Combining steroids, blood-cleaning treatment aids NMOSD outcomes
Patients given both therapies showed lower EDSS scores after 6 months
Combining blood-cleaning therapies such as plasma exchange or immunoadsorption with standard steroid treatment can improve recovery outcomes in patients having an attack of neuromyelitis optica spectrum disorder (NMOSD), a study that reported no significant safety concerns shows.
The study, “Efficacy and safety of apheresis therapy in AQP4 antibody‐positive NMOSD attack: A propensity score‐matched cohort study,” was published in CNS Neuroscience & Therapeutics by researchers in China.
In NMOSD, self-reactive antibodies trigger inflammatory attacks on the eye nerves and spinal cord that can result in impaired vision and movement-related problems. In most patients, the antibodies are directed against aquaporin-4 (AQP4), a water channel protein on the cells of the nervous system.
During an attack, patients often see their symptoms, such as vision loss or paralysis, worsen and require immediate and effective treatment to minimize long-term damage. Each attack brings more damage that builds up over time and can often lead to disability.
Treatment typically begins with an injection into the vein of the steroid methylprednisolone that helps calm the immune system and reduce inflammation. This approach alone only leads to remission in about 19% of patients, however.
Combining therapies
For moderate to severe relapses, or when a response to intravenous methylprednisolone isn’t adequate, combining the steroid with an early administration of blood-cleaning procedures may improve outcomes.
Two such procedures are plasma exchange, called plasmapheresis, and immunoadsorption. In plasma exchange, harmful antibodies are removed from the bloodstream, while immunoadsorption specifically filters out particular antibodies like those that target the AQP4 that plays a role in NMOSD attacks.
Combining plasma exchange or immunoadsorption with steroids has shown promise in NMOSD, but there remained a lack of quality evidence to support the approach, the researchers said. To address this, they compared the effectiveness of combining these blood-cleaning therapies with intravenous methylprednisolone against the steroid alone.
Researchers used data from 336 patients that included 90 attacks. Thirty were treated with plasma exchange or immunoadsorption plus intravenous methylprednisolone and 60 were treated with intravenous methylprednisolone alone.
At the time of an attack, median Expanded Disability Status Scale (EDSS) scores were similar between the two groups (6.25 vs. 6.75). EDSS measures and monitors disability levels, with scores ranging from 0 to 10 and higher scores indicating more disability.
After six months, scores dropped in both groups, but those given the combined treatment scored lower — 3 vs. 4.5 points. These patients were about half as likely as those treated with methylprednisolone alone to have higher EDSS scores, meaning more disability. Those given the combined treatment also had significantly better visual acuity than those just treated with methylprednisolone.
While immunoadsorption caused a drop in fibrinogen, a clotting protein, in 15 patients, no serious side effects were seen that required stopping either blood-cleaning procedure. This suggests the combined treatment is both effective and safe.
The most significant factor that influenced patients’ improvement was their initial level of disability. A predictive model developed for the combined treatment demonstrated high accuracy, indicating its potential usefulness in forecasting a recovery.
“Receiving corticosteroids combined with [plasma exchange/immunoadsorption] was a predictor of a good outcome, whereas severe acute disability (high EDSS score) was a predictor of a poor outcome,” the researchers wrote.
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