Approaches to NMOSD Treatment in Clinical Practice

EP: 1.Overview of Neuromyelitis Optica Spectrum Disorder (NMOSD)

EP: 2.Differential Diagnosis and Types of NMOSD

EP: 3.Pathophysiology of NMOSD

EP: 4.Progression of NMOSD Over Time

EP: 5.Initiating Treatment and Goals of Therapy for NMOSD

EP: 6.Treatment Selection in NMOSD

EP: 7.Recent Approvals for NMOSD Treatment

EP: 8.Safety Considerations for Therapies in NMOSD

EP: 9.Effects of Polymorphism in the Use of Anti-CD19 and Anti-CD20 B-cell Therapy in NMOSD

EP: 10.Use of FDA Approved Disease-Modifying Therapies vs Other Treatments in NMOSD

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EP: 11.Approaches to NMOSD Treatment in Clinical Practice

EP: 12.The Unmet Needs in NMOSD

EP: 13.Practice Pearls for Management of NMOSD

Brian Weinshenker, MD: There is some data for inebilizumab showing reduced hospitalizations and less disability over a 6-month trial. Do you consider that an important observation and distinguishing observation? Or what’s your interpretation of the significance?

Aaron Miller, MD, FAAN: Frankly, I think that’s just a reflection of how severe neuromyelitis optica spectrum disorder can be. If we have an agent that’s highly effective—all these agents have been highly effective—then it stands to reason that we’re going to be able to keep people out of the hospital and shorten their length of stay if we can get them on effective therapy. I’m not sure that that really sways me much more.

Brian Weinshenker, MD: It was the largest study. It had more statistical power.

Aaron Miller, MD, FAAN: Right.

Flavia Nelson, MD: Again, a lot of the times when a patient ends up in the hospital with an attack, this seems to be related to NMO. We don’t have access to the FDA-approved drugs or we don’t get an antibody test back within the time that the patient is in the hospital. Which is something important that we need to discuss. A lot of the patients who are being diagnosed are going to be in the hospital to be treated for the relapse. Where do we go if that’s the case? What drug do we go to if the patient is in the hospital and the FDA-approved drugs are unavailable in the hospital, as well as perhaps we don’t have an antibody-positive test?

Brian Weinshenker, MD: For acute treatment, do you think it matters that we know what antibody the patient might have? Or whether they have antibodies? In other words, for preventing their acute attacks, do you think we can wait?

Flavia Nelson, MD: That’s a very good point. A lot of times we’re going to treat the acute attack with steroids or plasma exchange depending on the severity. Many times, we’re trying to treat the patient before leaving the hospital with something available. Fortunately, one of the FDA-approved medications for NMO is now available through the hospital if we can get it on the formulary. I think that’s important to discuss.

Brian Weinshenker, MD: Let’s try to summarize our thoughts about the new FDA-approved drugs. Bob, could you tell us about inebilizumab? Which patients would you use this drug for, and what do you see as the main advantages and disadvantages?

Robert Shin, MD, FAAN: Well, for me, I would say any of these options I would consider for a newly diagnosed patient with NMO spectrum disorder or someone with a diagnosis of NMO spectrum disorder who is on therapy, but we’re not achieving our goals if they have a relapse. I’m going to ask myself if we can do better. Inebilizumab specifically just as a reminder, as Dr Nelson mentioned, is a once-every-6-months infusion. An advantage, I think for me, as someone who treats a lot of MS [multiple sclerosis] patients, it’s a familiar schedule. We have our infusion center set up to do this for many of our inpatients with MS for a different product. So, there’s that familiarity of a once-every-6-months infusion. This is the longest duration between treatments of our 3 treatment options. So, for some people, not having to do treatments over a 6-month time period can be an advantage.

In terms of disadvantage, it is an IV [intravenous] infusion, so you’re going to have, as Dr Miller said, to travel typically to an infusion center. And it’s well tolerated, but it’s going to take a number of hours to have this infused each time. So at least for me, those are some of the pros and cons.

Brian Weinshenker, MD: And you mentioned some concerns in patients who have hepatitis, history of TB [tuberculosis], hypogammaglobulinemia to start with. Presumably, that’s a small proportion of patients, but the odd patient. Aaron, I asked you about eculizumab; which patients do you think this is particularly suited for, and what are the disadvantages?

Aaron Miller, MD, FAAN: A strength of eculizumab was it really had a very remarkable reduction in the occurrence of relapses, I think something like 94% in one of the studies. So, it is highly, highly effective. It might not be my go-to first choice because of the disadvantages of the administration schedule, but certainly, if somebody looks like they’ve got a very bad disease and maybe they’ve had some breakthrough on another agent, I will not hesitate to go with eculizumab.

Also, I’d be particularly concerned about a population who’s more at risk than others for meningococcal infection. For example, a college student who is going to go live in a dormitory, somebody who’s going to be in the military, or somebody who’s going to be in places where we tend to see meningococcal outbreaks. I’d be even more cautious, even with the vaccine.

Brian Weinshenker, MD: And I suppose we have to acknowledge the cost is the highest for eculizumab among these drugs. Dr Nelson, could you tell us about the same considerations for satralizumab? Which patients do you think would be best for that drug, and what do you see as the advantages and disadvantages?

Flavia Nelson, MD: Yes, of course. So, for satralizumab, we had mentioned it is taken subcutaneously every 4 weeks. But also in the trial, SAkuraSky the results were not as impressive as with some of the other agents. So, if I had to consider satralizumab in one of my patients, I would say it would be someone who prefers not to have to go to an infusion center, and who prefers to do it subcutaneously at home every 4 weeks, but also perhaps doesn’t have as aggressive of a diagnosis.

Transcript edited for clarity