Rituximab and tocilizumab appear to have better efficacy in reducing neuromyelitis optica spectrum disorder (NMOSD) relapses than other immunosuppressant agents such as azathioprine, according to a recently published study in the Journal of Neurology

NMOSD follows a recurrent course in which each relapse tends to be more severe than the last, eventually leading to debilitating neurological deficits such as pain, visual disturbances, and bladder dysfunction, the researchers noted. Therefore, the prevention of relapses is the main objective of NMOSD therapy, they added.

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Currently, there is an ample variety of immunosuppressant drugs available, with azathioprine and rituximab being the most commonly used ones. However, there need to be more studies comparing the effectiveness of the many immunosuppressants currently on the market. The authors aimed to make this comparison through a network meta-analysis. 

The authors performed a search on several databases for studies, including adult patients with NMOSD receiving immunosuppressant drugs with placebo controls and reports of effectiveness outcomes, including annualized relapse rate (ARR), conference abstracts, case reports, and literature reviews were excluded from the search. Quality assessment and risk of bias evaluation were performed by two reviewers. 

“The ARR has been widely used to evaluate the risk of recurrence in NMOSD-related systematic reviews and clinical trials,” the authors wrote. “ Combined with the analysis of relapse rates, the effect of a specific monoclonal antibody or immunosuppressant on reducing recurrence in NMOSD patients is comprehensively evaluated.”

After playing the selection criteria, the authors selected 25 studies that collectively included close to 3000 patients. In the 25 studies, 10 different immunosuppressants were with placebo or with other immunosuppressants. 

Although several drugs, including azathioprine, inebilizumab, tacrolimus, and tocilizumab, were associated with lower ARRs compared to the placebo, there was no significant difference in the EDSS scales of patients treated with these drugs and placebo.

Results revealed that rituximab was associated with a lower ARR than the rest of the agents, including cyclophosphamide, corticosteroids, azathioprine, and mycophenolate mofetil.

The surface under the cumulative ranking curve (SUCRA) showed that rituximab ranked highest in ARR, while tocilizumab ranked highest on relapse rates, cyclophosphamide, and corticosteroids ranked lowest in ARR and relapse rates, respectively.

“We believe that RTX and tocilizumab have the best efficacy against NMOSD.” the authors concluded. 


Yin Z, Qiu Y, Duan A, et al. Different monoclonal antibodies and immunosuppressants administration in patients with neuromyelitis optica spectrum disorder: a Bayesian network meta-analysis. J Neurol. Published online February 20, 2023. https://doi.org/10.1007/s00415-023-11641-1