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Consensus recommendations for the diagnosis and management of neuromyelitis optica spectrum disorder: A Saudi expert panel review.

S. Aljarallah,A. Althobaiti,A. Abulaban,F. Aldosari,Saleh Alhasan,E. N. Ali,H. Alnajashi,Ahmad Al Mutlaq,I. Althubaiti,Rumaiza Alyafeai,Reem Bunyan,S. Makkawi,J. Saeedi,Lynn M. AlHajjar,Saeed Shahrani,Y. A. Malik,M. A. Jumah

Published 2025 in Multiple Sclerosis and Related Disorders

ABSTRACT

BACKGROUND Neuromyelitis Optica Spectrum Disorder (NMOSD) is a rare autoimmune demyelinating disorder of the central nervous system (CNS) that predominantly affects the optic nerve and spinal cord. Despite advancements in understanding NMOSD, challenges in management remain. Recommendations by Saudi experts on the management of NMOSD were published in 2022. However, regulatory approval of new treatments and recent developments in the understanding of MOGAD necessitated an update to the recommendations. This study aimed to develop expert-driven, evidence-based, up-to-date consensus recommendations for the management of NMOSD in Saudi Arabia. METHODS A multidisciplinary panel of neurologists, neuroimmunologists, epidemiologists, and pharmacists was convened under the Saudi Neurology Society - Multiple Sclerosis Chapter. The process included a systematic literature review and a GRADE assessment of 56 studies. Recommendations were drafted and refined by two independent reviewers before being subjected to a two-round Delphi survey where experts voted on the statements. The consensus was reached through iterative voting, feedback, and refinement rounds to ensure clarity and alignment with clinical practice needs. RESULTS The finalised recommendations addressed key areas, including diagnostic strategies, diagnostic criteria, and acute and chronic treatments in NMOSD, as well as recommendations regarding the diagnosis and treatment of MOGAD. Treatment recommendations covered acute attack management, initial immunosuppressive therapies, treatment duration, and prognostic factors at diagnosis for failure of first-line treatments. The use of Rituximab, azathioprine (Imuran), mycophenolate mofetil (CellCept), and newer therapies such as ravulizumab, tocilizumab, inebilizumab, satralizumab, and eculizumab is also discussed with the newer therapies offering potential advantages in specific patient populations. While newer therapies show promising efficacy, variations in safety, accessibility, and patient response highlight the need for further evaluation to determine their optimal role in treatment regimens. GRADE assessments indicated moderate to high certainty for most statements based on study design, sample size, and consistency of evidence. CONCLUSIONS This expert consensus provides evidence-based guidance for the diagnosis and management of NMOSD in Saudi Arabia, striking a balance between clinical evidence and expert opinion where data gaps exist. It emphasises individualised care, antibody testing, and long-term immunosuppressive strategies while highlighting the need for further research on treatment duration and failure criteria.

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