No support for IVIG as treatment of acute attacks in NMOSD

Results of a retrospective study from China did not support treatment with intravenous immunoglobulin (IVIG) alone as a first-line option for acute attacks of neuromyelitis optica spectrum disorders (NMOSD). However, the addition of IVIG therapy to high-dose intravenous steroids may be superior to steroids alone for NMOSD patients with high Expanded Disability Status Scale (EDSS) scores at onset.

Because NMOSD is an inflammatory autoimmune syndrome of the CNS with devastating clinical outcomes, adequate treatment of early attacks is decisive to prevent severe disability. The first-line treatment for acute attacks is high-dose intravenous steroid therapy. Therapeutic plasma exchange and immunoadsorption serve to remove plasma components involved in the inflammation. IVIG has been used for the treatment of a number of autoimmune disorders with various efficacy, but has not produced consistent results for acute attacks in immune-mediated demyelinating diseases. Currently, IVIG is considered empirically as an alternative and/or additional treatment for acute attacks of NMOSD after steroids and plasma exchange fail to offset symptoms or are contraindicated.

This retrospective study by Dr De-Cai Tian (Capital Medical University, China) investigated the efficacy of IVIG for patients with NMOSD during acute attacks [1]. A total of 198 patients were included; 85% was female, mean age at onset was 38 years, median EDSS at onset was 5.0. In these patients, 243 attacks occurred, classified as isolated acute myelitis (50.6%), isolated optic neuritis (9.9%), simultaneous acute myelitis and optic neuritis (14.0%), or other (25.5%). The following treatments were given:

• high-dose intravenous steroids in 153 attacks;
• IVIG in 14 attacks;
• episodes of IVIG plus high-dose intravenous steroids in 69 attacks; and
• plasma exchange in 7 attacks.

Of those attacks treated with IVIG alone, 35.7% showed a moderate decrease of EDSS score 33%-65%, while the other attacks alleviated poorly (<33% decrease). Significantly fewer patients treated with IVIG alone had better outcomes compared with patients who received high-dose intravenous steroids alone (P=0.004). No significant difference was found between IVIG plus high-dose steroids compared with steroids alone (P=0.073). When stratified by EDSS score at onset (≤6.0 versus ≥6.5), sequential treatments of IVIG in addition to high-dose steroids increased the likelihood of clinical improvement in severe attacks for patients with higher EDSS score at onset, compared with steroids alone (P=0.040).

1. Li X, et al. Intravenous immunoglobulin for acute attacks in neuromyelitis optica spectrum disorders. ECF 28^th Annual Meeting. Abstract 79.

Posted on 16 December, 202016 December, 2020