What is the treatment for Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD)?

Treatment of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD)

High-dose corticosteroids are the first-line treatment for acute MOGAD attacks, followed by a slow taper, with maintenance therapy options including rituximab, IVIG, mycophenolate mofetil, or azathioprine for relapsing disease. 1, 2

Acute Treatment

• Intravenous methylprednisolone at high doses (typically 30 mg/kg up to 1000 mg/day) is the first-line treatment for acute MOGAD attacks 1
• For patients with poor response to corticosteroids or severe attacks, second-line therapies include:
  • Intravenous immunoglobulin (IVIG) 2, 3
  • Plasma exchange (PLEX) 2, 3
• A prolonged oral corticosteroid taper (up to 3 months) after acute treatment is recommended to prevent early relapse 2, 4

Maintenance Therapy for Relapsing Disease

After the first relapse, maintenance therapy should be initiated to prevent further attacks, as neurologic disability in MOGAD is primarily relapse-driven 3, 4.

First-line Maintenance Options:

• Rituximab (most commonly used biologic agent) 5, 4
• Intravenous immunoglobulin (IVIG) - emerging evidence suggests this may be one of the most effective options 2, 4
• Mycophenolate mofetil 5, 4
• Azathioprine 5, 4
• Low-dose oral corticosteroids 5

Treatment for Refractory Disease:

• For patients who continue to relapse on first-line maintenance therapy, consider:
  • Switching to rituximab if not already used 4
  • Switching to or adding IVIG 4
  • Combination therapy with rituximab plus IVIG 4
  • IL-6 receptor antagonists (tocilizumab, satralizumab) for cases not responding to other treatments 3, 5
  • Ofatumumab may be considered in highly refractory cases 6

Important Considerations

• MOGAD treatment differs from multiple sclerosis - traditional MS disease-modifying therapies may worsen MOGAD outcomes 1
• Testing for MOG-IgG antibodies should be performed after the first recurrence of optic neuritis in patients diagnosed with MS 1
• Treatment decisions should be based on:
  • Attack severity and frequency 3
  • Prior treatment response 5
  • Patient comorbidities 5
  • Side effect profiles of medications 5

Treatment Monitoring

• Regular clinical assessment for relapse symptoms, particularly visual and neurological function 3
• Radiological monitoring may be necessary to detect subclinical disease activity 3
• MOG-IgG antibody status may not always correlate with disease activity - some patients can relapse despite becoming antibody negative 6

Emerging Therapies

• Prospective randomized clinical trials are currently evaluating:
  • IL-6 receptor inhibitors 3
  • Neonatal Fc receptor inhibitors 3
• These may provide more targeted treatment options in the future

The treatment of MOGAD continues to evolve as our understanding of this distinct disease entity improves. Early diagnosis and appropriate treatment are critical for preventing relapses and reducing long-term disability 3.