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Evaluation of effect of empirical attack-preventive immunotherapies in neuromyelitis optica spectrum disorders: An update systematic review and meta -analysis

  • Jia Ma
    Affiliations
    Department of Neurology, Beijing Shunyi Hospital, NO.3 Guangming South Street, Shunyi District, Beijing 101300, China

    Department of Neurology, Beijing Tiantan Hospital, China National Clinical Research Center for Neurological Diseases, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100160, China
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  • Haihua Yu
    Affiliations
    Department of Neurology, Beijing Shunyi Hospital, NO.3 Guangming South Street, Shunyi District, Beijing 101300, China
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  • Hao Wang
    Affiliations
    Department of Neurology, Beijing Shunyi Hospital, NO.3 Guangming South Street, Shunyi District, Beijing 101300, China
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  • Xinghu Zhang
    Correspondence
    Corresponding authors.
    Affiliations
    Department of Neurology, Beijing Tiantan Hospital, China National Clinical Research Center for Neurological Diseases, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing 100160, China
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  • Kai Feng
    Correspondence
    Corresponding authors.
    Affiliations
    Department of Neurology, Beijing Shunyi Hospital, NO.3 Guangming South Street, Shunyi District, Beijing 101300, China
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Published:December 16, 2021DOI:https://doi.org/10.1016/j.jneuroim.2021.577790

      Highlights

      • Neuromyelitis optica is a serious autoimmune disease of the central nervous system.
      • Rituximab, mycophenolate mofetil, azathioprine can effectively treat the disease.
      • RTX significantly reduced ARR ratio compared with the other two drugs.

      Abstract

      Background

      Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disease of the central nervous system, which mainly involves the optic nerve and spinal cord. Frequent relapse can accumulate the degree of disability. At present, the main treatment options are immunosuppressants and blood purification. The first-line immunosuppressants for NMOSD are mainly rituximab (RTX), mycophenolate mofetil (MMF) and azathioprine (AZA). Therefore, we designed this systematic review and meta-analysis to evaluate the safety and effect of the above three drugs in the treatment of NMOSD patients.

      Methods

      The following Medical Subject Heading (MeSH) and related entry terms are used to search English literature in PubMed, MEDLINE and CENTRAL databases, respectively. MeSH include: Neuromyelitis optic and Rituximab or Azathioprine or Mycophenolate Mofetil; entry terms include: NMO Spectrum Disorder, NMO Spectrum Disorders, Neuromyelitis Optica (NMO) Spectrum Disorder, Neuromyelitis Optica Spectrum Disorders, Devic Neuromyelitis Optica, Neuromyelitis Optica, Devic, Devic's Disease, Devic Syndrome, Devic's Neuromyelitis Optica, Neuromyelitis Optica (NMO) Spectrum Disorders, CD20 Antibody, Rituximab CD20 Antibody, Mabthera, IDEC-C2B8 Antibody, GP2013, Rituxan, Mycophenolate Mofetil, Mofetil, Mycophenolate, Mycophenolic Acid, Morpholinoethyl Ester, Cellcept, Mycophenolate Sodium, Myfortic, Mycophenolate Mofetil Hydrochloride, Mofetil Hydrochloride, Mycophenolate, RS 61443, RS-61443, RS61443, azathioprine sodium, azathioprine sulfate (note: literature retrieval operators “AND” “OR” “NOT” are used to link MeSH with Entry Terms.)
      The literature search found a total of 3058 articles about rituximab, mycophenolate mofetil and azathioprine in the treatment of NMOSD, 63 of which were included in this study after a series of screening.

      Results

      930,933,732 patients with NMOSD were enrolled, who had been treated with MMF, AZA and RTX, respectively. The pooled standardized mean difference (SMD) of EDSS before and after RTX treated was −0.58 (95%CI: −0.72, −0.44) (I2 = 0%, p = 0.477), before and after MMF treated was −0.47 (95%CI: −0.73, −0.21) (I2 = 85.6%, p<0.001), before and after AZA treated was −0.41 (95%CI: −0.60, −0.23) (I2 = 65.4%, p<0.001). there was no significant difference in the effect of the three drugs on reducing EDSS scores (RTX vs MMF, p = 0.522; RTX vs AZA, p = 0.214; MMF vs AZA, p = 0.732). The pooled standardized mean difference (SMD) of ARR before and after RTX treated was −1.45 (95%CI: −1.72, −1.18) (I2 = 72.4%, p<0.001), before and after MMF treated was −1.14 (95%CI: −1.31, −0.97) (I2 = 54.5%, p<0.001), before and after AZA treated was −1.11 (95%CI: −1.39, −0.83) (I2 = 83.4%, p<0.001). RTX significantly reduced ARR compared with the other two drugs (RTX vs MMF, p = 0.039; RTX vs AZA, p = 0.049; MMF vs AZA, p = 0.436).

      Conclusion

      The results of this systematic review and meta-analysis showed that the treatment of NMOSD patients with RTX, MMF and AZA is associated with decreased number of relapses and disability improvement as well, and there was no significant difference in the effect of the three drugs on reducing EDSS scores, but RTX significantly reduced ARR compared with the other two drugs

      Key words

      Abbreviations:

      AQP4-Ab (aquaporin-4 autoantibody), ARR (annualized relapse rate), EDSS (Expanded Disability Status Scale), SD (standard deviation), MeSH (Medical Subject Heading), NMO (neuromyelitis optica), RCT (randomized clinical trial), RTX (rituximab)
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