"These findings were not entirely surprising because IVIG has been found to be associated with a reduction in relapses in prior studies that included primarily pediatric patients," Dr. John Chen of Mayo Clinic in Rochester, Minnesota told Reuters Health by email.
"It was interesting that we found more frequent relapses in patients receiving lower or less frequent dosing of IVIG," he noted. "This dose response to IVIG helps support its effectiveness, but the ideal dose varies depending on the individual."
"IVIG can be considered for MOGAD patients with relapsing disease as first line, but because of costs and availability, other treatments can be utilized first," he advised. "In patients with relapsing disease who are not responding to some of the more traditional treatments - e.g., rituximab, mycophenolate, azathioprine - maintenance IVIG should be strongly considered."
As reported in JAMA Neurology analyzed data from 876 adults initially identified with MOGAD from 14 hospitals in nine countries.
The main outcome was relapse rates while receiving maintenance IVIG compared with before initiation of therapy.
Fifty-nine patients (median age, 36; 56%, women; 78%, white; 14%, Asian) were treated with maintenance IVIG. IVIG was initiated as first-line immunotherapy in 15 (25%), and as second-line therapy in 37 (63%) due to failure of previous immunotherapy and 7 (12%) due to intolerance to previous immunotherapy.
The median annualized relapse rate before IVIG treatment was 1.4, compared with a median annualized relapse rate of 0 while receiving IVIG.
Twenty patients (34%) had at least one relapse while receiving IVIG, with a median time to first relapse of one year; 17 patients (29%) were treated with concomitant maintenance immunotherapy.
Five of 29 patients (17%) who received 1 g/kg of IVIG every 4 weeks or more experienced a relapse compared with 15 of 30 patients (50%) treated with lower or less frequent dosing (hazard ratio, 3.31).
At the final follow-up, 52 patients (88%) were still receiving maintenance IVIG with a median duration of 1.7 years of therapy.
Seven of 59 patients (12%) discontinued IVIG therapy: 4 (57%) for inefficacy, 2 (29%) for adverse effects, and 1 (14%) after a period of disease inactivity.
Dr. Chen noted, "Subcutaneous IG may be another route that would allow weekly treatments from home, which may be an attractive option to some patients. Ultimately, a randomized clinical trial will be required to confirm the efficacy and establish the optimal dosing of IVIG and/or subcutaneous IG."
Dr. Rebecca Straus Farber, Assistant Professor of Neurology at Columbia University Medical Center and its MS Clinical Care and Research Center in New York City, commented on the study in an email to Reuters Health.
"MOGAD has only been recently defined as its own entity, and commercially available testing... is even newer," she said. "There have been no good prospective clinical trials for medications for this rare disease, and no agents are FDA-approved, so it's not surprising that there is no consensus on best treatment."
"A variety of maintenance treatments such as rituximab, mycophenolate, and azathioprine as well IVIG are commonly used," she said. "This retrospective (study) provides some evidence that maintenance IVIG could be a reasonable treatment strategy, especially in individuals for whom immunosuppression is risky."
"This does not obviate the need for randomized, controlled studies for additional guidance," she added. "We eagerly look forward to prospective clinical trials for this patient population."
SOURCE: https://bit.ly/38QQ3lJ JAMA Neurology, online April 4, 2022.
By Marilynn Larkin
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