Clinical efficacy and safety of single cycle rituximab as induction therapy for aggressive neuromyelitis optica spectrum disorder in a resource limited center: a preliminary study

Abstract

Aim: To analyse the efficacy of single dose rituximab (RTX) as induction therapy followed by conventional oral steroid-sparing agents (azathioprine, mycophenolate mofetil or methotrexate) in a cohort of patients with aggressive neuromyelitis optica spectrum disorder (NMOSD) without CD19, 20 and 27 biomarker testing. Methods: A retrospective analysis of clinical outcomes in eight patients with aggressive NMOSD treated with one course of RTX induction therapy in the Neurology Department at Kuala Lumpur Hospital from 2005 to 2018 was performed. The effectiveness of the treatment was determined by the number of relapses, expanded disability status scale, annualized relapsed rates, and modified Rankin Scale both before and after treatment. B cell enumeration testing was done instead of CD19, 20 and 27 biomarker testing. Results: There was a reduction in the mean annualized relapse rate from 4.7 to 0.5 attacks per year after treatment (P = 0.011). Mean expanded disability status scale and modified Rankin Scale values improved from 5.4 to 3.6 (P = 0.018) and 3.6 to 2.6 (P = 0.023), respectively. No patient developed any adverse effect. Conclusion: Single-course RTX induction therapy regime may be an alternative therapeutic option in resource limited hospitals to suppress NMOSD disease activity in the short term as pulse induction therapy whilst awaiting the effectiveness of conventional steroid-sparing agents. Further prospectively designed studies are required to prove efficacy.

Management of Idiopathic CNS inflammatory diseases during the COVID-19 pandemic: Perspectives and strategies for continuity of care from a South East Asian Center with limited resources.

“…At our center, rituximab is given as induction therapy as a single short course 1 g 2 weeks apart or as 6 monthly courses up to 2 years followed by de-escalation to modest potency IS/DMT's or longer as maintenance treatment in NMO/NMOSD/MS (Malaysian Clinical Practice 2015; Ong et al, 2020). Alternatively, we use IVIG as acute treatment for relapses and maintenance treatment in NMO/NMOSD, MOGAD, ADEM and MS patients (Malaysian Clinical Practice 2015; Ong et al, 2020;Salzer et al, 2016;Viswanathan et al, 2015;Olyaeemanesh et al, 2016;Sutton and Visintini, 2018;Lünemann et al, 2016;Young et al, 2020;Tsantes et al, 2019). Based on modest local data and guidelines,it is given as induction monthly infusions for 3 months followed by 3 monthly infusions (Malaysian Clinical Practice 2015; Ong et al, 2020;Viswanathan et al, 2015).…”

“…Alternatively, we use IVIG as acute treatment for relapses and maintenance treatment in NMO/NMOSD, MOGAD, ADEM and MS patients (Malaysian Clinical Practice 2015; Ong et al, 2020;Salzer et al, 2016;Viswanathan et al, 2015;Olyaeemanesh et al, 2016;Sutton and Visintini, 2018;Lünemann et al, 2016;Young et al, 2020;Tsantes et al, 2019). Based on modest local data and guidelines,it is given as induction monthly infusions for 3 months followed by 3 monthly infusions (Malaysian Clinical Practice 2015; Ong et al, 2020;Viswanathan et al, 2015). During this pandemic IVIG was given as bridging to pwMS unable to obtain supply/funding for first line injectables/ orals, as add-on to existing IS (Azathioprine/Mycophenolate mofetil/cyclophosphamide) (Young et al, 2020;Tsantes et al, 2019) in NMO/ NMOSD/MOGAD (Young et al, 2020) or for those deferring more aggressive DMT/IS 's such as rituximab (Malaysian Clinical Practice 2015; Viswanathan et al, 2015;Olyaeemanesh et al, 2016;Sutton and Visintini, 2018;Young et al, 2020;Tsantes et al, 2019) (See Table 3).…”

“…In all cases, proper pre-screening for symptoms of COVID-19 was advised. Recent studies from our center showed benefit of alternatives like short course induction rituximab followed by IS and IVIg in patient's with NMO/NMOSd as maintenance therapies as well as modest quality Ong et al, 2020;Viswanathan et al, 2015). In the majority of the pwiCNSIDs we continued DMT's or IS without interruptions or lengthened/deferred for the short term potent DMT's/IS(oral/infusions) and blood/neuroimaging surveillances with a plan for revision once the local epidemiology of COVID-19 cases reduced.…”