Early Treatment Initiation With Oral Prednisolone for Relapse Prevention Alleviates Depression and Fatigue in Aquaporin-4-Positive Neuromyelitis optica Spectrum Disorder

Anti-IL-6 receptor antibody suppresses onset of paralytic symptoms in AQP4 peptide-immunized mice without lowering bone strength or mineral density

Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune disease characterized by the production of autoantibodies against aquaporin-4 (AQP4). Treatment with prednisolone (PSL) or anti-IL-6 receptor (IL-6R) antibody can reduce the frequency of relapse in patients with AQP4 antibody-positive NMOSD. We previously established a mouse model of paralysis induced by intradermal immunization with AQP4 peptide. In this study, we investigated the effects of PSL and anti-IL-6R antibody treatment on paralysis and on bone fragility in this NMOSD mouse model. Prednisolone and anti-IL-6R antibody treatment each suppressed the clinical scores and incidence of paralytic symptoms in AQP4 peptide-immunized mice. High-PSL treatment induced thinning of cortical bone and reduction of tissue mineral density in the femoral shaft and a decrease in femoral bone strength, although it increased bone volume/tissue volume in the trabecular bone of the distal femur. In contrast, anti-IL-6R treatment showed no significant differences in bone strength or cortical thickness compared to the non-immunized naive group. Bone morphometric analysis showed that high-PSL treatment reduced the bone formation rate in both cortical and trabecular bone, with a predominance of bone resorption, whereas anti-IL-6R treatment demonstrated no notable effect on bone metabolism. These results suggest that anti-IL-6R antibody can prevent the development of paralytic symptoms in AQP4 peptide-immunized mice without reducing bone strength.

Effectiveness and safety of glucocorticoids bridging rituximab in neuromyelitis spectrum disorder

BACKGROUND

Anti-CD20 monoclonal antibody rituximab have been widely used to prevent relapses in patients with neuromyelitis optica spectrum disorder (NMOSD), but data on early use of oral prednisone overlapping with rituximab for effective reduction of relapses are limited. In this study, we evaluated the long-term efficacy of oral prednisone bridging rituximab therapy in NMOSD patients with anti-aquaporin-4 antibody (AQP4-IgG).

METHODS

We collected the medications and disease activities in patients with AQP4-IgG+ NMOSD patients in this retrospective study. Time to first relapse was evaluated after starting stable doses of prednisone and/or initiating rituximab. We compared the efficacy and safety of different doses of prednisone with sequential rituximab treatment in NMOSD.

RESULTS

211 patients fulfilled the inclusion criteria for the study, including 91 patients who were treated with prednisone monotherapy and 120 patients who were treated with prednisone bridging rituximab. In total, 59.3% (54/91) of patients in the prednisone monotherapy group experienced new relapses. The proportions of patients with relapses were different in the subgroups of prednisone monotherapy, with 100% (23/23) in the group of dose ≤ 5mg/d, 64.1% (25/39) in the group of doses 7.5-10mg/d, and 20.7% (6/29) in the group of dose ≥ 12.5mg/d. 24.2% (29/120) of patients in the prednisone bridging rituximab group experienced relapses. Bridging rituximab regimen significantly reduced the risk of relapses compared to prednisone monotherapy (hazard ratio: 0.24, 95% CI: 0.15-0.38, p < 0.0001). Patients with prolonged usage of prednisone tapering (6-12 months) had a significant reduction in the relapse risk compared to those with prednisone tapering 3-6 months (hazard ratio: 0.3119, 95% CI: 0.09125-1.066, p = 0.0264). The most common adverse events were hyperlipidemia in the prednisone monotherapy group (17.6%) and infections in the prednisone bridging rituximab group (25.8%).

CONCLUSIONS

Prednisone bridging rituximab therapy is associated with the reduced relapse risk in patients with AQP4-IgG+ NMOSD, especially when the bridging time is over 6 months.

The Importance of Bright Spotty Lesions on Magnetic Resonance Imaging in Predicting Chronic Neuropathic Pain in Myelitis

Background/Objectives: Chronic neuropathic pain (CNP) stands as one of the most debilitating complications in patients with myelitis owing to its challenging management. Bright spotty lesions (BSLs) are frequently observed in neuromyelitis optica spectrum disorder (NMOSD), but few reports have discussed CNP in myelitis. We aim to demonstrate that BSLs could be one of the potential prognostic factors for CNP development in myelitis. Methods: We examined 63 patients diagnosed with myelitis. Patients were categorized into CNP and non-CNP groups. We assessed the severity of clinical symptoms and the oral steroid dose administered after pulse therapy. Spine magnetic resonance imaging (MRI) of each patient was reviewed to analyze the characteristics of myelitis. Serological and cerebrospinal fluid (CSF) findings were also examined to confirm the etiology. Results: CNP was observed in 27 patients (42.9%). The mean onset age of patients with CNP was 45.26 ± 14.16 years. The MRI lesions exhibited more enhanced features and bright spotty lesions (BSLs) in the CNP group (χ2 test, p < 0.05). Patients with CNP received a lower oral steroid dose during the first month after symptom onset (χ2 test, p < 0.05). Multivariate logistic regression analysis revealed that patients with CNP exhibited significant BSLs in their myelitis lesions on spine MRI (OR 4.965; 95% CI, 1.282 to 19.235, p = 0.02). Conclusions: Although the exact mechanism remains unknown, the presence of BSLs on spine MRI could serve as an independent prognostic factor for CNP development. Additionally, our study suggests that lower oral steroid doses administered immediately after symptom onset are associated with CNP development. Further investigation with a larger cohort is warranted to validate our findings.

Effect of ginseng on fatigue related to neuromyelitis optica spectrum disorder: A double-blinded randomized controlled clinical trial

Background

The effects of ginseng on fatigue have been proven in patients with multiple sclerosis (MS), which have several similar manifestations to neuromyelitis optica spectrum disorder (NMOSD) patients. This study was designed to evaluate the effects of ginseng on fatigue in NMOSD patients.

Methods

In this double-blinded randomized controlled clinical trial, 64 patients were recruited and were allocated into two study groups (ginseng or placebo) via block randomization. The participants received either 250-mg ginseng or placebo twice daily for a 3-month period. Also, the measurement of outcome was performed using the valid and reliable Persian version of fatigue severity scale (FSS) questionnaire, which was filled by patients once after enrollment in the study and once at the end of the study post-intervention.

Results

In total, 58 patients finished the study with no major side effects. There were no significant differences in demographic, clinical, as well as FSS between two study groups (p>0.05). Ginseng supplementation significantly reduced fatigue (40.21±13.51 vs. 28.97±14.18; p˂0.01), while patients in the placebo group showed significantly higher fatigue score after 3 months post-intervention (35.03±13.51 vs. 38.79±12.27; P: 0.02). The extent of changes in the fatigue score in the ginseng group was significantly greater than in the placebo group (p ˂0.01).

Conclusion

This study revealed positive effects of ginseng on reducing fatigue in NMOSD patients with no major side effects. In this regard, further studies are warranted to evaluate and clarify the effects of ginseng on fatigue in NMOSD.

The prevalence of depression, anxiety, and sleep disturbances in patients with neuromyelitis optica spectrum disorders (NMOSD): A systematic review and meta-analysis

OBJECTIVE

To estimate pooled prevalence of depression, anxiety, and sleep disturbances in neuromyelitis optica spectrum disorders (NMOSD) cases.

METHODS

Electronic database of PubMed (MEDLINE), the Cochrane Central Register of Controlled Trials (CENTRAL), Embase and Web of Science ware systematically searched to identify relevant studies published not later than June 10, 2022. Specifically, original articles that reported the prevalence of depression, anxiety and sleep disturbances were selected. All pooled prevalence and 95 % confidence intervals (CIs) were calculated using a random-effects model. Publication bias was examined using funnel plots, and sensitivity analysis was used to explore the stability of the pooled results.

RESULTS

A total of 31 studies involving 4213 participants were included in this review. The pooled prevalence of depression was 40 % (95 % CI: 32-49 %), the pooled prevalence of anxiety was 45 % (95 % CI: 24-66 %), and the pooled prevalence of sleeping disturbances was 55 % (95 % CI: 46-64 %). The depression and anxiety prevalence estimates varied based on different screening tools.

CONCLUSIONS

There is a high prevalence of depression, anxiety, and sleep disturbances among NMOSD. These findings underscore the importance of regular monitoring of psychological status in NMOSD as well as the need for preventive approaches, early diagnosis, and intervention to improve medical and psychosocial outcomes.