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At present there is no cure for NMO so management focuses on the following key areas:
a. Treating acute attacks/relapses
b. Preventing relapses
c. Treating the residual symptoms of the relapse
High dose steroids, Methylprednisolone (solumedrol) is usually given during a relapse. Steroids work by dampening the immune system and reducing inflammation around the site of nerve damage. They are given:
• Intravenously 1g daily for 5-7 days or
• Orally 500mg-2g daily for 5-7 days,
• In combination of intravenous and oral, followed by
• A tapering course of oral steroids over several months.
If steroids don’t help, what next?
When attacks progress or do not respond to corticosteroid treatment, there are two further options, Plasma Exchange or Intravenous Immunoglobulins.
Immunosuppressants are used to dampen down the activity of the body’s immune system. Drugs such as Prednisolone, Azathioprine, Methotrexate or Mycophenolate are used to allow reduction of steroids. All these treatments increase the risk of serious infections therefore blood should be monitored for full blood count, kidney and liver function.
Rituximab may be considered if first line treatment has failed ie the patient had a further relapse.
Specific issues to consider when caring for a person with NMO
Visual difficulties – Due to optic neuritis, consider the patient may have very poor eyesight. Check what they can actually see/not see as this may have implications on their activities such as taking medicines, drinks etc
Bladder/Bowel difficulties due to transverse myelitis the signals cannot pass through the spinal cord. Treat the symptoms similar to a person with spinal cord injury.
Pain tends to be neuropathic due to demyelination of sensory nerves of spinal cord. It can be very difficult to manage and is often described as burning, stabbing or ice burns. Movement does not make much difference, although often laying absolutely still eases the pain. However this will then cause joint stiffness and musculoskeletal pain so movement of limbs is encouraged.
Spasms due to nerve pathways ‘short-circuiting’ often cause very painful spasms but only lasting 30-60 seconds. Baclofen is often not helpful although a small dose of Carbamazepine maybe helpful. If spasms are quite new always check if there are any precursors such as infection, constipation or pressure sores and treat accordingly.
Pressure sores on feet and buttocks are a risk due to numbness of the limbs and lack of sensation, the person is unaware there is a problem and the sore will take a long time to heal.
Steroids are also good immunosuppressants but can cause side effects such as weight gain, acne, indigestion, diabetes, osteoporosis and mood and behavioural changes. To reduce the side effects of Prednisolone other medication is usually taken such as antacids, calcium supplements and Alendronic acid.