In a survey of neurologists who treat pediatric patients with myelin oligodendrocyte glycoprotein antibody disease (MOGAD), results showed a substantial amount of variability in management decisions, especially following first and second neuroinflammatory episodes. Despite the publication of diagnostic criteria in 2023, these data highlight the knowledge gaps in therapeutics for MOGAD.1
Launched through the Practice Current Section of Neurology Clinical Practice in April-October 2024, the survey analysis comprised 346 neurologists who answered 12 questions about decision making for pediatric patients with MOGAD. Of these, 52.3% were general neurologists, 32.1% neuroimmunologists (NIs), and 15.6% made up other neurology fields. Led by E. Ann Yeh, MD, principal investigator and staff neurologist at SickKids, the study included demographic questions as well as a comparative analysis between self-identified NIs and other clinicians.
Regarding MOGAD treatment experience, 55.7% (n = 193) of respondents had managed 1-5 newly diagnosed patients with MOGAD in the past year while approximately a quarter (23.7%) had not treated any (“0”). Following first episode of acute optic neuritis, most respondents were on the same page, opting to choose to send MOG-IgG antibody testing (90.4%), as well as serum aquaporin-4 (AQP4) IgG antibody (84.9%), cerebrospinal fluid (CSF) and serum oligoclonal bands (84.3%), and MRI whole spine (71.1%). Additional infectious testing and ophthalmologic testing, used by 36.1% and 35.2% of respondents, was less common.
When examining choices based on specialization, NIs were more likely to order MRI whole spine (81.9% vs 65.9%; P = .0002), send CSF and serum oligoclonal bands (93.6% vs 80%; P <.001), send for serum MOG-IgG antibody (99.1% vs 86.3%; P <.001) and anti-AQP4 (93.6% vs 80.8%; P = .001) testing, send for additional infectious testing (43.2% vs 31.4%; P = .04), and send for additional ophthalmologic testing (45.9% vs 31.4%; P = .01).
“Despite established diagnostic criteria and treatment recommendations for MOGAD, real-world clinical practice often deviates from published guidelines for reasons that need to be evaluated in future studies,” Yeh et al wrote. “Many questions remain unanswered, particularly regarding optimal treatment strategies for children with relapsing forms of the disease.”
Following the first clinical attack of acute optic neuritis, almost all participants (93.6%) elected to treat with steroids. In the acute setting, 84.1% claimed they use a short course (3-5 days) of high-dose intravenous (IV) steroids, while other approaches like IVIg and plasma exchange were used significantly less. Among those who chose to give a short course of either IV or oral high-dose corticosteroids, approximately one-third (33%) chose to offer an oral corticosteroid taper over 2-4 weeks and 27.1% chose a 7-12-week taper. The remaining 20.9% did not choose to offer an oral corticosteroid taper after acute corticosteroid treatment.
Positive MOG-IgG antibody testing led to 44.5% of respondents electing for maintenance therapy, with rituximab the most common (28.5%), followed by daily low-dose oral prednisolone (20.7%) and azathioprine (16.2%). When breaking this down based on specialty, more individuals who treated children only opted for maintenance therapy (54.3%) vs others who treat adults only (43.1%) and those who treat adults and children (42.6%).
READ MORE: Serum Neurofilament Light Chain Limited in Predicting MOGAD Attacks but Correlates With Attack Severity
When presented with a MOG-IgG antibody-positive pediatric patient, almost all respondents (98.2%) chose to initiate maintenance therapy following a second clinical attack. Once again, rituximab, accounting for 37% of the responses, was the most commonly used agent, followed by monthly IVIg (25.5%). In terms of treatment duration, 42.9% stated they would provide maintenance therapy for 2 years or less while 35.2% opted to continue past 2 years and 21.7% chose to maintain therapy indefinitely.
Choice of maintenance therapy also differed between NIs and non-NIs. Following first clinical event, non-NIs mainly opted for rituximab (29.3%), followed by daily low-dose oral prednisolone (23.3%), whereas for NIs, monthly IVIg (47.6%) was the most frequently chosen option. In contrast, among NIs who chose to start maintenance therapy after the first event, monthly IVIg (47.6%) was the most frequently chosen option. Notably, none of the 8 NIs who mainly treated children opted to initiate maintenance therapy after a first clinical event.
After the second clinical attack, most non-NIs (97.8%) and nearly all NIs (99.1%) chose to initiate maintenance therapy; however, rituximab was most commonly used by non-NIs (41.7%) whereas monthly IVIg (50%) was most used by NIs. Significant differences were found for the maintenance therapies used, including monthly IVIg (55/110 among NIs vs 32/230 among non-NIs; P < 0.001) and azathioprine (9/110 among NIs vs 49/230 among non-NIs; P = 0.002). When asked about repeating MOG-IgG antibody testing in follow-up, one-third of respondents (36.1%) chose not to repeat testing while another third (35.2%) chose to reassess it 6 months after clinical onset.
This study had several limitations. Nearly 39% of respondents did not complete the survey, which may affect the generalizability of findings. Recruitment through U.S.-based channels may have biased the sample toward neurologists with neuroimmunology interests and those practicing in the United States. While some responses came from low- and middle-income countries, broader outreach—such as through international societies—could have improved global representation. Most respondents were adult neurologists, limiting insights into pediatric practice patterns. Additionally, the survey’s streamlined design may have restricted deeper exploration of decision-making factors.
Regarding the unanswered questioned that remain from this study, Yeh et al concluded by saying “Improving education and increasing awareness among neurologists, along with fostering collaborative efforts to con- duct large-scale, high-quality studies, are crucial to addressing these gaps in clinical practice.”