Trends in Management Practices of Seropositive Neuromyelitis Optica Spectrum Disorder: Lessons from a Multicenter Academic Cohort
Leah Zuroff1, Jaeleene Wijangco3, Rachel Brandstadter2, Myla Goldman4, Edith Graham5, Rebecca Farber6, Navid Valizadeh7, Leorah Freeman7, Bruce Cree8, Riley Bove9, Dina Jacobs2
1Hospital of the University of Pennsylvania, 2Neurology, Hospital of the University of Pennsylvania, 3Neurology, University of California San Francisco, 4Neurology, Virginia Commonwealth University, 5Neurology, Northwestern University, 6Neurology, Columbia University Irving Medical Center, 7Neurology, Dell Medical School, The University of Texas at Austin, 8UCSF, Multiple Sclerosis Center, 9Neurology, University of California, San Francisco
Objective:
To characterize evolving management of neuromyelitis optica spectrum disorder (NMOSD) in clinical practice.
Background:
Timely initiation of high-efficacy DMT is critical for preventing disability in NMOSD. Three targeted disease-modifying therapies (DMTs) for aquaporin 4-seropositive NMO have been recently approved and augment existing treatments such as rituximab. Real-world data on factors likely to influence management decisions, such as treatment epoch or race/ethnicity, are lacking.
Design/Methods:
A multicenter collaboration was established to evaluate real-world NMOSD outcomes. Demographic and clinical data were retrospectively collected from medical records of seropositive NMO patients from two participating centers. Treatment epochs were divided into pre-2010 (N=25), 2010-2018 (N=71), and 2019+ (N=37). Comparisons were performed using Pearson’s chi2 or Wilcoxon rank sum test.
Results:
These 163 seropositive patients were predominantly female (86.5%) and racially diverse (Asian, 18.4%; Black 26.4%; Non-Hispanic White, 23.9%; Hispanic 21.5%). Median (IQR) baseline EDSS was 4(2.5-6.5). The most common initial DMT across all epochs was rituximab (48.0%, 61.1%, 51.3%). The second most common initial DMT varied: MS-specific therapies pre-2010 (36%), mycophenolate mofetil 2010-2019 (22.2%), and eculizumab 2019+ (24.3%). Since 2019+, newer agents were rarely the initial prescription (inebilizumab, 8.1%; satralizumab: 0%). Key factors influencing choice of new FDA-approved DMT were perceived drug efficacy (42.8%), side effect profile (28.5%), and dosing schedule (11.4%). A preliminary investigation revealed no association between race/ethnicity and differences in baseline EDSS, number of medication trials, or use of FDA-approved DMT (p>0.05 for each).
Conclusions:
In this cohort, despite introduction of new NMOSD DMTs, rituximab remained the most widely used. Treatment decisions appeared based primarily on disease activity and therapy-specific features, with no apparent association with patient race. Further work in the larger geographically diverse collaborative cohort will explore the potential impact of race/ethnicity and other sociodemographic factors on early access to NMOSD specialist care and its impact on disease outcomes.