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Severe Relapse After Switching From Eculizumab to Satralizumab in Neuromyelitis Optica Spectrum Disorder
Elisabeth Maillart1, Anne-Laure Dubessy1, Natalia Shor2
1APHP, Pitié-Salpêtrière Hospital, Department of Neurology, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle, Paris, France.
Objectives:
Several treatments have been approved for the prevention of attacks in AQP4-IgG+ neuromyelitis optica spectrum disorder (NMOSD). However, because of the rarity of the disease, little is known concerning how to switch from one treatment to another in case of lack of effectiveness or side effects. In this article, we report a severe attack in a patient with NMOSD after switching from eculizumab to satralizumab.
Methods:
A 44-year-old woman with NMOSD was treated with azathioprine and then rituximab, without optimal control of the disease. Eculizumab was initiated with clinical efficacy. Two years later, after the onset of rheumatoid arthritis and because of difficult venous access, a switch to satralizumab was proposed.
Results:
After switching, a severe attack occurred 11 weeks after the last eculizumab infusion. Severe tetraplegia was related to a new extensive cervical lesion associated with a tumefactive lesion of the corpus callosum. The patient was treated with 10 infusions of methylprednisolone and 10 plasma exchanges. Eculizumab was reintroduced 20 days after symptom onset. Three months later, mild improvement was observed.
Discussion:
In clinical practice, in case of intolerance or side effects, anticomplement therapy should be switched to another NMOSD treatment with caution because of a high risk of relapse.
Classification Of Evidence:
This case report provides Class IV evidence that eculizumab should be stopped with caution and switched to another treatment immediately. This is a single observational study without controls.
Insights
Switching treatments for Aquaporin-4 IgG-positive neuromyelitis optica spectrum disorder (NMOSD) carries a high relapse risk. A patient experienced a severe NMOSD attack after switching from eculizumab to satralizumab, highlighting the need for caution.
Area of Science:
- Neurology
- Immunology
- Neuroinflammation
Background:
- Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune condition targeting Aquaporin-4 (AQP4) IgG antibodies.
- Approved treatments exist for NMOSD attack prevention, but data on treatment switching is limited due to disease rarity.
Purpose of the Study:
- To report a case of severe NMOSD relapse after switching from eculizumab to satralizumab.
- To highlight the risks associated with treatment modification in AQP4-IgG+ NMOSD.
Main Methods:
- Case report of a 44-year-old woman with AQP4-IgG+ NMOSD.
- Patient initially treated with azathioprine and rituximab, then eculizumab with efficacy.
- Switch to satralizumab due to rheumatoid arthritis and venous access issues.
Main Results:
- A severe NMOSD attack occurred 11 weeks after the last eculizumab infusion.
- The attack involved severe tetraplegia, a new cervical lesion, and a corpus callosum lesion.
- Treatment included methylprednisolone, plasma exchange, and reintroduction of eculizumab, with mild improvement observed.
Conclusions:
- Switching anticomplement therapy in NMOSD requires caution due to a high risk of relapse.
- Immediate and careful consideration is needed when discontinuing eculizumab and initiating alternative treatments.
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