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Effectiveness and tolerability of immunosuppressants and monoclonal antibodies in preventive treatment of neuromyelitis optica spectrum disorders: A systematic review and network meta-analysis

Published:August 09, 2019DOI:https://doi.org/10.1016/j.msard.2019.08.009

      Highlights

      • The first NMA comparing the 5 drugs used in preventive treatment for NMOSD.
      • Rituximab ranked first to improve ARR with good tolerability.
      • Mycophenolate mofetil performed best tolerability.
      • Low dose of cyclosporine A may be a promising alternative therapy.
      • Multiple adverse events limited azathioprine and cyclophosphamide'effectiveness.

      Abstract

      Background

      Several immunosuppressants or monoclonal antibodies have been used as preventive treatment for neuromyelitis optica spectrum disorders (NMOSD); however, the optimal therapies have not been clarified. In this study, we aimed to compare and rank the effectiveness and tolerability of all preventive therapies for NMOSD.

      Methods

      Qualified studies were identified in a search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases. We combined direct and indirect evidence via meta-analyses. The annualized relapse rate (ARR) was defined as the primary outcome. Secondary outcomes included the Expanded Disability Status Scale (EDSS) score and hazard ratios (HR) for the counts of adverse events (AEs).

      Results

      We identified one randomized controlled trial (RCT) and five observational studies including a total 631 patients with NMOSD. Among these, the follow-up time ranged from 12 to 40 months. For the primary outcome, rituximab (RTX) was hierarchically superior, with the significant standardized mean difference versus azathioprine (−0.86; 95% confidence interval: −1.60, −0.11). Mycophenolate mofetil (MMF) was ranked the most tolerable therapy, whereas cyclophosphamide was the least tolerable.

      Conclusion

      RTX and MMF may be recommended as optimal treatments to prevent relapse in NMOSD. Low-dose cyclosporine A could be a promising alternative therapy.

      Keywords

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