A New retrospective analysis of data from patients with myelin oligodendrocyte glycoprotein antibody disease (MOGAD) suggests that immunotherapy is associated with a lower risk of recurrence. However, the authors note that many MOGAD patients never experience a recurrence and that it is difficult to identify the patients who get a recurrence.
MOGAD can cause optic nerve inflammation, transverse myelitis and acute disseminated encephalomyelitis (ADEM).The disease was first described in 2007, and the best therapeutic approaches are not yet known. The new study is at least a starting point for understanding treatment outcomes, according to Dr. Philippe Bilodeau, who presented the study during a poster session at the annual meeting of the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS).
Predicting which patients will have a recurrence
«I think one of the biggest unanswered clinical questions with MOGAD is trying to determine who is going to have a recurrence. About 30 to 40% of patients with MOGAD never experience a second seizure. So one of the big questions is: how can we identify the patients who would benefit from immunotherapy, and how can we identify the patients who have a more harmless course of the disease and may not need treatment,» says Bilodeau (Massachusetts General Hospital/Brigham and Women’s Hospital in Boston).
The scientists analyzed the data of 143 patients who had presented with their first seizure at Massachusetts General or Brigham and Women’s Hospital.With a follow-up period of 5 years, the recurrence rate was 61.8%. The scientists looked at various factors, including age at onset of the disease, high MOG titers, type of seizure, and male sex, and found that only the latter factor came close to predicting recurrence, even if it had no clinical significance (hazard ratio [HR] 0.61; P = 0.07)
However, treatment with mycophenolate, azathioprine, intravenous immunoglobulins (IVIG), rituximab or tocilizumab predicted a significantly lower probability of recurrence (HR 0.25; P <0,0001).
The most effective treatment for recurrent MOGAD
In a separate poster, his team examined a subset of the cohort of 88 patients treated with mycophenolate mofetil, B-cell depletion, rituximab, or IV immunoglobulins (IVIG) during a first or second recurrence, as well as an analysis of each recurrence patients experienced over the course of their disease. «Using negative binomial regression, we examined annualized recurrence rates and the ratio of incidence rates between different treatments.Regardless of how you looked at the data — even when looking at the total duration of IVIG treatment, when looking at the duration of monotherapy, excluding concomitant treatment with combined IVIG and rituximab treatment, when looking only at patients on high-dose IVIG — IVIG was by far the best treatment and rituximab was always the least effective, and mycophenolate was always between IVIG and rituximab. So I think we can say with some certainty in this cohort that IVIG is the most effective treatment for recurrent MOGAD,» Bilodeau said.
The retrospective studies cannot prove causality. «We need to find more covariates to make sure there’s no confounding factor that explains this, and to make sure there aren’t other demographic or clinical factors that explain the link. But as it stands, I think starting treatment with immunotherapy at this point is the only thing we know will reduce the risk of future recurrence.We need to do a lot more analysis,» Bilodeau said.
According to him, the study also provides some preliminary findings on the treatment of the disease in children. «We have interesting data from the analysis that MOGAD responds particularly well to [mycophenolate] in children, better than in adults.» And: «At this point, I think a rational approach when someone comes in with a first recurrence is to assess their risk tolerance. If it is a very risk-averse patient, I think it is reasonable to treat him. I think it makes sense to monitor the titers. There is some data that says that if there is a negative seroconversion, immunotherapy can be discontinued. If the disease is recurrent and occurs in adults, IVIG should be the first choice of treatment. In a pediatric disease outbreak, either [mycophenolate] or IVIG are likely to be a good first-line treatment.»
«A good start»
The studies are a good start for a better understanding of MOGAD treatment, according to ophthalmologist Dr. Michael Cossoy, who attended the poster session and commented on the study.
«It’s interesting because the MOG antibody-associated disease is relatively new, so we don’t yet have a clear idea of who needs to be treated.Should we treat them with immunosuppressive therapy or wait and see? At the moment, this is a kind of tautology. You know that if you treat people from the first event, some of those people won’t have a second event. Others have reduced the risk of a second event if the treatment is effective. So that’s what they’ve shown, which is great. The question, however, is whether you can predict who will suffer a second event, and whether you can know who should and shouldn’t be treated. It’s too early to know, but this is a good start,» said Cossoy, an assistant professor of ophthalmology at the University of Manitoba.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.It was translated by Dr. Petra Kittner.
This full text is unfortunately reserved for medical professionals
You have reached the maximum number of articles for unregistered visitors
Source — https://www.univadis.de/viewarticle/mog-antik%25C3%25B6rper-assoziierte-erkrankung-immuntherapie-2023a100057d