitis reduced the chances by 62%.

Age was also an independent predictor of complete response with the likelihood decreasing by 3% per year and 24% with each decade, the researchers report.

“Our data have immediate clinical implications for the management of NMO patients”, stress Kleiter and colleagues.

“The outcome of attacks is generally poor. Escalation of attack therapy improves the outcome, and the sequence of treatments is crucial.”

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