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Ong et al. Neuroimmunol Neuroinflammation 2020;7:311-8 I http://dx.doi.org/10.20517/2347-8659.2020.05 Page 313

Figure 1. Protocol of single dose rituximab as induction therapy for aggressive NMOSD patients in Kuala Lumpur Hospital, Malaysia.
NMOSD: neuromyelitis optica spectrum disorder; IPND: international panel for neuromyelitis optica diagnosis

This clinical outcome study is a retrospective analysis of patients with aggressive NMOSD treated with
RTX in the Neurology Department at Kuala Lumpur Hospital from 2005 to 2018. The study included
eight NMOSD patients who had received one course of RTX induction therapy. Clinical, laboratory and
neuroimaging data from both in-patient admission and outpatient records of all patients were collected
and analyzed. The primary outcomes included were the number of relapses, EDSS, annualized relapse rates
(ARR), and modified Rankin Scale (mRS) before and after treatment. The EDSS was used to quantify the
disability of our patients. It was assessed during six-monthly follow-up. ARR was defined as the number of
clinical attacks per year. The secondary objective was to analyse the side effects of a single course rituximab
treatment.

Treatment protocol
During the acute attack, high dose intravenous methylprednisolone at 1000 mg daily was given for
5 days. Patients who continued to deteriorate or did not show significant improvement in clinical signs and
symptoms after 2 weeks treatment were given plasma exchange (consisting of five cycles each). RTX was
used thereafter for aggressive NMOSD patients who continued to have frequent relapses in a year while on
oral immunosuppressant therapy.

All patients received RTX infusion as per our Department’s protocol [Figure 1]. At the initiation of
treatment, the medication was given as a slow intravenous (IV) infusion of two doses 2 weeks apart at
[6]
1000 mg each. A similar regime was applied by Cree et al. and other RTX studies [5,12-14] . Patients were
given premedication which consisted of IV promethazine 12.5 mg, IV hydrocortisone 100 mg and oral
acetaminophen 1000 mg before the start of RTX infusion. All patients were then followed-up regularly
at the Neurology outpatient clinic and assessed for further relapses, EDSS, mRS and side effects. Patients
were monitored with full blood counts including lymphocyte counts and B cells (in selected patients), renal
profile, liver function tests and C-reactive protein. Screening for chest infections were done with imaging
and serum immunoglobulin levels were checked annually, if necessary.

While on RTX therapy, all patients had their pre-existing conventional steroid-sparing agents withdrawn
and they were only re-initiated as per protocol 2 to 4 weeks after RTX induction therapy to prevent
cumulative effects of infection or hematological and liver dysfunction amongst the patients.