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Rituximab as First-Line Compared to Escalation Immunotherapy Is Associated With Lower Disability Accumulation in
Daniel Engels1, Chiara Rocchi2, Mirasol Forcadela2
1Institute of Clinical Neuroimmunology and Biomedical Center (BMC), LMU University Hospital, Faculty of Medicine, Ludwig-Maximilians-University Munich, Munich, Germany.
Background:
Aquaporin-4-IgG-positive neuromyelitis optica spectrum disorder (AQP4-IgG+ NMOSD) can cause significant disability after a single attack. Long-term immunotherapy reduces disability accumulation, but the choice of first-line therapy varies. In the United Kingdom, rituximab is typically used as escalation therapy after conventional immunosuppressants fail, while in Germany, it is widely used as first-line treatment.
Methods:
We compared attack risk and disability outcomes based on the Expanded Disability Status Scale (EDSS) in AQP4-IgG+ NMOSD patients treated with rituximab as first-line versus escalation therapy. Furthermore, attack suppression and risk factors for attacks in individuals who received treatment with azathioprine and mycophenolate mofetil (with/without escalating to rituximab) were analyzed.
Results:
The risk of attack was lower in individuals who received rituximab as first-line therapy (n = 52) compared to escalation therapy (n = 81, HR = 0.45, 95% CI = 0.30-0.67). Once escalated to rituximab, there was no altered risk of attack between first-line rituximab and escalation therapy (HR = 1.15, 95% CI = 0.64-2.08). Rituximab as first-line compared to escalation therapy was associated with lower EDSS scores at therapy start (3.0 vs. 6.0, p = 1.10 × 10-3). In patients who remained on azathioprine or mycophenolate mofetil (n = 45), age < 50 years and treatment with azathioprine were identified as risk factors for attacks.
Conclusions:
Rituximab as a first-line therapy shows significant reduction in disability accumulation compared to escalation treatments. However, a subgroup of patients with AQP4-IgG+ NMOSD may still respond well to conventional immunosuppression-specifically older patients treated with mycophenolate mofetil.
