Balancing Efficacy, Safety, and Cost When Deciding Treatment Options for NMOSD: Michael Levy, MD, PhD


The associate professor of neurology at Harvard Medical School discussed how clinicians face the challenging decision with their patients in choosing between off-label and approved medications for NMOSD. [WATCH TIME: 4 minutes]

WATCH TIME: 4 minutes

"These new drugs are remarkably effective, scientifically proven, and offer reduced risks, making them compelling options for patients still on older, off-label medications."

Patients with neuromyelitis optica spectrum disorder (NMOSD) typically experience recurrent, unpredictable, and debilitating relapses which can lead to blindness, paralysis, and increased risk of mortality. To prevent relapses, immunosuppressive agents such as rituximab, which target CD20-positive B-cells, have been used historically as off-label in the clinical practice.1 Several newer agents such as inebilizumab (Uplizna; Amgen), a humanized and glycoengineered monoclonal antibody targeting CD19-positive B-cells, have recently been approved for the treatment of NMOSD.

In a case series newly published in Frontiers in Neurology, investigators observed that in a small group of patients with NMOSD (n = 14) who transitioned from rituximab to inebilizumab, the therapy demonstrated clinical benefit with effective disease control and a favorable safety profile.2 Conducted by senior author Michael Levy, MD, PhD, associate professor of neurology at Harvard Medical School, and colleagues, 10 patients (71.4%) had a combined 17 attacks while treated with rituximab because of either breakthrough disease (n = 10) or treatment delay (n = 7). Notably, the mean duration on rituximab was 38.4 months and mean duration on inebilizumab was 19.3 months. Additionally, researchers reported no observation of any subsequent attacks while patients were on inebilizumab.

Levy, who also serves as the chairman for the medical advisory board at The Sumaira Foundation, recently sat down with NeurologyLive® in an interview to discuss why there might be a need to switch patients with NMOSD from older off-label medications to newly approved treatments. He also spoke about the benefits of newer drugs like inebilizumab compared with rituximab for patients with NMOSD. Moreover, Levy, research director of the Division of Neuroimmunology & Neuroinfectious Disease at Massachusetts General Hospital, talked about how financial considerations may impact the choice of medication for patients with NMOSD in the US.

1. Royston M, Kielhorn A, Weycker D, et al. Neuromyelitis Optica Spectrum Disorder: Clinical Burden and Cost of Relapses and Disease-Related Care in US Clinical Practice. Neurol Ther. 2021;10(2):767-783. doi:10.1007/s40120-021-00253-4
2. Osborne B, Romanow G, Hemphill JM, et al. Case report: Transition from anti-CD20 therapy to inebilizumab for 14 cases of neuromyelitis optica spectrum disorder. Front Neurol. 2024;15:1352779. Published 2024 Apr 16. doi:10.3389/fneur.2024.1352779
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