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Clinical course, therapeutic responses and outcomes in relapsing MOG antibody-associated demyelination.

J Neurol Neurosurg Psychiatry. 2017 Nov 15. pii: jnnp-2017-316880.

Ramanathan S1,2,3, Mohammad S1,2,4, Tantsis E1,2,5, Nguyen TK1,2, Merheb V1,2, Fung VSC3,6, White OB7,8, Broadley S9,10, Lechner-Scott J11,12, Vucic S3,6, Henderson APD3,6,13, Barnett MH14, Reddel SW14, Brilot F1,2,14, Dale RC4,14; Australasian and New Zealand MOG Study Group.

Abstract
OBJECTIVE:

We characterised the clinical course, treatment and outcomes in 59 patients with relapsing myelin oligodendrocyte glycoprotein (MOG) antibody-associated demyelination.
METHODS:

We evaluated clinical phenotypes, annualised relapse rates (ARR) prior and on immunotherapy and Expanded Disability Status Scale (EDSS), in 218 demyelinating episodes from 33 paediatric and 26 adult patients.
RESULTS:

The most common initial presentation in the cohort was optic neuritis (ON) in 54% (bilateral (BON) 32%, unilateral (UON) 22%), followed by acute disseminated encephalomyelitis (ADEM) (20%), which occurred exclusively in children. ON was the dominant phenotype (UON 35%, BON 19%) of all clinical episodes. 109/226 (48%) MRIs had no brain lesions. Patients were steroid responsive, but 70% of episodes treated with oral prednisone relapsed, particularly at doses <10 mg daily or within 2 months of cessation. Immunotherapy, including maintenance prednisone (P=0.0004), intravenous immunoglobulin, rituximab and mycophenolate, all reduced median ARRs on-treatment. Treatment failure rates were lower in patients on maintenance steroids (5%) compared with non-steroidal maintenance immunotherapy (38%) (P=0.016). 58% of patients experienced residual disability (average follow-up 61 months, visual loss in 24%). Patients with ON were less likely to have sustained disability defined by a final EDSS of ≥2 (OR 0.15, P=0.032), while those who had any myelitis were more likely to have sustained residual deficits (OR 3.56, P=0.077).
CONCLUSION:

Relapsing MOG antibody-associated demyelination is strongly associated with ON across all age groups and ADEM in children. Patients are highly responsive to steroids, but vulnerable to relapse on steroid reduction and cessation.

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