First-Line Attack Management in Neuromyelitis Optica Spectrum Disorder
Acute attacks of neuromyelitis optica spectrum disorder (NMOSD) carry a high risk of lasting neurological disability. Early, structured intervention is essential — delays in initiating therapy are associated with worse outcomes.
This protocol addresses the acute attack phase in NMOSD, providing a first-line approach for managing the active relapse. The clinical priority is to limit neurological damage and support recovery as rapidly as possible.
Treatment approach — partial overview
First-line attack therapy is built around high-dose intravenous corticosteroid therapy, followed by a structured oral taper, with supportive prophylactic measures incorporated throughout. The complete regimen — including sequencing, dose adjustments, duration, and all accompanying measures — is outlined in the full protocol.
References
DOI: 10.1007/s00415-024-12288-2
- Attack therapy must be initiated as early as possible in NMOSD attacks.
- Methylprednisolone (MP) should be usually administered intravenously (i. v.) at a dose of 1000 mg per day for 3–5 days, followed by an oral MP taper (starting with either 1 mg/kg/day or 20–30 mg/day and then tapered to 10–15 mg/day within 2–3 weeks) in combination with proton pump inhibition and thrombosis prophylaxis.
- Low-dose oral glucocorticoids for up to 3–6 months are also considered beneficial for preventing subsequent early attacks, although there is a lack of prospective studies.
- Following attack therapy (high-dose glucocorticoid therapy and/or apheresis therapy), an oral taper of glucocorticoids should be administered for up to 3–6 months to prevent subsequent attacks, especially at the start or switch of long-term immunotherapy.
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