Neuromyelitis optica spectrum disorders and pregnancy: relapse-preventive measures and personalized treatment strategies

Risks and outcomes of pregnancy in neuromyelitis optica spectrum disorder: A comprehensive review

Neuromyelitis optica spectrum disorder (NMOSD) is a rare central nervous system autoimmune disease. Aquaporin-4 antibody (AQP4-IgG) is present in over 75% of cases and criteria also exist for the diagnosis of seronegative NMOSD. AQP4-IgG NMOSD has a strong female predominance (9:1 ratio), with a median onset age of 40 years. Pregnancy in those with NMOSD is therefore an important topic. Fecundity in NMOSD is likely impaired, and for females who conceive, obstetric complications including miscarriages and pre-eclampsia are significantly higher in NMOSD compared to the general population and in related conditions such as multiple sclerosis (MS). In contrast to MS, NMOSD disease activity does not subside during pregnancy. Also, relapse risk substantially rises above pre-pregnancy rates in the early postpartum period. In view of the evolving landscape of NMOSD, we provide a contemporary update of the impacts of pregnancy in NMOSD.

Advances in the long-term treatment of neuromyelitis optica spectrum disorder

Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune neuroinflammatory disorder with a prevalence of 1-5/100,000 globally, characterized by attacks of the central nervous system including but not limited to optic neuritis, transverse myelitis and brainstem lesions, including area postrema lesions. These autoimmune attacks can lead to irreversible damage if left untreated, therefore strategies have been developed to prevent relapses. Initial off-label treatments have achieved variable levels of success in relapse prevention, but improved relapse prevention and quality of life remain a goal in the field. A better understanding of the underlying pathophysiology of NMOSD over the last 10 years has led to newer, more specific approaches in treatment, culminating in the first FDA approved treatments in the disease. In this review, we will discuss the seminal trials of PREVENT or Eculizumab in the treatment of aquaporin-4 (AQP4)-IgG positive NMOSD, N-Momentum or Inebilizumab in the study of NMOSD (both AQP4-IgG positive and negative) and SAkura Sky and SAkuraStar which studied satralizumab in AQP4-IgG seropositive and seronegative NMOSD patients. We will also discuss the extension trials of each of these medications and what lead to their approval in AQP4-IgG seropositive NMOSD patients. We will then examine treatments in the pipeline for adult and pediatric NMOSD patients and conclude with discussions on treatment considerations in pregnant patients and how to approach treatment of NMOSD patients during COVID.

Update on the diagnosis and treatment of neuromyelitis optica spectrum disorders (NMOSD) - revised recommendations of the Neuromyelitis Optica Study Group (NEMOS). Part II: Attack therapy and long-term management

This manuscript presents practical recommendations for managing acute attacks and implementing preventive immunotherapies for neuromyelitis optica spectrum disorders (NMOSD), a rare autoimmune disease that causes severe inflammation in the central nervous system (CNS), primarily affecting the optic nerves, spinal cord, and brainstem. The pillars of NMOSD therapy are attack treatment and attack prevention to minimize the accrual of neurological disability. Aquaporin-4 immunoglobulin G antibodies (AQP4-IgG) are a diagnostic marker of the disease and play a significant role in its pathogenicity. Recent advances in understanding NMOSD have led to the development of new therapies and the completion of randomized controlled trials. Four preventive immunotherapies have now been approved for AQP4-IgG-positive NMOSD in many regions of the world: eculizumab, ravulizumab - most recently-, inebilizumab, and satralizumab. These new drugs may potentially substitute rituximab and classical immunosuppressive therapies, which were as yet the mainstay of treatment for both, AQP4-IgG-positive and -negative NMOSD. Here, the Neuromyelitis Optica Study Group (NEMOS) provides an overview of the current state of knowledge on NMOSD treatments and offers statements and practical recommendations on the therapy management and use of all available immunotherapies for this disease. Unmet needs and AQP4-IgG-negative NMOSD are also discussed. The recommendations were developed using a Delphi-based consensus method among the core author group and at expert discussions at NEMOS meetings.

[Pregnancy-associated neuromyelitis optical spectrum disorder combined with primary Sjögren's syndrome: A critical illness case report]

Central nervous system involvement in primary Sjögren's syndrome (pSS) is less common and usually presents as white matter lesions, neuromyelitis optica spectrum disorder (NMOSD), or transverse myelitis. NMOSD is an immune-mediated inflammatory demyelinating disease of the central nervous system with a high rate of relapse and significant disability. Studies have shown that patients with pSS combined with NMOSD have more severe symptoms and poorer prognosis. Here, we present a case of critical illness in pregnancy-associated NMOSD combined with Sjögren's syndrome. The patient was a 30-year-old pregnant woman with a history of Sjögren's syndrome who was diagnosed with NMOSD. She received combination therapy with steroids, intravenous immunoglobulin (IVIG), and hydroxychloroquine during pregnancy, resulting in partial resolution of numbness below the waist. However, due to irregular medication adherence outside the hospital setting, she developed weakness in her right lower limb accompanied by inability to move it, while her left lower limb still had some mobility but occasional numbness along with urinary and fecal incontinence. Ten days later, she was admitted to the emergency department where an emergency cesarean section was performed to deliver a healthy baby boy. However, her condition worsened postpartum as she developed high fever accompanied by bilateral lower limb paralysis and weakness along with loss of voluntary control over urination and defecation. The patient underwent ano-ther course of treatment consisting of steroids and IVIG; however there was limited improvement in symptoms observed after this intervention. Following administration of rituximab for the first time, the patient developed urinary tract infection which was successfully managed before continuing regular infusions. In later stages the patient could walk slightly with a limp and regained control over urination and defecation, allowing her to resume normal activities. This case suggests that combination therapy with steroids, IVIG, and hydroxychloroquine should be considered for the patients with pregnancy-associated NMOSD combined with Sjögren's syndrome. Rituximab can significantly improve symptoms such as postpartum paralysis in patients with NMOSD, however, there may be a risk of infection associated with its use.

Neuromyelitis optica spectrum disorder safely and successfully treated with satralizumab during pregnancy and breastfeeding: a case report

Background

Satralizumab, a monoclonal antibody that recognizes interleukin-6 receptors, is known to reduce the relapse rate in neuromyelitis optica spectrum disorder (NMOSD), but its safety during pregnancy has not been established. We present the case of an NMOSD patient who safely completed pregnancy, parturition, and breastfeeding under satralizumab treatment. Importantly, satralizumab transfer to umbilical cord blood, infant serum, or breast milk was not observed.

Case presentation

A 37-year-old Japanese female developed anti-aquaporin 4 antibody-positive NMOSD with left optic neuritis. Despite responding to steroid and azathioprine therapy, she experienced moon face and weight gain and desired the prompt reduction of the steroid dosage. She also wanted to conceive a child with a safe and preferably early pregnancy and parturition. Because pregnancy and parturition after the onset of NMOSD elevate the risk of relapse and miscarriage, treatment with satralizumab was initiated with the patient's consent. She experienced normal parturition and continued with satralizumab, steroid, and azathioprine treatments while breastfeeding without experiencing any relapses. Concentrations of satralizumab in the umbilical cord blood, infant serum, and breast milk were below the detection sensitivity.

Conclusion

These findings suggest that satralizumab may be safe and effective for the perinatal management of NMOSD, especially when there are concerns about continuing pregnancy and the risk of relapse after parturition.

International Delphi Consensus on the Management of AQP4-IgG+ NMOSD: Recommendations for Eculizumab, Inebilizumab, and Satralizumab

BACKGROUND AND OBJECTIVES

Neuromyelitis optica spectrum disorder (NMOSD) is a rare debilitating autoimmune disease of the CNS. Three monoclonal antibodies were recently approved as maintenance therapies for aquaporin-4 immunoglobulin G (AQP4-IgG)-seropositive NMOSD (eculizumab, inebilizumab, and satralizumab), prompting the need to consider best practice therapeutic decision-making for this indication. Our objective was to develop validated statements for the management of AQP4-IgG-seropositive NMOSD, through an evidence-based Delphi consensus process, with a focus on recommendations for eculizumab, inebilizumab, and satralizumab.

METHODS

We recruited an international panel of clinical experts in NMOSD and asked them to complete a questionnaire on NMOSD management. Panel members received a summary of evidence identified through a targeted literature review and provided free-text responses to the questionnaire based on both the data provided and their clinical experience. Responses were used to generate draft statements on NMOSD-related themes. Statements were voted on over a maximum of 3 rounds; participation in at least 1 of the first 2 rounds was mandatory. Panel members anonymously provided their level of agreement (6-point Likert scale) on each statement. Statements that failed to reach a predefined consensus threshold (≥67%) were revised based on feedback and then voted on in the next round. Final statements were those that met the consensus threshold (≥67%).

RESULTS

The Delphi panel comprised 24 experts, who completed the Delphi process in November 2021 after 2 voting rounds. In round 1, 23/25 statements reached consensus and were accepted as final. The 2 statements that failed to reach consensus were revised. In round 2, both revised statements reached consensus. Twenty-five statements were agreed in total: 11 on initiation of or switching between eculizumab, inebilizumab, and satralizumab; 3 on monotherapy/combination therapy; 7 on safety and patient population considerations; 3 on biomarkers/patient-reported outcomes; and 1 on research gaps.

DISCUSSION

An established consensus method was used to develop statements relevant to the management of AQP4-IgG-seropositive NMOSD. These international statements will be valuable for informing individualized therapeutic decision-making and could form the basis for standardized practice guidelines.

Skin Manifestations of Neuromyelitis Optica Spectrum Disorder With Secondary Systemic Lupus Erythematosus During Pregnancy: A Three-Year Follow-Up

Neuromyelitis optica spectrum disorder (NMOSD) is a disease of the central nervous system and the optic nerves that disproportionately affects women and occasionally coexists with other autoimmune diseases. NMOSD manifesting as skin lesions is a rare phenomenon. Furthermore, these skin lesions in the setting of NMOSD during pregnancy have not been described. We report the case of a 31-year-old woman from sub-Saharan Africa who presented with initial recurrent skin lesions followed by paraparesis during her second trimester of pregnancy. Her next pregnancy was associated with sudden vision loss. She had positive serology for aquaporin-4 antibodies and subsequently developed a positive dsDNA antibody two years after the initial NMOSD diagnosis. Her skin lesions and symptoms improved following the administration of azathioprine. This case highlights the impact of pregnancy on NMOSD and the significance of a heightened level of suspicion for NMOSD in patients who exhibit recurring skin lesions preceding paraparesis events.

Efficacy and safety of monoclonal antibodies in neuromyelitis optica spectrum disorders: A survival meta-analysis of randomized controlled trials

Background

Monoclonal antibodies such as rituximab (RTX), eculizumab, inebilizumab, satralizumab, and tocilizumab have been found to be effective therapies for neuromyelitis optica spectrum disease ​(NMOSD) in several clinical randomized controlled trials.

Objective

The purpose of this meta-analysis of randomized controlled trials was to assess the efficacy and safety of monoclonal antibodies in the treatment of NMOSD.

Methods

We searched the following databases for relevant English language literature from the establishment of the database to June 2021: PubMed, Embase, Cohorane Library, the Central Register of Controlled Trials (CENTRAL), and Web of Science. Randomized controlled trials of monoclonal antibodies were the targets of the review.

Results

We included seven trials containing 775 patients (485 in the monoclonal antibody group and 290 in the control group). Patients in the monoclonal group (HR 0.24, 95% CI: 0.14 to 0.40, P ​< ​0.00001), as well as patients with seropositive AQP4-IgG (HR 0.18, 95% CI: 0.11 to 0.29, P ​< ​0.00001), both had a higher free recurrence rate than that in the control group. In the first year (HR 0.25, 95% CI: 0.09 to 0.71, P ​= ​0.009) and the second year (HR 0.32, 95% CI: 0.13 to 0.81, P ​= ​0.02), no relapses were documented. The average changes of the expanded disability status scale (EDSS) score decreased by 0.29 (95% CI: -0.09 to 0.51, P ​= ​0.005). Upper respiratory tract infection (OR 1.52, 95% CI: 0.76 to 3.04, P ​= ​0.24), urinary tract infection(OR 0.79, 95% CI: 0.51 to 1.21, P ​= ​0.27), and headache (OR 1.30, 95% CI: 0.78 to 2.17, P ​= ​0.31) were three most frequent adverse reactions.

Conclusions

Monoclonal antibodies are particularly effective treatments in avoiding recurrence for NMOSD patients, according to this meta-analysis. The associated adverse responses are not significantly different from those seen with traditional immunosuppressants.

Correlation between ERα gene polymorphism and multiple sclerosis and neuromyelitis optica

OBJECTIVE

To study the polymorphism distribution of estrogen receptor (ER) α gene and the correlation between different types of polymorphism in multiple sclerosis (MS) and neuromyelitis optica (NMO) patients.

METHODS

Forty-six cases of MS and NMO diagnosed from June 2018 to December 2019 were collected. Peripheral venous blood samples were collected. The patient's gender, age of onset, course of disease, and other clinical data were recorded. Fifty-eight healthy volunteers of the same age and sex were selected. By means of Pvu II and Xba I restriction fragment length polymorphism enzyme recognition sites of ER α gene, polymerase chain reaction-restriction fragment length polymorphism analysis was conducted.

RESULTS

There was no significant difference in the frequency distribution of ER α gene's PP, Pp, and pp genotype between MS and NMO case group and control group (P = .598). Frequency distribution of ER α gene's XX, Xx, and xx was statistically significant between MS and NMO case group and control group (P = .021). Among them, distribution of Xx and Xx gene frequency between patient group and the control group was statistically significant (P = .001, OR = 4.622, 95% CI: 1.803-11.852). There was no significant correlation between ER α genotypes and the onset age in patient group (P > .05). The difference was statistically significant in disease duration of XX and Xx genotype (P = .006). The comparison of Xx and xx genotype frequency distribution in gender exists a difference(P = .047, OR = 7.500, 95% CI: 1.023-54.996).

CONCLUSIONS

Xba I gene polymorphisms in the ER α gene have correlation with MS and NMO. Xba I gene could be a risk factor of MS and NMO pathogenesis, especially the women with Xx genotype are more vulnerable. Xba I gene polymorphisms in the ER α gene may impact the disease duration of MS and NMO, or rather, the disease duration of Xx genotype persists longer than Xx genotype. Pvu II gene polymorphisms in the ER α gene has no correlation with MS and NMO.

The description of neuromyelitis optica spectrum disorder: Patient registry in Yangtze River Delta area of China

OBJECTIVE

To describe the clinical features of neuromyelitis optica spectrum disorder (NMOSD) through patient registry in Yangtze River Delta area of China.

METHODS

A total of 502 consecutive patients diagnosed with aquaporin-4 antibody (AQP4-ab)-positive NMOSD were registered between December 2018 to January 2021 in multiple tertiary referral centers within the framework of Yangtze River Delta of China. Their baseline data were reviewed, and follow-up clinical information were collected prospectively.

RESULTS

The mean age at onset was 37.3 (range 3-80 years) years and the female-to-male ratio was 8.1:1. The median disease duration was 47 months (interquartile range [IQR] 25-84 months). A total of 1372 attacks of the 502 patients were recorded till the last follow-up, with a median annualized relapse rate of 0.4 (IQR 0.3-0.6). Nearly one-fourth (24.5%, 336/1372) of the attacks had prodromic events, including upper respiratory tract infection (36.3%, 122/336), fever (20.2%, 68/336) and pregnancy-related issues (17.9%, 60/336), etc. Myelitis was the most common attack type throughout the disease course (51.4%, 705/1372), followed by optic neuritis (ON, 43.1%, 592/1372). As for onset phenotype, ON (37.3%, 187/502) prevailed over myelitis (28.3%, 142/502). The median time to first relapse was 12 months (IQR 5-25 months). Patients with brainstem encephalitis at onset were more likely to have other anatomical region involved in subsequent attacks (p < 0.001), compared to other onset type. The median serum AQP4-ab titer measured by cell-based assays was 1:100 (IQR 1:32-1:320, range 1:10-1:10,000). The baseline AQP4-ab titer in cerebrospinal fluid (r = 0.542, p <0.001), overall ARR (r = 0.232, p< 0.001) and the EDSS scores at last follow-up (r = 0.119, p = 0.022) significantly correlated with baseline serum AQP4-ab titer. Antinuclear antibodies (48.4%), thyroid peroxidase antibodies (30.7%), and anti-SSA antibodies (26.2%) represented the most frequent concomitant antibodies, while autoimmune thyroid disorders (13.1%, 66/502) and Sjogren's syndrome (10.8%, 54/502) were the most common accompanying autoimmune diseases. Till the last follow-up, 403 patients received preventive treatments. Azathioprine represented the most common initial treatment, mycophenolate mofetil and rituximab was the most common second and third-line treatment, respectively. The EDSS score at the last follow-up ranged from 0 to 8.5 with a median of 2 (IQR 1-3).

CONCLUSIONS

A comprehensive clinical picture of patients with AQP4-ab-positive NMOSD in Yangtze River Delta area of China was presented. More information on disease tragedy and predictive prognostic factors could be generated through long-term observations.

Pregnancy-Related Attack in Neuromyelitis Optica Spectrum Disorder With AQP4-IgG: A Single-Center Study and Meta-Analysis

Objective

This study aimed to investigate the demographic characteristic of pregnancy-related attacks (PRAs) in neuromyelitis optica spectrum disorder (NMOSD). In addition, we investigated the predictors of PRAs as well as the effect of immunosuppressive (IS) therapy in patients with pregnancy-related NMOSD.

Method

We retrospectively analyzed data on clinical and diagnostic characteristics, therapeutic management, and pregnancy outcomes for PRAs in AQP4-IgG-positive NMOSD patients admitted to the Second Xiangya Hospital of Central South University. Moreover, we searched the literature (without any temporal restriction) to identify all such similar cohorts and performed a meta-analysis to evaluate the effectiveness and safety of IS therapy on NMOSD patients with PRAs.

Result

We collected clinical data on 117 women with AQP4 antibody-positive NMOSD; we ultimately included 33 patients (34 pregnancies). Ten patients were relapse-free during pregnancy, and 23 (69.7%) had PRA; attacks were most common during the first trimester of the postpartum period. Maintenance of IS treatment during pregnancy was found to greatly reduce PRAs in patients with NMOSD. PRAs were associated with a higher neutrophil-to-lymphocyte ratio (NLR) at relapse during pregnancy and shorter time interval between the last relapse and conception. The meta-analysis suggested that maintenance of IS treatment during pregnancy can significantly reduce the RR of NMOSD (95%CI=0.35-0.62; z=5.18, p<0.0001) and had no adverse effect on the miscarriage rate. However, the unhealthy newborn occurrence among those receiving IS treatment was 3.73 times higher than that of those not receiving treatment during pregnancy (95%CI=1.40–9.91; z=2.64, p=0.008).

Conclusion

Our study results demonstrates that pregnancy can induce the onset or relapse of attacks in NMOSD patients. The increased NLR value and disease activity may be a predictor for PRAs in patients with NMOSD. Moreover, administration of IS treatment during pregnancy can reduce the relapse rate. However, the dosage of drugs and risks of adverse effects to the fetus need to be considered. Future prospective studies with larger sample sizes are needed to confirm and extend our findings.

INFLUENCE OF PREGNANCY ON NEUROMYELITIS OPTICA FROM AN OPHTHALMOLOGICAL POINT OF VIEW. A CASE REPORT

Neuromyelitis Optica (NMO, Devics disease) is a rare demyelinating disease of the central nervous system, leading to optic neuritis and transverse myelitis. The clinical course of the disease and ocular changes in pregnancy are still not well known. Here we present the subclinical ophthalmological changes which were evaluated by spectral domain optical coherence tomography (SD-OCT) during the 39 weeks gestation and postpartum period in a pregnant woman with a diagnosis of NMO. In addition, we present the obstetric and neurological course of our patient and review the literature. A 30-year-old female with a history of NMO was ophthalmologically examined and SD-OCT was performed periodically every trimester to observe the effects of pregnancy on the disease course. No ophthalmological changes were observed during the pregnancy and postpartum period. Caesarean delivery was preferred due to obstetric indication. The patient was discharged on the second day of the postpartum period.

Neuromyelitis optica spectrum disorders: from pathophysiology to therapeutic strategies

Neuromyelitis optica (NMO) is a chronic inflammatory autoimmune disease of the central nervous system (CNS) characterized by acute optic neuritis (ON) and transverse myelitis (TM). NMO is caused by a pathogenic serum IgG antibody against the water channel aquoporin 4 (AQP4) in the majority of patients. AQP4-antibody (AQP4-ab) presence is highly specific, and differentiates NMO from multiple sclerosis. It binds to AQP4 channels on astrocytes, triggering activation of the classical complement cascade, causing granulocyte, eosinophil, and lymphocyte infiltration, culminating in injury first to astrocyte, then oligodendrocytes followed by demyelination and neuronal loss. NMO spectrum disorder (NMOSD) has recently been defined and stratified based on AQP4-ab serology status. Most NMOSD patients experience severe relapses leading to permanent neurologic disability, making suppression of relapse frequency and severity, the primary objective in disease management. The most common treatments used for relapses are steroids and plasma exchange.Currently, long-term NMOSD relapse prevention includes off-label use of immunosuppressants, particularly rituximab. In the last 2 years however, three pivotal clinical trials have expanded the spectrum of drugs available for NMOSD patients. Phase III studies have shown significant relapse reduction compared to placebo in AQP4-ab-positive patients treated with satralizumab, an interleukin-6 receptor (IL-6R) inhibitor, inebilizumab, an antibody against CD19⁺ B cells; and eculizumab, an antibody blocking the C5 component of complement. In light of the new evidence on NMOSD pathophysiology and of preliminary results from ongoing trials with new drugs, we present this descriptive review, highlighting promising treatment modalities as well as auspicious preclinical and clinical studies.

FLAIR-hyperintense lesions in anti-MOG-associated encephalitis with seizures (FLAMES) unmasked by withdrawal of immunosuppression for Crohn's disease?

A 31-year-old pregnant woman presented with headache, fever and left-sided focal motor seizures, which progressed to bilateral tonic-clonic seizures. Her medical history included Crohn's disease treated with azathioprine and adalimumab, which were discontinued when she became pregnant. Her cerebro-spinal fluid was entirely normal and viral PCR negative. Extensive testing for infectious, autoimmune or malignant causes of encephalitis were non-revealing. MRI head showed unilateral cortical FLAIR-hyperintensity which on interval scans was seen bilaterally. Anti-myelin-oligodendrocyte glycoprotein (MOG)-IgG was positive leading to a diagnosis of cortical FLAIR-hyperintense lesions in Anti-MOG-associated Encephalitis with seizures (FLAMES).

Timing of plasma exchange for neuromyelitis optica spectrum disorders: A meta-analysis

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSDs) are autoimmune astrocytopathies with predominant involvement of the optic nerves and spinal cord. The current management is high-dose intravenous methylprednisolone, followed by apheresis therapy if it fails. We aimed to investigate plasma exchange (PE) benefits in corticosteroid-refractory NMOSDs.

METHODS

From Embase, PubMed, Cochrane, Web of Science, and Clinical Trials, we identified PE-based studies published between Jan 2007 and Dec 2019. We pooled the information of these studies in a binomial meta-analysis. We investigated the factors affecting the efficacy of PE and its adverse events. The effectiveness of PE was assessed using the Expanded Disability Status Scale (EDSS). The timing of PE initiation was assessed using Spearman correlation analysis.

RESULTS

We included 561 records and identified 8 observational studies, including 228 NMOSD patients. The mean time to the initiation of PE was 11 days, and the average volume of each exchange was 1.5-2 L. PE treatment reduced the mean EDSS score by -1.04 (95% CI, -1.44 to -0.64). The initiation time of PE significantly affected the outcome (EDSS reduction) (P = 0.01; 95% CI, -1.30 to 0.28). In the ≤ 7-day and 8-23-day groups, the mean EDSS decreased by 0.64 (95% CI, -0.93 to -0.34) and 1.41 (95% CI, -1.79 to -1.02), respectively. In addition, PE showed the same efficacy for alleviating the symptoms of NMOSDs, regardless of the day between 8 to 23 days on which it was performed (P = 0.29). Thirty-five (20.8%) of the 168 patients had adverse events.

CONCLUSION

PE can ameliorate severe NMOSDs. PE effectiveness was associated with the duration between disease and the initiation of PE, and the optimal timing for PE initiation is 8 to 23 days after the onset of the disease.

Neuromyelitis optica spectrum disorder: pregnancy-related attack and predictive risk factors

OBJECTIVES

To investigate the influence of pregnancy on patients with neuromyelitis optica spectrum disorder (NMOSD) and to identify risk factors that predict pregnancy-related attack.

METHODS

From January 2015 to April 2019, 418 female patients with NMOSD were registered at Huashan Hospital. We retrospectively reviewed their medical records and identified 110 patients with 136 informative pregnancies, of whom 83 were aquaporin-4 antibody (AQP4-ab)-positive and 21 were myelin oligodendrocyte glycoprotein-antibody-positive. Pregnancy-related attack was defined as an attack that occurred during pregnancy or within 1 year after delivery/abortion. We compared annualised relapse rate (ARR) during 12 months before pregnancy with that during every trimester of pregnancy and after delivery/abortion. Multivariate analyses were used to explore the independent risk factors involved and a nomogram was generated for the prediction of pregnancy-related attack. Thirty-five female patients from 3 other centres formed an external cohort to validate this nomogram.

RESULTS

ARR increased significantly during the first trimester after delivery (p<0.001) or abortion (p=0.019) compared with that before pregnancy. Independent risk factors predicting pregnancy-related attack included age at delivery/abortion (20-26.5, p=0.018; 26.5-33, p=0.001), AQP4-ab titre (≥1:100, p=0.049) and inadequate treatment during pregnancy and postpartum period (p=0.004). The concordance index of nomogram was 0.87 and 0.77 using bootstrap resampling in internal and external validation.

CONCLUSIONS

The first trimester post partum is a high-risk period for NMOSD recurrence. Patients with younger age, higher AQP4-ab titre and inadequate treatment are at higher risk for pregnancy-related attack.

Recent progress in maintenance treatment of neuromyelitis optica spectrum disorder

Background

Treatment of neuromyelitis optica spectrum disorder (NMOSD) has so far been based on retrospective case series. The results of six randomized clinical trials including five different monoclonal antibodies targeting four molecules and three distinct pathophysiological pathways have recently been published.

Methods

Literature search on clinical trials and case studies in NMOSD up to July 10. 2020.

Results

We review mechanism of action, efficacy and side effects, and consequences for reproductive health from traditional immunosuppressants and monoclonal antibodies including rituximab, inebilizumab, eculizumab, tocilizumab and satralizumab.

Conclusion

In NMOSD patients with antibodies against aquaporin 4, monoclonal antibodies that deplete B cells (rituximab and inebilizumab) or interfere with interleukin 6 signaling (tocilizumab and satralizumab) or complement activation (eculizumab) have superior efficacy compared to placebo. Tocilizumab and rituximab were also superior to azathioprine in head-to-head studies. Rituximab, tocilizumab and to some extent eculizumab have well-known safety profiles for other inflammatory diseases, and rituximab and azathioprine may be safe during pregnancy.

Gender issues of antibody-mediated diseases in neurology: (NMOSD/autoimmune encephalitis/MG)

Neuromyelitis optica spectrum disorder (NMOSD), autoimmune encephalitis (AE), myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS) are antibody-mediated neurological diseases. They have mostly female predominance, affecting many women during childbearing age. Interactions between the underlying disease (or necessary treatment) and pregnancy can occur in every of these illnesses. Herein, we present the characteristics of NMOSD, AE, MG and LEMS in general, and review published data regarding the influence of the different diseases on fertility, pregnancy, puerperium, treatment strategy during pregnancy and post-partum period, and menopause but also male factors. We summarise key elements that should be borne in mind when confronted with such cases.

Is Fertility Affected in Women of Childbearing Age with Multiple Sclerosis or Neuromyelitis Optica Spectrum Disorder?

Multiple sclerosis (MS) is a chronic immune-mediated demyelinating disease of the central nervous system (CNS), which is more prevalent among women of childbearing age. Neuromyelitis optica spectrum disorder (NMOSD) is a severe autoimmune disease of the CNS with similar prevalence features to MS and has recently been considered a different entity from MS. Measuring ovarian reserve is one way of evaluating fertility. Anti-Müllerian hormone (AMH) is a peptide hormone produced by ovarian granulosa cells of early follicles and is considered to be a marker for ovarian reserve. With MS and NMOSD predominance in young women, the present study aimed to address the possibility of these diseases affecting fertility by measuring AMH levels in MS and NMOSD patients and comparing it with healthy controls. The present study included 23 relapsing-remitting MS (RRMS) patients, 23 seronegative NMOSD patients, and 23 healthy age-matched controls between 18 and 45 years of age. Serum samples of the three groups were collected, and the AMH levels were measured with AMH Gen II Enzyme-Linked Immunosorbent Assay, Beckman Coulter kit. In the present study, the AMH levels did not differ significantly between the groups (p = 0.996). The mean AMH in the RRMS group was 3.59 ± 0.55 ng/ml compared with the mean of 3.60 ± 0.50 ng/ml in healthy controls. The mean AMH levels in the NMOSD group were 3.66 ± 0.61 ng/ml. Lower levels of AMH were found to be negatively associated with annualized relapse rate (in both groups of patients) and MS severity score. However, the difference was not significant. In NMOSD patients, the serum levels of AMH were negatively associated with disease duration (r = - 0.42, p = 0.023). There had been a significant negative correlation between mean AMH serum levels with Expanded Disability Status Scale (EDSS) at the time of diagnosis and at the time of study in the NMOSD group (r = - 0.402, p = 0.03 and r = - 0.457, p = 0.014, respectively). There was not a significant difference in mean serum AMH levels between RRMS and NMOSD patients compared with that of healthy controls. Further studies with larger sample sizes should be conducted, which take more variables affecting fertility in women with either RRMS or NMOSD into account to put an end to the controversial issue of fertility in this area.

Pre-pregnancy, obstetric and delivery status in women with neuromyelitis optica spectrum disorder

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is a potentially disabling disease which affects predominantly women of reproductive age.

OBJECTIVES

To evaluate the pre-pregnancy condition and to investigate the prevalence of obstetrical and neonatal complaints in NMOSD.

METHODS

An observational retrospective study of 37 NMOSD patients positive for aquaporin-4-immunoglobulin-IgG. Age at menarche, menstrual cycle, gravidity, type of delivery obstetrical complications and perinatal problems were recorded. We assessed the annualized relapse rate (ARR).

RESULTS

A total of 23 patients (62%) suffered from irregular menstruations and two from infertility after disease onset. 11 patients had 20 informative pregnancies with 14 deliveries (5 cesareans) and six abortions, four spontaneous, and two ectopic pregnancies after the first trimester. Additionally, three patients experienced threatening abortion and one preeclampsia. No stillbirth or premature birth was recorded. None of the patients experienced attacks during pregnancy, but postpartum relapses occurred after 10 deliveries (71,4%) with the highest ARR (0.937; p = 0.037) during the first three months postpartum compared to pre-pregnancy ARR (0.375). Four patients (10.8%) developed the initial symptoms of NMOSD postpartum.

CONCLUSION

Irregular menstruation in more than half of NMOSD patients may reflect a hormonal imbalance. Pregnancies were associated with obstetrical complications and increased disease activity postpartum.

[Neuromyelitis optica and neuromyelitis optica spectrum disorders]

The review is devoted to up-to-date data on epidemiology, aspects of the pathogenesis of neuromyelitis optica (NMO) and neuromyelitis optica spectrum disorders (NMOSD). The authors consider a role of myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG) in the syndromes phenotypically similar to NMO and NMOSD. Special attention is drawn to the methods of MOG-IgG antibodies detection and indications for testing. The approaches and management for treatment and prevention of NMO relapses, risks of complications during pregnancy and immediately after delivery, as well as methods for their prevention and treatment, are described.

Suggestions for improving the design of clinical trials in multiple sclerosis-results of a systematic analysis of completed phase III trials

This manuscript reviews the primary and secondary endpoints of pivotal phase III trials with immunomodulatory drugs in multiple sclerosis (MS). Considering the limitations of previous trial designs, we propose new standards for the planning of clinical trials, taking into account latest insights into MS pathophysiology and patient-relevant aspects. Using a systematic overview of published phase III (pivotal) trials performed as part of application for drug market approval, we evaluate the following characteristics: trial duration, number of trial participants, comparators, and endpoints (primary, secondary, magnetic resonance imaging outcome, and patient-reported outcomes). From a patient perspective, the primary and secondary endpoints of clinical trials are only partially relevant. High-quality trial data pertaining to efficacy and safety that stretch beyond the time frame of pivotal trials are almost non-existent. Understanding of long-term benefits and risks of disease-modifying MS therapy is largely lacking. Concrete proposals for the trial designs of relapsing (remitting) multiple sclerosis/clinically isolated syndrome, primary progressive multiple sclerosis, and secondary progressive multiple sclerosis (e.g., study duration, mechanism of action, and choice of endpoints) are presented based on the results of the systematic overview. Given the increasing number of available immunotherapies, the therapeutic strategy in MS has shifted from a mere “relapse-prevention” approach to a personalized provision of medical care as to the choice of the appropriate drugs and their sequential application over the course of the disease. This personalized provision takes patient preferences as well as disease-related factors into consideration such as objective clinical and radiographic findings but also very burdensome symptoms such as fatigue, depression, and cognitive impairment. Future trial designs in MS will have to assign higher relevance to these patient-reported outcomes and will also have to implement surrogate measures that can serve as predictive markers for individual treatment response to new and investigational immunotherapies. This is an indispensable prerequisite to maximize the benefit of individual patients when participating in clinical trials. Moreover, such appropriate trial designs and suitable enrolment criteria that correspond to the mode of action of the study drug will facilitate targeted prevention of adverse events, thus mitigating risks for individual study participants.

Novel uses of retinal imaging with optical coherence tomography in multiple sclerosis

Introduction: Multiple Sclerosis (MS) is the most common chronic autoimmune neuroinflammatory condition in young adults. It is often accompanied by optic neuritis (ON) and retinal neuro-axonal damage causing visual disturbances. Optical coherence tomography (OCT) is a sensitive non-invasive method for quantifying intraretinal layer volumes. Recently, OCT not only showed to be a reliable marker for ON-associated damage, but also proved its high prognostic value for functional outcome and disability accrual in patients with MS. Consequently, OCT is discussed as a potential marker for monitoring disease severity and therapeutic response in individual patients. Areas covered: This article summarizes our current understanding of structural retinal changes in MS and describes the future potential of OCT for differential diagnosis, monitoring of the disease course and for clinical trials. Expert commentary: Today, OCT is used in clinical practice in specialized MS centers. Standardized parameters across devices are urgently needed for supporting clinical utility. Novel parameters are desirable to increase sensitivity and specificity in terms of MS.