Monday, June 2, 2014

Treatment of Devic's: comparison study

Mealy MA, Wingerchuk DM, Palace J.  Comparison of relapse and treatment failure rates among patietns with neuromyelitis optica: multicenter study of treatment efficacy.  Jama Neurology 2014; 71:324-330.
Retrospective analysis od 90 patients seen over 10 years at Mayo Clinic and JHH treated with azathioprine (n=32), mycophenolate (n=28), and /or rituximab (n=30).
Azathioprine reduced the relapse rate 72 % with 53 % failure rate despite concurrent use of prednisone
Mycophenolate reduced relapse rate 87 % with a 36 % failure rate.
Rituximab had an 88 % reduction in relapse rate, with 33 % failure rate.
With optimal dosing, rituximab had only a 17 % failure rate.  Ideal dosing was 1000 mg iv, with premedication dose of 100 mg methylprednisolone, with dosage repeated 2 weeks later.  CD 19 was tested monthly, and repeat paired rituximab dosing occurred upon detection of greater than 0.1 % CD19 in total lymphocytes or at regular 6 month intervals.   

Anti MOG antibody disease

Kitley J, Waters P, Woodhall M, et al. Neuromyelitis optica spectrum disorders with aquaphorin-4 and Myelin-oligodendrocyte glycoprotein antibodies: a comparative study.
see Levy M. Does aquaphorin-4-seronegative neuromyelitis optica exist? (editorial) JAMA Neurology 2014; 71:271-2.
Authors of both studies ferret out a subtype of seronegative NMO that is actually yet another disease.   Anti MOG positve patients with clinical features of NMO have a slightly different phenotype with features of ADEM also.  This group encompasses young males with severe episodes with better recoveries that are more likely to be monophasic, sometimes with simultaneous or rapidly sequential optic neuritis and transverse myelitis.. AntiMOG patients also had more conus involvement on spine MRI and more involvement of deep gray nuclei on brain MRI.  There were no patients with both anti MOG and anti AQU4 antibodies.  anti MOG antibodies are available at Neuroimmunology Testing Service, Oxford, England for 30 pounds).  "n" of the study was 10 aq-4 patients and 9 MOG AB patients. 
More clinical information:  4/9 anti MOG and 6/20 AQU$ AB patients had ON as initial invoolvement or part of ; anti MOG had more bilateral ON involvement (75 v. 33 %); both had severe ON when it did happen.  12/20 AQU$ 4 and 9/9 antiMOG had spinal cord involvement initially; Transverse myelitis differed with more bladder involvement in anti MOG patients as iniital symptom (33 v. 0 %) and more late sphincter disturbance in NMO ab patients.  Brain MRI was more likley to be ADEM like in MOG ab patients (44 %) v. 0 % in NMO. 

Wednesday, April 23, 2014

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