Adult Optic Neuritis Medication

Updated: Jan 22, 2021
  • Author: Andrew A Dahl, MD, FACS; Chief Editor: Edsel B Ing, MD, MPH, FRCSC, PhD, MA  more...
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Medication

Medication Summary

Eculizumab, a monoclonal antibody that targets C5, is the first drug specifically approved by the US Food and Drug Administration (FDA) for adults with neuromyelitis optica spectrum disorder (NMOSD) who are seropositive for anti-aquaporin-4 (AQP4) antibody. [15]  Inebilizumab, a monoclonal antibody that binds to CD19, and satralizumab, a monoclonal antibody that targets the interleukin-6 (IL-6) receptor, are also approved for treating NMOSD. [16, 52, 53]

Other pharmacologic therapy for optic neuritis (ON) is directed at ameliorating the acute symptoms of pain and decreased vision caused by demyelinating inflammation of the nerve. Varying regimens of corticosteroids have been used for this purpose. A 3-day course of high-dose intravenous (IV) methylprednisolone followed by a rapid oral taper of prednisone has been shown to provide a rapid relief of symptoms in the acute phase. This treatment may also delay the short-term development of multiple sclerosis (MS) after ON; however, IV steroids do little to affect the ultimate visual acuity in patients with ON.

For patients with ON whose brain lesions on magnetic resonance imaging (MRI) indicate a high risk of developing clinically definite MS, treatment with immunomodulators (eg, interferon beta-1a, interferon beta-1b, glatiramer acetate) may be considered. [17]  Intravenous immunoglobulin treatment of acute ON has been shown to have no beneficial effect.

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Monoclonal Antibodies

Class Summary

Monoclonal antibodies (eg, eculizumab, inebilizumab, satralizumab) that target aquaporin-4-antibody production or binding have been approved by the FDA for adults with neuromyelitis optica spectrum disorder (NMOSD).

Eculizumab (Soliris)

Monoclonal antibody that specifically binds to the complement protein C5 with high affinity, thereby inhibiting its cleavage to C5a and C5b and preventing the generation of the terminal complement complex C5b-9. The precise mechanism by which eculizumab exerts its therapeutic effect in NMOSD is unknown, but is presumed to involve inhibition of aquaporin-4-antibody–induced terminal complement C5b-9 deposition. It is indicated for adults with neuromyelitis optica spectrum disorder (NMOSD) who are anti-aquaporin-4 (AQP4) antibody–positive.

Inebilizumab (Uplizna)

Monoclonal antibody that binds with high affinity to CD19, a protein expressed on a broad range of B cells, including antibody-secreting plasmablasts and plasma cells. After binding to CD19, these cells are rapidly depleted from the circulation. Approximately 80% of patients with NMOSD have autoantibodies to a water channel protein called aquaporin-4 (AQP4). These AQP4-IgG autoantibodies are produced by plasmablasts and plasma cells and bind primarily to astrocytes in the central nervous system. Binding of AQP4-IgG antibodies to CNS cells is believed to trigger attacks, which can damage the optic nerve, spinal cord, and brain.

Satralizumab (Enspryng)

Monoclonal antibody that targets the interleukin 6 (IL-6) receptor. Cytokine IL-6 is thought to be a key cause of NMOSD, triggering the inflammation cascade and leading to damage and disability. It is indicated for NMOSD in adults who are antiaquaporin-4 (AQP4) antibody positive. 

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Corticosteroids

Class Summary

These have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Methylprednisolone (Solu-Medrol, Depo-Medrol, Medrol)

Methylprednisolone is a synthetic corticosteroid used intravenously as an anti-inflammatory and immunosuppressant agent. It has been shown to facilitate the recovery of vision in the acute phase of optic neuritis even though it may not change the long-term visual outcome. In addition, treatment with methylprednisolone may delay the development of MS.

Prednisone

Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear (PMN) leukocyte activity. It is a commonly used oral agent. Prednisone is used for an oral taper of steroids, which may reduce the emotional effects of steroid withdrawal and the risk of the development of adrenocortical insufficiency. However, these risks are not very high after only 3 days of treatment with high-dose steroids, and most neurologists do not use a prednisone taper.

Prednisolone (Pediapred, Prelone, Orapred)

Prednisolone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear (PMN) leukocyte activity. It is a commonly used oral agent. Prednisolone is used for an oral taper of steroids, which may reduce the emotional effects of steroid withdrawal and the risk of the development of adrenocortical insufficiency. However, these risks are not very high after only 3 days of treatment with high-dose steroids, and most neurologists do not use a prednisone taper.

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