Perspectives on the treatment of neuromyelitis optica: a literature review

Abstract

Introduction: Neuromyelitis optica (NMO) is an autoimmune inflammatory demyelinating disease that affects the central nervous system, predominantly impacting the optic nerves and spinal cord. Clinical manifestations usually occur in a relapsing-remitting manner, becoming progressively disabling and carrying a high risk of mortality (Luo et al., 2022). To prevent these relapses and disabilities, new sequential treatments are of great interest for medical practice. Objective: To compare current sequential treatments for neuromyelitis optica. Methodology: This is a literature review on current sequential treatments for NMO. Data were obtained through a search in the “Biblioteca virtual de saúde” Virtual Health Library (BVS) using the search strategy: "neuromyelitis optica" AND "therapy." Three articles that met the criterion of a systematic review with meta-analysis from the last five years on the main topic of NMO treatment were selected. Results and Discussion: Sequential therapy is based on oral corticosteroids and, primarily, on the immunosuppression of altered immune system cells, especially the depletion of B-type lymphocytes. In this context, several drugs are employed such as eculizumab (ECZ), azathioprine (AZA), and rituximab (RTX). The first has proven effective in preventing relapses in 98.9% of patients over 2 years, while RTX and AZA stand out for their safety (Luo et al., 2022). Furthermore, RTX shows greater efficacy than AZA in reducing the annual relapse rate (Weighted Mean Difference of 1.45 after treatment) and in the progression measured by the Expanded Disability Status Scale (EDSS) (Dong; Meng; Xiao, 2022), thus standing out among treatment options. Additionally, autologous hematopoietic stem cell transplantation after local conditioning with immunosuppressants has shown to be favorable for severe cases, with a reduction of 0.81 points in the EDSS (Nabizadeh et al., 2022). Conclusion: Rituximab has emerged as the most promising new sequential therapy due to its safety and efficacy compared to other immunosuppressants.