Neuromyelitis optica spectrum disorder (NMOSD) is a rare disease that affects the central nervous system (CNS), especially the optic nerves and spinal cord. You may also hear this condition referred to as neuromyelitis optica or its former name, Devic’s disease. NMOSD is a relapsing condition, meaning attacks can happen repeatedly — and they can be severe, sometimes causing vision loss or paralysis. That’s why early and effective treatment is so important.

If you or a loved one is facing NMOSD, it can feel overwhelming. However, new treatments can help many people control the disease and improve their quality of life.

In this article, we’ll discuss the most common treatment options for NMOSD. Acute treatments, used during an attack, are different from long-term treatments that help prevent future attacks. We’ll explain how each works and what to expect. Remember, treatment decisions should be made together with your healthcare providers. Be open about your goals and preferences, and your team will work with you to find the best approach for your needs.

1. Immunosuppressive Therapy

Neuromyelitis optica is an autoimmune disorder, which means it’s caused by the immune system attacking its own healthy cells. The immune system makes proteins called antibodies to fight harmful germs. In most people with NMOSD, abnormal antibodies (called autoantibodies) target a specific protein (aquaporin 4), mistakenly attack healthy tissues, and cause damage. Whether or not someone with NMOSD has these autoantibodies can help doctors predict which treatments are more likely to be effective.

The goal of immunosuppressants is to calm down the immune system to reduce the risk of NMOSD attacks.

Autoimmune diseases like NMOSD are often treated with immunosuppressants, a type of immunotherapy drug. These medications work by calming down the immune system to prevent further damage. Immunosuppressants are taken by mouth as pills or as injections or received at a clinic or hospital using IV infusion (into a vein).

The goal of immunosuppressants is to lower the risk of NMOSD relapses (attacks). By preventing future attacks, these medications can reduce further damage to the CNS and prevent long-term disabilities such as loss of vision or paralysis. Even if you haven’t had a relapse recently, it’s important to continue taking medications as prescribed by your doctor. Stopping could raise the risk of attacks.

Common immunosuppressive drugs for treating NMOSD are often used along with a low dose of corticosteroids (discussed below). Immunosuppressants include:

• Azathioprine (Azasan, Imuran) — Helps lower the risk of relapses
• Mycophenolate mofetil (CellCept) — Suppresses the immune response to prevent attacks
• Methotrexate — Commonly used for other autoimmune diseases as well

Other options, such as cyclosporin A, tacrolimus, and mitoxantrone, were studied in the past but are rarely used today. Newer treatments are preferred because they target NMOSD more specifically and have fewer side effects.

2. Monoclonal Antibodies

Monoclonal antibodies are human-made versions of antibodies that can be designed to attack a certain target. These drugs treat autoimmune diseases by blocking specific parts of the immune system that cause damage. As of late 2024, these four monoclonal antibodies were approved by the U.S. Food and Drug Administration (FDA) to treat antibody-positive NMOSD:

• Eculizumab (Soliris)
• Inebilizumab-cdon (Uplizna)
• Satralizumab-mwge (Enspryng)
• Ravulizumab-cwvz (Ultomiris)

Monoclonal antibodies are human-made versions of immune proteins designed to specific target parts of the immune system involved in NMOSD attacks.

These drugs work in different ways. Eculizumab and ravulizumab-cwvz stop a protein called complement C5 from causing damage. Inebilizumab-cdon reduces the number of B cells, immune cells responsible for producing the antibodies that mistakenly attack healthy tissues in NMOSD. Satralizumab-mwge lowers levels of interleukin-6, a molecule that promotes inflammation. By targeting these processes, monoclonal antibodies help prevent relapses and protect the CNS from further damage.

Rituximab (Rituxan) is another monoclonal antibody that may be used as an immunosuppressant. Although not FDA-approved for NMOSD, rituximab is commonly used off-label (outside its approved use) to treat the disease. Tocilizumab (Actemra, Tofidence, and Tyenne) can also be used off-label to treat NMOSD.

These therapies are highly effective for NMOSD, particularly in reducing relapses. Doctors may prescribe them for people with more severe cases or those who can’t have or don’t respond well to traditional immunosuppressants.

Like all medications, monoclonal antibodies have potential side effects. Some people may have an increased risk of infections, headaches, nausea, or infusion-related reactions. It’s important to work closely with your doctor to watch for or manage any side effects.

3. Corticosteroids

Corticosteroids (also simply called steroids) such as prednisone are a cornerstone of treatment for NMOSD, especially during acute attacks. These drugs work by quickly reducing inflammation and limiting damage to the optic nerves, spinal cord, and other tissues. This approach is similar to treating MS flares, but because NMOSD attacks are usually more severe, the dosage and timing may be different.

Corticosteroids are effective at reducing inflammation and stopping NMOSD attacks, but they cause serious side effects if used long term.

For acute attacks, high-dose IV methylprednisolone is typically given in a hospital. Once the attack is under control, doctors may switch to oral corticosteroids for ongoing treatment. However, long-term use can lead to weight gain, osteoporosis (weakened bones), and high blood sugar. To avoid these side effects, steroids are usually given at low doses and combined with other therapies.

4. Plasma Exchange

Plasma exchange, or plasmapheresis, is often used for severe attacks of NMOSD that don’t respond well to steroids. This procedure involves first removing the plasma (the liquid part of blood) that contains harmful autoantibodies causing the attacks. The blood is then returned with donor plasma or a plasma substitute.

Although not a long-term treatment, plasma exchange can be lifesaving in acute situations. If you have symptoms that don’t improve with corticosteroids, plasma exchange may help reverse some of the damage. Plasma exchange is also sometimes used in people with MS, but it’s more commonly needed in NMOSD.

5. Intravenous Immunoglobulin

“Immunoglobulin” is another term for “antibody.” Intravenous immunoglobulin (IVIG) is a treatment option that delivers healthy antibodies from donated blood to help block the harmful ones causing damage in NMOSD.

The procedure involves receiving antibodies through an IV line, usually in your arm, over a few hours in a hospital or clinic. IVIG may be used during a relapse or when other treatments aren’t working well. Studies show that IVIG may also help lower the rate of relapse.

6. Medications To Manage Symptoms

If you develop symptoms from your attacks, your doctor may recommend additional medications. For nerve pain, antidepressant or anticonvulsant medications such as amitriptyline or gabapentin (Neurontin) may be recommended. For painful muscle spasms, your doctor might prescribe a muscle relaxant such as baclofen or carbamazepine. Bladder or bowel problems might be treated with oxybutynin or laxatives.

7. Lifestyle and Supportive Care

Although medications and procedures are essential, managing NMOSD also means addressing overall health and well-being. Supportive care plays an important role in improving daily life.

Physical and occupational therapists can help people with NMOSD regain strength, mobility, and independence if symptoms persist after an attack. For instance, a physical therapist may recommend exercises to improve balance and coordination. Occupational therapy can provide strategies for adapting to reduced vision or mobility challenges.

Adaptive tools can be very helpful for severe vision loss or mobility issues. For example, screen readers, canes, or wheelchairs can greatly improve independence and quality of life.

Are You Living With Neuromyelitis Optica Spectrum Disorder?

NMOSD and MS have some similarities, but they’re distinct conditions that require unique approaches to treatment. It’s important to have a neurology team that understands both diseases well because some treatments that help one condition may make another worse. For instance, some MS therapies, like interferon beta (Avonex, Extavia), natalizumab (Tysabri), and fingolimod (Gilenya), can make NMOSD worse.

Neuromyelitis optica spectrum disorder is a complex condition. However, with the right combination of therapies and supportive care, you can live a fulfilling life. If you or a loved one has NMOSD that isn’t responding to current treatment, ask your healthcare team or a neurologist if there are newer options. If you’re interested in taking part in clinical trials for emerging therapies, they can give you more information about those, too.

Talk With Others Who Understand

MyMSTeam is the social network for people with MS and their loved ones. On MyMSTeam, more than 218,000 members come together to ask questions, give advice, and share their stories with others who understand life with MS.

Are you living with MS or neuromyelitis optica spectrum disorder? How do you manage your condition? Share your experience in the comments below, or start a conversation by posting on your Activities page.