Treatment

Early detection and treatment improve overall outcomes for neuromyelitis optica spectrum disorder (NMO). The number and severity of attacks worsen the outcomes of the disease. Because of this, it is important to get the correct diagnosis and treatment as soon as possible.1

Neuromyelitis optica treatments can be described as acute (immediate or short-term) or preventative.2

Acute treatments

Acute treatment for NMO is used to decrease symptoms of the disease right when they start. Acute treatment includes high-dose steroids and plasma exchange (also called parapheresis or PLEX).2

High-dose steroids

Steroids (corticosteroids) are strong anti-inflammatory drugs. Your body normally makes steroids in the adrenal glands, but when given in doses larger than the amount your body makes, steroids work to quickly decrease inflammation.3

In NMO, high-dose steroids are essential to help prevent vision loss during an attack of optic neuritis (inflammation of the nerve fibers in the eye) or to treat transverse myelitis (inflammation of the spinal cord). Methylprednisolone is the most common steroid given to those with NMO.2,4

High-dose steroids also help decrease inflammation and prevent long-term, irreversible damage to the spinal cord during an NMO attack that includes transverse myelitis.4

Plasma exchange

Antibodies are proteins in your body that normally protect you from different germs that can make you sick. In autoimmune diseases such as NMO, some antibodies mistake healthy cells for harmful ones and attack them. This leads to different damage and symptoms depending on the location of the attack.5

In NMO, the antibody that attacks a protein called aquaporin-4 (AQP4) causes damage to the protective coating on nerve cells in the brain and spinal cord. This coating is known as myelin. While many people with NMO have AQP4 antibodies (AQP4-IgG) in their blood, 1 in 4 people do not. Some have no antibodies at all. This adds to the complexity of the disease.6,7

Plasma exchange may be an effective treatment in those who have sudden, severe attacks that do not respond to high-dose IV steroids. It involves removing some blood and using a machine to separate the blood cells from the fluid (plasma). Blood cells are then mixed with a replacement solution (donor plasma) and returned to the body. This process filters the blood in order to remove harmful immune system antibodies.8-10

Studies have shown that plasma exchange may improve NMO symptoms. However, this treatment should be started early for it to be effective. Many times, plasma exchange treatments are given in the hospital for proper monitoring.9

Preventative treatments

The goal of preventative treatment is to decrease the number or severity of attacks. An attack can lead to worsening disability, making it critical to prevent them. Until recently, prevention drugs were not available to those with NMO.11

Biologics are drugs made from living cells. These cells can come from parts of the blood, proteins, viruses, or tissue. Components from these cells are isolated and tested for activity against human diseases. This process turns the cells into drugs that can treat conditions like NMO.12

As of early 2021, the U.S. Food and Drug Administration (FDA) has approved 3 biologic drugs for the treatment of those with AQP4 antibody (AQP4-IgG) NMO:11

Soliris (eculizumab)

Soliris (eculizumab) is a laboratory-made antibody used to decrease the risk of an NMO attack. The exact way Soliris works is not known. Soliris is given by IV infusion, usually every 5 weeks.13,14

Enspryng™ (satralizumab)

Enspryng™ (satralizumab) is the first approved treatment in NMO that is made to block interleukin-6 (IL-6). IL-6 is a protein made by cells in the body and plays a role in the inflammation that occurs in NMO. Enspryng blocks IL-6 from attaching to the cell surface. The medicine is given by self-injection once per month. If your doctor prescribes this drug, you will receive training on the safe and correct way to inject it.15,16

Uplizna™ (inebilizumab)

Uplizna™ (inebilizumab) is believed to work by lowering the number of your body’s B cells, which are part of your immune response. With fewer of these cells, the immune system of those with NMO may not react as severely. Uplizna is given twice a year by IV infusion.17,18

Off-label drug use

For a drug to be approved by the FDA, a company must show data about the safe and effective use of the drug. All drugs have side effects, so something being “safe” does not mean that it has no side effects. Instead, the FDA decides that an approved drug has more benefits than risks (side effects).19

FDA approval takes time and requires careful evaluation. Sometimes, doctors decide an approved drug may benefit another condition that the drug was not approved to treat. This is called off-label use. It can also be off-label use if a drug is given in a different dose (such as taking 2 pills instead of 1) or in another way (like taking a liquid form instead of a pill) from the dose or way approved by the FDA.19

Off-label uses are common in rare diseases where not many drugs are used to treat the condition. If you and your doctor decide on off-label use of a drug, you should understand that the FDA has not yet declared the drug is safe when used the way you are taking it. However, this does not mean your use of the drug is unsafe. Often, it just means there has not been a large, official clinical trial of this specific drug for this specific rare disease. Talk to your doctor about your treatment questions and needs.19

Some off-label and unapproved drugs commonly used to treat NMO include:20-25

  • Rituxan (rituximab), a laboratory-made antibody
  • Mitoxantrone, an anti-cancer drug
  • Campath and Lemtrada (alemtuzumab), which are laboratory-made antibodies
  • Imuran and Azasan (azathioprine), which are drugs that decrease the immune response
  • CellCept (mycophenolate mofetil), a drug that decreases the immune response
  • Trexall, Otrexup, and Rasuvo (methotrexate), which are disease-modifying antirheumatic drugs (DMARDs)
  • Actemra (tocilizumab), a laboratory-made antibody

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Written by: Katie Murphy | Last reviewed: September 2021