High-efficacy therapies reduce clinical and radiological events more effectively than traditional treatments in neuromyelitis optica spectrum disorder

Background: People with neuromyelitis optica spectrum disorder (pwNMOSD) experience debilitating neurological attacks, resulting in permanent disability. Objective: To evaluate if high-efficacy treatment was better than traditional agents at preventing disease advancement in pwNMOSD. Methods: A retrospective study of pwNMOSD at one academic center was performed. Timelines were created for treatments subjects were exposed to along with clinical/radiological events related to disease worsening. High-efficacy treatments included eculizumab, inebilizumab, satralizumab, rituximab, ocrelizumab, tocilizumab, and sarilumab while therapies such as azathioprine, methotrexate, cyclophosphamide, and mycophenolate mofetil were classified as traditional agents. Poisson regression and mixed effects logistics models were constructed, and a subject-specific random intercept was used for intrasubject correlation. Results: Of 189 pwNMOSD identified, 161 were aquaporin-4 IgG positive (AQP4 +) with 92 (77 female; median disease duration (MDD) (range) of 6.6 years (y) (1.2–18.6)) exposed only to high-efficacy therapy, 33 (28 female; 10.4 y (0.8–32.7)) only to traditional therapy, and 64 (54 female; 10.8 y (0.7–20.2)) to both. High-efficacy treatments reduced the rate of MRI advancement by 62.4% (95% CrI = [– 86.9%, – 16.8%]), relapses by 99.8% (95% CrI = [– 99.9%, – 99.6%]), and hospitalizations by 99.3% (95% CrI = [– 99.6%, – 98.8%]) when compared to traditional treatments. For AQP4 + subjects, a 655.7-fold increase in the odds of new spinal cord lesion development (95% CrI = [+ 37.4-fold, + 3239.5-fold]) was observed with traditional agents (p < 0.0001). Conclusion: High-efficacy treatments maximize opportunity for preventing disease advancement in newly diagnosed and established pwNMOSD.