medwireNews: Patients with myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) who are treated within 5 days of their first attack have better clinical outcomes than those treated later, a study suggests.
The results of the retrospective study showed that patients treated within 5–14 days (intermediate) or beyond 14 days (late) of the first attack were more than twice as likely to relapse as those treated early, with respective adjusted hazard ratios (aHRs) of 2.02 and 2.64. A relapse was defined as a new clinical episode occurring at least 30 days after the onset date of the previous acute attack.
Additionally, patients treated early were seven times more likely than those treated later to convert to seronegative status for disease biomarker MOG-immunoglobulin G (MOG-IgG).
“This finding can be especially useful in clinical practice of MOGAD, as acute treatment may eliminate a requirement for any long-term medical treatment in a proportion of patients and has significantly less adverse effects compared with its counterpart, diverse NSIS [nonsteroidal immunosuppressant] and/or oral corticosteroid maintenance treatment,” write Sung-Min Kim (Seoul National University College of Medicine, Seoul, Republic of Korea) and colleagues in JAMA Neurology.
The investigators obtained clinical records and samples from 240 patients in hospitals in South Korea. Eligible participants had adult-onset MOGAD and either had experienced a relapse or were followed up for more than 12 months after disease onset and had a detailed medical record of their first attack.
The patients (52.1% women) had a median age at disease onset of 40.4 years and a median disease duration of 3.07 years. The most common symptom at onset was optic neuritis, which occurred in 52.1% of the participants, and the vast majority (97.1%) of patients were seropositive for MOG-IgG.
A total of 76.7% of patients received acute treatment within a month and the majority (97.8%) received intravenous corticosteroids, while 11.7% and 6.7% received additional intravenous immunoglobulin and therapeutic plasma exchange, respectively. A total of 62.4% of the patients also received oral corticosteroids for at least 1 month and 41.2% received NSIS maintenance.
Relapse occurred in 45.8% patients after a median duration of 0.45 years. The researchers note that there were no differences between this group and the 54.2% of patients who remained monophasic in terms of the severity of the onset attack, type of acute treatment, and type of NSIS maintenance.
However, patients who did not relapse were significantly more likely than those who did to have a shorter time to treatment of the first acute MOGAD attack, at a median 8.5 (3–14 days) versus 13 days (5–31 days). They were also significantly more likely to receive oral corticosteroids for at least a month (61.6 vs 38.4%) and NSIS maintenance treatment (63.1 vs 15.5%), such as azathioprine and mycophenolate mofetil.
Receipt of NSIS maintenance treatment (aHR 0.24) was an independent risk factor for relapse alongside early treatment of the first MOGAD attack in multivariable analysis, whereas receipt of corticosteroids was not.
Kim and colleagues also highlight that time to treatment of the first attack remained a significant independent risk factor for relapse irrespective of NSIS maintenance treatment. Among a subgroup of 141 patients who did not receive NSIS maintenance treatment, the aHR for relapse was 2.68 among patients who received intermediate treatment and 3.51 for those who received late treatment, compared with early treatment.
Moreover, among 116 patients who completed two MOG-IgG tests at least 12 months apart, 25.0% converted to MOG-IgG negative, and the odds of achieving this were significantly increased among patients treated early after the first attack (aHR=7.04), whereas there was no association with receipt of NSIS maintenance treatment.
“We speculate that although NSIS treatment might merely suppress the immune system and therefore may allow potential breakthrough relapses, early acute treatment of the first MOGAD attack may truly modulate humoral autoimmunity,” write Kim et al.
Given that the study was retrospective, they note that there was variation in how MOG-IgG was tested and limited data to understand the link between the onset levels of MOG-IgG and disease prognosis.
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