Neuromyelitis optica (NMO - including NMO spectrum disorders [NMOSD])  is a relapsing autoimmune disorder with attacks of optic neuritis (ON) and transverse myelitis (TM). A large proportion of NMOSD patients have no or a partial recovery after relapse. 

Up until recently, there were no proven agents to treat to prevent relapses and therefore progression.  The utility of newly indicated agents depend on the mechanism of action (MOA), rapidity of the onset of action (OOA), duration of efficacy and long-term safety.  Frequency of administration, route of administration and monitoring will also assuredly play a role for the patient and the clinician. 

The neuro-immunological community now has a number of indicated agents for NMOSD therapy including eculizumab [Solaris®], inebilizumab (Uplinza®) and satralizumab (Enspryng®) with different mechanisms of action (MOA), rapidity of the onset of action (OOA) and issues of long-term safety. Autologous hematopoietic stem cell bone marrow transplantation (AHSCBMT) may be another therapeutic option. What would be the optimal therapeutic approach using the available interventions?

The advantages of eculizumab is preservation of immunosurveillance, immediate onset of action and persistent efficacy but frequent IV administration and cost. Inebilizumab allows a slight decrease in relapse free subjects over time but decreases B and plasmablast cell disease-inducing pathogenic antibody production. However, inebilizumab may cause immunosuppression. Satralizumab is immunomodulatory and self-administration but has delayed onset of action.  AHSCBMT may be the best overall semi-permanent therapeutic option for the prevention and therefore the progression of NMO.  

In NMO, as a 1st step control the complement (eculizumab), with subsequent reconstitution of the immune system (AHSCBMT),and then ultimately transition to immunomodulation (satralizumab) and reserve immunosuppression (inebilizumab) as 4th line. Also utilize AHSCBMT as salvage therapy for severe breakthrough disease during or after NMO-DMTs.