Page 22 - Read Online

Ong et al. Neuroimmunol Neuroinflammation 2020;7:311-8 I http://dx.doi.org/10.20517/2347-8659.2020.05 Page 317

that 10% of the patients experienced infusion-related adverse effects, but we managed to reduce this risk by
premedicating our patients with IV promethazine, IV hydrocortisone and oral acetaminophen as stated in
the treatment protocol. In addition, the absence of infection and leukopenia in our cohort of patients may
be related to the withdrawal of immunomodulators prior to RTX and a delay of reinitiating the therapy for
two to four weeks after treatment. We acknowledge that our small sample size might not reflect the actual
safety profile of such an approach, however the absence of major side effects in our cohort of patients is
promising for our therapeutic plan. We postulate that the lack of adverse events may be due to the absence
of the cumulative effect of immunomodulators with RTX and the short frequency dosing as reported by
[22]
others .

Nevertheless, there are several limitations to our study. Firstly, being a retrospective study, the analysis of
data from medical records was subjected to recording bias. In addition, the patient group at baseline was
heterogenous with regard to their pre-RTX status and have variable disease duration, number of relapses
and EDSS severity. Oral immunosuppressant maintenance therapies and steroid doses following RTX
treatment were also variable. Although our results were derived from a tertiary care institution, our sample
size was small, which further highlights the challenges of access to RTX at tertiary establishments in a
resource-limited setting.

In conclusion, pulse induction therapy with a single course of RTX followed by subsequent de-escalation to
oral immunosuppressants may be a convenient and economical approach in managing NMOSD patients.
In resource-limited hospitals with restricted access to RTX, such an approach can potentially be effective to
reduce relapses and improve EDSS scores with minimal side effects. This treatment plan allowed adequate
time for optimization of other oral medications to achieve their therapeutic benefits. Moreover, the ability
to achieve and maintain remission suggests that RTX has long-term effects extending beyond treatment
discontinuation. Nevertheless, we concede that a further, larger prospective cohort study is required to
demonstrate the efficacy of such a treatment approach.

DECLARATIONS

Acknowledgments
The authors would like to thank the Director General of Health Malaysia for the permission to publish this
paper.

Authors’ contributions
Performed data acquisition, analysis and interpretation, prepared the manuscript, Tables and Figures: Ong
TL
Made substantial contributions to the conception and design of the study and performed data analysis and
interpretation: Viswanathan S
Performed data acquisition, analysis and interpretation. Contributed in manuscript preparation: Ong S,
Hiew FL

Availability of data and materials
All data used for this study were collected as part of ongoing work under the auspices of the Demyelinating
Disease Database, established at the Neurology Department of Kuala Lumpur Hospital.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.