Skip to content
How It Works
Explore
Resources Ask a Question
Who It's For
Patients
Decode results, prep for appointments, weigh options.
Caregivers & advocates
Carry the research load for someone you love.
Providers & clinicians
Resources for patients in your practice.
Log In Ask a Question
PubMed This is a summary of 20 peer-reviewed journal articles Updated
Neurology

Preventing Future Attacks: Targeted Maintenance Therapies

At a Glance

The most important goal of NMOSD treatment is preventing relapses, as every attack risks permanent damage. Continuous, long-term use of targeted maintenance therapies—such as complement inhibitors, B-cell depleters, or IL-6 blockers—is essential to suppress the immune pathways causing the disease.

Because NMOSD is “attack-driven,” the single most important goal of your medical care is to prevent the next relapse from ever happening. Every attack carries a risk of permanent damage to your vision or mobility, so doctors focus on “maintenance” therapies that keep your immune system from starting a new fire [1][2].

Unlike general immunosuppressants that quiet the entire immune system, modern NMOSD treatments are “targeted”—they act like a precision strike against the specific biological pathways that cause this disease [3][4].

The Targeted Toolkit

There are currently four main FDA-approved therapies for adults with AQP4-IgG-positive NMOSD, along with one widely used “off-label” option [3][5].

1. Complement Inhibitors: Eculizumab and Ravulizumab

  • How They Work: Remember that the “complement system” is the part of your immune system that can damage your astrocytes [6]. These drugs block a protein called C5, effectively putting a “safety cap” on the complement system so it cannot cause damage [7][8].
  • The Difference: Eculizumab is given as an IV infusion every two weeks [9]. Ravulizumab was developed as a long-acting version that only requires an infusion every eight weeks [10][11].
  • Safety Note: Because the complement system also helps fight certain bacteria, anyone taking these drugs must be vaccinated against meningococcal disease (meningitis) [12][13].

2. B-Cell Depleters: Inebilizumab and Rituximab

  • How They Work: B-cells are the “factory” cells that produce the harmful AQP4 antibodies. These drugs seek out and remove B-cells from your bloodstream [14][8].
  • Inebilizumab: This is FDA-approved specifically for NMOSD. It targets a marker called CD19 and is given as an IV infusion once every six months [14][8].
  • Rituximab: While not FDA-approved specifically for NMOSD (it is “off-label”), it has been used for years and is highly effective [15][16]. It targets a different marker called CD20 and is also typically given every six months [17][18].
  • Safety Note: By removing B-cells, these drugs suppress your overall immune system. This increases your risk for general infections, such as upper respiratory tract infections or urinary tract infections (UTIs). Your doctor will also screen you for Hepatitis B before starting, as these drugs can cause dormant infections to reactivate.

3. IL-6 Receptor Blocker: Satralizumab

  • How It Works: Interleukin-6 (IL-6) is a chemical messenger that tells your immune system to create inflammation and produce more antibodies. Satralizumab blocks the “ears” (receptors) of the cells so they cannot hear the IL-6 message [15][19].
  • Convenience: This medication is unique because it is a subcutaneous (under-the-skin) injection that you can often learn to give yourself at home every four weeks [19].
  • Safety Note: Similar to B-cell depleters, blocking IL-6 slightly suppresses your immune system, increasing your risk for common infections. Regular blood monitoring is important while on this therapy.

Why Treatment Must Be Continuous

It is common for patients to want to stop medication once they have felt healthy for a few years. However, in NMOSD, the immune system’s tendency to attack the AQP4 protein does not go away on its own.

  • The Risk of Stopping: Research shows that stopping or “tapering” medication too quickly leads to a high rate of severe relapses [20].
  • Lifelong Protection: Think of these therapies like a seatbelt. You don’t wear it because you expect to crash every day; you wear it every single time you are in the car so that you are protected if a “crash” (an attack) ever tries to happen [1][2].

A Note on Family Planning

Because NMOSD primarily affects women in their 30s and 40s, family planning is a common concern. Being on an immunosuppressive maintenance therapy means you must have detailed conversations with your neuro-immunologist and obstetrician before trying to get pregnant. Some therapies must be paused or switched prior to conception, while others may be continued depending on your specific risks. Never stop your medication without medical supervision, as doing so abruptly can trigger a severe relapse.

Common questions in this guide

What are the approved maintenance therapies for NMOSD?
There are currently four main FDA-approved targeted therapies for adults with AQP4-IgG-positive NMOSD. These include complement inhibitors like eculizumab and ravulizumab, the B-cell depleter inebilizumab, and the IL-6 receptor blocker satralizumab. Your doctor may also prescribe rituximab off-label.
Can I stop taking my NMOSD medication once I feel healthy?
No, you should never stop your medication without medical supervision. Stopping or tapering therapy too quickly leads to a high rate of severe relapses, because your immune system's tendency to attack does not go away on its own.
Why do I need a meningitis vaccine before taking complement inhibitors?
Because complement inhibitors block the part of your immune system that fights certain bacteria, you must be vaccinated against meningococcal disease (meningitis) before starting these medications. You may also need to take preventative antibiotics while the vaccine takes effect.
Will I have to go to a clinic for my NMOSD treatments?
It depends on the specific medication. Complement inhibitors and B-cell depleters require IV infusions at a clinic every few weeks or months. However, the IL-6 receptor blocker satralizumab is a subcutaneous injection that you can often learn to administer yourself at home.
Is it safe to get pregnant while taking NMOSD maintenance therapy?
Because NMOSD maintenance therapies suppress your immune system, you must have detailed conversations with your care team before trying to get pregnant. Some medications must be paused or switched prior to conception, but this must be done carefully to avoid triggering a relapse.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Based on my antibody status and lifestyle, which of the targeted pathways—complement inhibition, B-cell depletion, or IL-6 blocking—is the best fit for me?
  2. 2.If we choose a complement inhibitor like eculizumab or ravulizumab, which meningococcal vaccines do I need, and do I need to take preventative antibiotics while they take effect?
  3. 3.What is the schedule for my infusions or injections, and can any of these be done at home?
  4. 4.If we use rituximab off-label, how will you monitor my B-cell counts to know when it's time for the next dose?
  5. 5.How soon after my acute attack should I start this preventative therapy to ensure there is no 'gap' in my protection?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (20)
  1. 1

    New therapies for neuromyelitis optica spectrum disorder.

    Levy M, Fujihara K, Palace J

    The Lancet. Neurology 2021; (20(1)):60-67 doi:10.1016/S1474-4422(20)30392-6.

    PMID: 33186537
  2. 2

    Long-Term Safety and Efficacy of Eculizumab in Aquaporin-4 IgG-Positive NMOSD.

    Wingerchuk DM, Fujihara K, Palace J, et al.

    Annals of neurology 2021; (89(6)):1088-1098 doi:10.1002/ana.26049.

    PMID: 33586143
  3. 3

    Hope for patients with neuromyelitis optica spectrum disorders - from mechanisms to trials.

    Pittock SJ, Zekeridou A, Weinshenker BG

    Nature reviews. Neurology 2021; (17(12)):759-773 doi:10.1038/s41582-021-00568-8.

    PMID: 34711906
  4. 4

    Neuromyelitis optica spectrum disorders: a review with a focus on children and adolescents.

    Paolilo RB, Paz JAD, Apóstolos-Pereira SL, et al.

    Arquivos de neuro-psiquiatria 2023; (81(2)):201-211 doi:10.1055/s-0043-1761432.

    PMID: 36948203
  5. 5

    Progress in the Treatment of Neuromyelitis Optica Spectrum Disorder: From Pathogenic Insights to Biologics.

    Ikeguchi R, Shimizu Y, Todo K

    Internal medicine (Tokyo, Japan) 2026; doi:10.2169/internalmedicine.6772-25.

    PMID: 41730623
  6. 6

    Endothelial cell-secreted SPARC suppresses astrocytic CD59 expression and promotes astrocytopathy in a mouse model of neuromyelitis optica spectrum disorders.

    Cui T, Gong Y, Wang Z, et al.

    Nature communications 2026; (17(1)).

    PMID: 42120878
  7. 7

    Safety Profile of Monoclonal Antibodies and Subsequent Drug Developments in the Treatment of Paroxysmal Nocturnal Hemoglobinuria.

    Mallenahalli Neeekantappa V, Kamath A, Bharathi Rajaduraivelpandian P

    Medicina (Kaunas, Lithuania) 2024; (60(3)) doi:10.3390/medicina60030379.

    PMID: 38541105
  8. 8

    Drug Treatment of Neuromyelitis Optica Spectrum Disorders: Out with the Old, in with the New?

    Held F, Klein AK, Berthele A

    ImmunoTargets and therapy 2021; (10()):87-101 doi:10.2147/ITT.S287652.

    PMID: 33777853
  9. 9

    Eculizumab in Aquaporin-4-Positive Neuromyelitis Optica Spectrum Disorder.

    Pittock SJ, Berthele A, Fujihara K, et al.

    The New England journal of medicine 2019; (381(7)):614-625 doi:10.1056/NEJMoa1900866.

    PMID: 31050279
  10. 10

    An evaluation of ravulizumab for the treatment of neuromyelitis optica spectrum disorder.

    Balaban DT, Levy M, Borrow R, Anderson MR

    Expert opinion on biological therapy 2024; (24(11)):1193-1198 doi:10.1080/14712598.2024.2423002.

    PMID: 39460545
  11. 11

    Intravenous ravulizumab in mechanically ventilated patients hospitalised with severe COVID-19: a phase 3, multicentre, open-label, randomised controlled trial.

    Annane D, Pittock SJ, Kulkarni HS, et al.

    The Lancet. Respiratory medicine 2023; (11(12)):1051-1063 doi:10.1016/S2213-2600(23)00082-6.

    PMID: 36958364
  12. 12

    Investigational drugs in development to prevent neuromyelitis optica relapses.

    Paul F, Murphy O, Pardo S, Levy M

    Expert opinion on investigational drugs 2018; (27(3)):265-271 doi:10.1080/13543784.2018.1443077.

    PMID: 29465257
  13. 13

    Eculizumab impairs Neisseria meningitidis serogroup B killing in whole blood despite 4CMenB vaccination of PNH patients.

    Langereis JD, van den Broek B, Franssen S, et al.

    Blood advances 2020; (4(15)):3615-3620 doi:10.1182/bloodadvances.2020002497.

    PMID: 32766853
  14. 14

    Advances in the long-term treatment of neuromyelitis optica spectrum disorder.

    Anderson M, Levy M

    Journal of central nervous system disease 2024; (16()):11795735241231094 doi:10.1177/11795735241231094.

    PMID: 38312734
  15. 15

    Recent progress in maintenance treatment of neuromyelitis optica spectrum disorder.

    Holmøy T, Høglund RA, Illes Z, et al.

    Journal of neurology 2021; (268(12)):4522-4536 doi:10.1007/s00415-020-10235-5.

    PMID: 33011853
  16. 16

    Effect of rituximab on disease activity in latin American patients with anti-aquaporin-4 (+) neuromyelitis optica spectrum disorder.

    Gomez-Figueroa E, Noriega-Morales G, Casallas-Vanegas A, et al.

    Clinical neurology and neurosurgery 2020; (196()):106007 doi:10.1016/j.clineuro.2020.106007.

    PMID: 32559706
  17. 17

    The correlation between rituximab dose reduction and acute relapses of neuromyelitis optica spectrum disorder, lessons from COVID-19 epidemic.

    Ashtari F, Mehdipour R, Asgari M, Ghalamkari A

    Multiple sclerosis and related disorders 2024; (92()):105940 doi:10.1016/j.msard.2024.105940.

    PMID: 39426125
  18. 18

    Precision therapy for neuromyelitis optica spectrum disorder: A retrospective analysis of the use of class-switched memory B-cells for individualised rituximab dosing schedules.

    Trewin BP, Adelstein S, Spies JM, et al.

    Multiple sclerosis and related disorders 2020; (43()):102175 doi:10.1016/j.msard.2020.102175.

    PMID: 32417664
  19. 19

    Satralizumab treatment in patients with AQP4-IgG-seropositive neuromyelitis optica spectrum disorder after rituximab treatment: A case series.

    Abboud H, Steingo B, Vargas D, et al.

    Journal of neuroimmunology 2025; (403()):578585 doi:10.1016/j.jneuroim.2025.578585.

    PMID: 40132364
  20. 20

    Optimal management of neuromyelitis optica spectrum disorder with aquaporin-4 antibody by oral prednisolone maintenance therapy.

    Takai Y, Kuroda H, Misu T, et al.

    Multiple sclerosis and related disorders 2021; (49()):102750 doi:10.1016/j.msard.2021.102750.

    PMID: 33524925

This page is for informational purposes only and does not replace professional medical advice. Always consult your neuro-immunologist before starting, stopping, or changing your NMOSD maintenance therapies.

Get notified when new evidence is published on Neuromyelitis optica spectrum disorder.

We monitor PubMed for new peer-reviewed studies on this topic and email a short summary when something meaningful changes.