Basic Neuroscience · Neuropharmacology
NMOSD & MOGAD Treatment
Treatment options for AQP4-IgG NMOSD and MOGAD in one view. The Disease & approval column shows what each agent is FDA-approved or used for — note all 4 FDA-approved drugs are AQP4-NMOSD only; MOGAD is treated off-label (no FDA-approved MOGAD therapy exists as of 2026). Verify dosing/screening against current prescribing information.
| Drug | Disease & approval | Mechanism | Dose / route | Key side effects | Clinical tips |
|---|---|---|---|---|---|
| FDA-approved maintenance — adult AQP4-IgG NMOSD | |||||
| Eculizumab (Soliris) | NMOSD (AQP4+) — FDA 2019 | Terminal complement C5 inhibitor | 900 mg IV weekly ×4, then 1200 mg q2 wk | Meningococcal infection (boxed warning), infusion reactions, headache, URTI | Meningococcal vaccine ≥2 wk before (or antibiotic prophylaxis); no role in AQP4-negative or MOGAD |
| Ravulizumab (Ultomiris) | NMOSD (AQP4+) — FDA 2024 | Long-acting C5 inhibitor | Weight-based IV load, then q8 wk | Meningococcal infection (boxed warning), infections, headache | Much longer dosing interval than eculizumab; meningococcal vaccination required |
| Inebilizumab (Uplizna) | NMOSD (AQP4+) — FDA 2020 | Anti-CD19 B-cell depletion | 300 mg IV day 1 & 15, then q6 mo | Infusion reactions, infections, hypogammaglobulinemia, lymphopenia, HBV reactivation | Screen HBV/TB, quantitative Ig, vaccines; broader B-cell depletion than anti-CD20 |
| Satralizumab (Enspryng) | NMOSD (AQP4+) — FDA 2020 | IL-6 receptor antagonist | 120 mg SC wk 0/2/4, then q4 wk | Infections, injection reactions, ↑ LFTs, ↓ neutrophils | SC self-injection; monitor LFTs/neutrophils; IL-6 blockade can blunt CRP/fever (mask infection) |
| Off-label maintenance — NMOSD ± MOGAD | |||||
| Rituximab | NMOSD off-label (1st-line) · MOGAD off-label (less reliable) | Anti-CD20 B-cell depletion | 1 g IV ×2 (2 wk apart) or 375 mg/m²; redose q6 mo or by B-cell return | Infusion reactions, infections, hypogammaglobulinemia, HBV reactivation, rare PML | Time redosing by CD19/CD27 memory B-cell reconstitution; HBV screen; widely used in both diseases |
| Tocilizumab | Both (off-label; refractory) | IL-6 receptor antagonist (IV/SC) | 8 mg/kg IV q4 wk | Infections, ↑ LFTs, ↓ neutrophils/platelets, GI perforation, ↑ lipids | For disease refractory to B-cell depletion; monitor LFTs/CBC/lipids |
| Azathioprine | Both (off-label; maintenance) | Purine antimetabolite | 2–3 mg/kg/day PO | Myelosuppression, hepatotoxicity, ↑ malignancy, GI | Check TPMT / NUDT15 + CBC/LFT; slow onset (~3–6 mo) → bridge with steroids |
| Mycophenolate mofetil | Both (off-label; maintenance) | Inhibits IMPDH (purine synthesis) | 1–1.5 g PO BID | GI upset, leukopenia, infection, teratogenic | Bridge with steroids at start; contraception required; monitor CBC |
| IVIG | MOGAD maintenance (off-label, esp. pediatric); acute rescue | Immunomodulation (multiple) | 1–2 g/kg q4 wk (maintenance varies) | Headache, aseptic meningitis, thrombosis, renal, anaphylaxis (IgA deficiency) | Preferred maintenance in MOGAD, esp. children; acute use mainly MOGAD rescue (not standard acute NMOSD); check IgA |
| Acute attack — both diseases | |||||
| IV methylprednisolone | Both (acute, 1st-line) | High-dose corticosteroid | 1 g IV daily ×3–5 days | Hyperglycemia, insomnia, mood change, infection | First-line for acute attacks; often followed by an oral taper (esp. MOGAD, which is steroid-dependent) |
| Plasma exchange (PLEX) | Both (acute; steroid-refractory) | Removes circulating autoantibodies | 5–7 exchanges every other day | Line complications, hypocalcemia, coagulopathy, hypotension | Early PLEX improves recovery in severe NMOSD attacks — consider first-line for severe/refractory attacks |
⚠ Avoid MS disease-modifying therapies in AQP4-NMOSD — interferon-β, natalizumab, fingolimod / S1P modulators, and alemtuzumab can worsen AQP4-NMOSD; glatiramer is ineffective. Confirm AQP4/MOG serostatus before any “MS” DMT. MS DMTs are also generally ineffective in MOGAD. When to start maintenance: AQP4+ NMOSD — after the first attack; MOGAD — usually after a relapse or severe residual deficit (many monophasic cases need none).
Neuro-Pharmacology — NeurologyResident.Net by Ahmed Koriesh