Characterization of Disease Severity and Stability in NMOSD: A Global Clinical Record Review with Patient Interviews

Disease characteristics of NMOSD and their relationship with disease burden: Observations from a large single-center cohort

OBJECTIVE

To assess the demographic, clinical, and outcome data in patients with NMOSD across a single-center adult cohort and find out associations, if any, with the disease burden.

BACKGROUND

Neuromyelitis Optica spectrum disorder is an autoimmune condition with unpredictable course and relapses. The clinical and economic burden of NMOSD has been studied less.

DESIGN/METHODS

A retrospective analysis of patients diagnosed with NMOSD according to 2015 criteria at the UT Health Houston (UTH) system from 2010 to 2024 was done.

RESULTS

Of the 68 patients, aged 40.03 yrs. (SD = 14.05), 56 (82.35 %) were females, and 17 (25.75 %) had a median household income below 2 times the poverty threshold. 51 (76.11 %) had positive aquaporin4 antibodies, 39 had optic neuritis (57.35 %), and 29 (42.63 %) had myelitis. We classified total relapses into less than 3 vs more than 3, cumulative days of hospitalization into less than 5 vs more than 5, and readmission frequency as less than 1 vs more than 1 per year. The majority of cases had less than 3 relapses (SN = 38 vs 11, MN = 22 vs 6, p > .05), less than 5 days of cumulative hospitalizations (SN = 29 vs 6, MN = 15 vs 5, p > .05), and less than 1 readmissions in a year (SN 15 vs 5, p > .05, MN = 14 vs 10, p > .05).

CONCLUSION

The severity of the disease can be attributed to the major clinical criteria at the time of diagnosis. This can be helpful to identify cases that may have a higher disease burden to the patient and the hospital. Larger studies are needed to confirm the same.

Therapeutic inertia in the management of neuromyelitis optica spectrum disorder

Introduction and objective

Limited information is available on how neurologists make therapeutic decisions in neuromyelitis optica spectrum disorder (NMOSD), especially when new treatments with different mechanisms of action, administration, and safety profile are being approved. Decision-making can be complex under this uncertainty and may lead to therapeutic inertia (TI), which refers to lack of treatment initiation or intensification when therapeutic goals are not met. The study aim was to assess neurologists' TI in NMOSD.

Methods

An online, cross-sectional study was conducted in collaboration with the Spanish Society of Neurology. Neurologists answered a survey composed of demographic characteristics, professional background, and behavioral traits. TI was defined as the lack of initiation or intensification with high-efficacy treatments when there is evidence of disease activity and was assessed through five NMOSD aquaporin-4 positive (AQP4+) simulated case scenarios. A multivariate logistic regression analysis was used to determine the association between neurologists' characteristics and TI.

Results

A total of 78 neurologists were included (median interquartile range [IQR] age: 36.0 [29.0-46.0] years, 55.1% male, median [IQR] experience managing demyelinating conditions was 5.2 [3.0-11.1] years). The majority of participants were general neurologists (59.0%) attending a median (IQR) of 5.0 NMOSD patients (3.0-12.0) annually. Thirty participants (38.5%) were classified as having TI. Working in a low complexity hospital and giving high importance to patient's tolerability/safety when choosing a treatment were predictors of TI.

Conclusion

TI is a common phenomenon among neurologists managing NMOSD AQP4+. Identifying TI and implementing specific intervention strategies may be critical to improving therapeutic decisions and patient care.

In patients with mild disability NMOSD: is the alteration in the cortical morphological or functional network topological properties more significant

Objective

To assess the alteration of individual brain morphological and functional network topological properties and their clinical significance in patients with neuromyelitis optica spectrum disorder (NMOSD).

Materials and methods

Eighteen patients with NMOSD and twenty-two healthy controls (HCs) were included. The clinical assessment of NMOSD patients involved evaluations of disability status, cognitive function, and fatigue impact. For each participant, brain images, including high-resolution T1-weighted images for individual morphological brain networks (MBNs) and resting-state functional MR images for functional brain networks (FBNs) were obtained. Topological properties were calculated and compared for both MBNs and FBNs. Then, partial correlation analysis was performed to investigate the relationships between the altered network properties and clinical variables. Finally, the altered network topological properties were used to classify NMOSD patients from HCs and to analyses time- to-progression of the patients.

Results

The average Expanded Disability Status Scale score of NMOSD patients was 1.05 (range from 0 to 2), indicating mild disability. Compared to HCs, NMOSD patients exhibited a higher normalized characteristic path length (λ) in their MBNs (P = 0.0118, FDR corrected) but showed no significant differences in the global properties of FBNs (p: 0.405-0.488). Network-based statistical analysis revealed that MBNs had more significantly altered connections (P< 0.01, NBS corrected) than FBNs. Altered nodal properties of MBNs were correlated with disease duration or fatigue scores (P< 0.05/6 with Bonferroni correction). Using the altered nodal properties of MBNs, the accuracy of classification of NMOSD patients versus HCs was 96.4%, with a sensitivity of 93.3% and a specificity of 100%. This accuracy was better than that achieved using the altered nodal properties of FBNs. Nodal properties of MBN significantly predicted Expanded Disability Status Scale worsening in patients with NMOSD.

Conclusion

The results indicated that patients with mild disability NMOSD exhibited compensatory increases in local network properties to maintain overall stability. Furthermore, the alterations in the morphological network nodal properties of NMOSD patients not only had better relevance for clinical assessments compared with functional network nodal properties, but also exhibited predictive values of EDSS worsening.

Understanding Treatment Decisions in Neuromyelitis Optica Spectrum Disorder: A Global Clinical Record Review with Patient Interviews

INTRODUCTION

We sought insights into neuromyelitis optica spectrum disorder (NMOSD) treatment practices worldwide.

METHODS

Neurologists from the USA, Germany, Italy, Brazil, South Korea, and China completed an online survey, contributing clinical records for aquaporin-4 (AQP4) immunoglobulin G (IgG)-seropositive adults with NMOSD, which included patient demographics, diagnosis, maintenance treatment history, relapse occurrence, and severity. Interviewed patients receiving NMOSD maintenance therapy provided information about their diagnosis, treatment, perceptions about relapse severity or disease stability, and treatment switches.

RESULTS

A total of 389 neurologists submitted clinical records for 1185 patients with AQP4-IgG-seropositive NMOSD; 33 patients with NMOSD were interviewed. Approximately 25% (228/910) of patients from the clinical record review (CRR) were initially misdiagnosed; 24% (8/33) of patients interviewed reported formal misdiagnosis. Misdiagnosis was associated with treatment delay and more relapses compared with correct diagnosis (mean 3.3 vs 2.8). Maintenance therapy was not initiated within 2 months for 47% (221/472) of patients from the CRR and 24% (8/33) of interviewed patients. Oral corticosteroids/immunosuppressive therapies were typically the first maintenance treatment initiated, except for the USA, where monoclonal antibodies were equally likely to be prescribed. Relapse severity influenced the decision to initiate/change therapy and use monoclonal antibodies. Of interviewed patients, 76% (25/33) did not recall having a choice of treatment and many did not know the rationale for treatment choice.

CONCLUSION

Misdiagnosis of NMOSD appears to be common and is associated with a delay in initiation of maintenance therapy, with decisions influenced by relapse severity. Further real-world studies assessing relapse severity in treatment initiation/switch are required to revise NMOSD treatment recommendations.