From the Guidelines
For a patient with suspected MOGAD relapse who recently received IV methylprednisolone and IVIG and is currently on tapering oral prednisolone, I recommend restarting high-dose IV methylprednisolone (1000 mg daily for 3-5 days) as the immediate intervention. This approach is based on the understanding that MOGAD relapses often respond to corticosteroids, as suggested by studies such as 1, which highlights the importance of early and aggressive treatment to manage the inflammatory process.
Key Considerations
- The patient's recent treatment with IV methylprednisolone and IVIG, and current tapering dose of oral prednisolone, indicates a need for careful management to prevent further relapses, as noted in 1.
- The absence of plasma exchange services at the current facility necessitates consideration of alternative treatments or urgent transfer, as plasma exchange has been shown to be effective in some cases of MOGAD, particularly those that are severe or refractory to initial treatments, as discussed in 1.
- Maintenance immunosuppression with agents like mycophenolate mofetil or azathioprine may be necessary to prevent further relapses, as these medications can help in managing the disease's chronic aspect, as mentioned in 1.
Treatment Approach
- Restart high-dose IV methylprednisolone (1000 mg daily for 3-5 days) as the first line of treatment for the suspected relapse.
- If the patient shows inadequate response within 48-72 hours, arrange for urgent transfer to a facility with plasma exchange capabilities.
- While awaiting transfer, increase the oral prednisolone dose to 1-1.5 mg/kg/day to maintain adequate immunosuppression.
- Consider repeating IVIG (2 g/kg divided over 2-5 days) if the relapse is severe and transfer for plasma exchange is delayed, as IVIG has been shown to be beneficial in some cases, as indicated in 1.
- After acute treatment, implement maintenance immunosuppression with agents like mycophenolate mofetil (starting at 500 mg twice daily, increasing to 1000-1500 mg twice daily as tolerated) or azathioprine (1-2.5 mg/kg/day) to prevent further relapses, as suggested by the treatment guidelines and recommendations in 1 and 1.
From the Research
Management of Suspected Relapse in MOGAD
- The patient has already received intravenous (IV) methylprednisolone and a 2-day course of Intravenous Immunoglobulin (IVIG) one week ago, and is currently on a tapering dose of oral prednisolone 2, 3.
- Given the suspected relapse, the first step would be to consider re-initiating high-dose IV corticosteroids, as this is a common approach for acute attacks in MOGAD 2, 4.
- If the patient has a poor response to corticosteroids, IVIG or plasma exchange could be considered as second-line therapies 3, 4. However, since the facility has no plasma exchange service, IVIG could be a viable alternative.
- Maintenance treatment should be considered to prevent further relapses, with options including rituximab, azathioprine, mycophenolate mofetil, or monthly IVIG 3, 5, 4.
- The choice of maintenance treatment may depend on various factors, including the patient's response to previous treatments, disease activity, and individual risk factors for relapse 5.
Considerations for Maintenance Treatment
- Rituximab and IVIG have been associated with a lower risk of relapse in MOGAD patients 5.
- Maintenance steroids may be associated with a higher estimated relapse risk, and their use should be carefully considered 5.
- The patient's demographic characteristics, such as female sex and Hispanic/Latino ethnicity, may also influence the risk of relapse 5.