Relapse risk predicted for little-known autoimmune disease

A lot remains unknown about the autoimmune condition known as myelin oligodendrocyte glycoprotein antibody disease (MOGAD), with consensus on diagnostic criteria only published last year. A team of over 50 Australian scientists, headed by Professor Fabienne Brilot from The University of Sydney and the Kids Neuroscience Centre at Westmead, are helping to change this.

Often referred to as a cousin of multiple sclerosis (MS) due to shared symptoms, MOGAD is a little-known autoimmune condition where the body attacks a protein in the brain, resulting in a swollen central nervous system. The disease affects both adults and children and can result in blindness and paralysis, but is much less common, and less understood, than MS.

One of the biggest challenges with the condition is that some people will experience only one attack in their lifetime while around 40% have recurring attacks, each leading to additional impairment and disability. Strong immunosuppressants can help prevent relapses, but drug side effects mean it is vital to identify which patients need this ongoing treatment. The researchers have now discovered a way to predict which adult patients will experience a relapsing course by examining where the MOG autoantibody binds on the MOG protein (the epitope).

They found that in around 25% of patients, the antibody was not binding at the dominant epitope (called non-p42 epitope) and these were the patients experiencing a relapse. They also found this was most common in patients who at the initial onset of the disease were affected by vision impairment (lesions on the optic nerve) as opposed to those experiencing issues with movement (lesions on the spinal cord). Brilot said the clinical translation of the finding, which was published in the Journal of Neurology, Neurosurgery & Psychiatry (JNNP), is hugely significant given this is the first and only ‘test’ available.

“The prediction of a relapsing course in MOGAD means neurologists can make more informed treatment decisions,” she said. “They can initiate maintenance immunosuppression early rather than waiting for relapse to occur, as has happened with multiple sclerosis.

“It will help prioritise patients in busy neuroimmunology clinics and will also help recruitment into clinical trials which are vital to uncover the best treatments for this disease.”

Based on her experience overseeing MOG autoantibody testing in her lab at Westmead, Brilot aims to have testing for early identification of those at risk of relapsing disease available for clinical purposes in adults soon. Her team is also carrying out the same research with children with MOGAD, in the hope that the discovery could help young people impacted by the disease.

“The disease is so new, and so newly described, that there is a lot we still don’t know,” she said. “But whether or not patients will relapse is the number one question asked of neurologists — one we can now potentially answer.”

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