Immunosuppressive treatment in neurology

1. Big picture

Immunosuppressive treatment in neurology is used when neurological disease is caused by an abnormal immune attack against the nervous system, neuromuscular junction, nerve roots, peripheral nerves, muscle, vessels, or CNS myelin.

The key exam sentence:

Immunosuppressive therapy is used in immune-mediated neurological diseases to stop inflammation, reduce relapses, prevent irreversible neurological damage, and treat life-threatening immune attacks.

Important neurological diseases where immunosuppression is used:

• multiple sclerosis relapses;
• neuromyelitis optica spectrum disorder;
• myasthenia gravis;
• autoimmune encephalitis;
• CNS vasculitis;
• inflammatory myopathies;
• chronic inflammatory demyelinating polyneuropathy;
• autoimmune neuropathies;
• neuropsychiatric autoimmune disease;
• neurosarcoidosis;
• Behçet disease;
• paraneoplastic and antibody-mediated neurological syndromes.

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2. Definition

Immunosuppression means reducing the activity of the immune system to stop immune-mediated tissue damage.

In neurology, immunosuppression may be used to target:

• T cells;
• B cells;
• autoantibodies;
• complement;
• cytokines;
• inflammatory cell migration;
• macrophage-mediated tissue injury.

Important distinction:

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3. Main goals of immunosuppressive treatment

Immunosuppressive treatment is used for five practical goals:

1. Treat acute inflammation quickly Example: high-dose intravenous methylprednisolone in MS relapse, myelitis, optic neuritis, autoimmune encephalitis.

2. Prevent future attacks or relapses Example: azathioprine, rituximab or mycophenolate in neuromyelitis optica.

3. Reduce antibody-mediated damage Example: plasma exchange in myasthenic crisis or severe demyelinating attack.

4. Maintain long-term remission Example: azathioprine in myasthenia gravis or autoimmune neurological disease.

5. Prevent irreversible disability or death Example: early treatment of myasthenic crisis, autoimmune encephalitis, severe myelitis, CNS vasculitis.

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4. Main drug groups used in neurology