Background: Anti–John Cunningham virus (JCV) antibody testing is routinely used for risk stratification in patients with multiple sclerosis (MS) who are receiving or being considered for high-efficacy disease-modifying therapies, particularly natalizumab. However, real-world data describing anti-JCV testing practices and serostatus in Southeast Asian MS populations remain limited.Objective: To describe anti-JCV antibody status in a real-world cohort of Thai patients with MS undergoing evaluation for or receiving high-efficacy therapies.Methods: This single-center cross-sectional study included consecutive adults with MS who underwent clinically indicated anti-JCV antibody testing at the Siriraj Hospital MS Center, Thailand, between October 2018 and October 2025. Anti-JCV antibodies were measured using the STRATIFY JCV™ two-step enzyme-linked immunosorbent assay. Demographic and clinical characteristics were obtained from medical records. Seropositivity was summarized with exact binomial 95% confidence intervals (CIs).Results: Twenty-four patients underwent anti-JCV antibody testing. Mean age was 40.2 ± 7.6 years, 91.7% were female, and all were Thai. Anti-JCV antibody positivity was observed in 16 patients (66.7%; 95% CI 44.7–84.4). Among seropositive patients, the median antibody index was 3.02 (interquartile range [IQR] 2.07–3.45). At testing, 9 patients (37.5%) were receiving rituximab, 4 (16.7%) cladribine, and 3 (12.5%) fingolimod; smaller numbers were receiving other therapies or were treatment-naïve. Exploratory comparisons revealed no consistent differences between seropositive and seronegative patients.Conclusion: In this real-world cohort of selectively tested Thai patients with MS, approximately two-thirds were anti-JCV seropositive, consistent with international reports. Although the findings are not intended to represent the broader Thai MS population, they provide baseline evidence supporting the clinical use of anti-JCV antibody testing for treatment planning and risk stratification in routine practice.

Background:In many low-resource settings, access to several therapies for multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) is still limited. Although rituximab (RTX) is considered off-label for some indications, it provides a relatively affordable alternative. However, its long-term use raises concerns about adverse effects such as secondary hypogammaglobulinemia and infection. Extending the dosing interval according to circulating cluster of differentiation 19 (CD19) B-cell counts has been proposed to preserve efficacy while minimizing complication and cost. Methods:This study retrospectively assessed the long-term efficacy and safety of RTX with CD19-guided, extended dosing intervals in patients with MS and aquaporin-4 immunoglobulin G-positive NMOSD. All treatments were delivered at Siriraj Hospital, Thailand, between January 1994 and February 2025. Clinical data, CD19 lymphocyte profiles, immunoglobulin levels and imaging findings were extracted for patients who had received RTX for at least 2 years. Results:Eighty-seven patients satisfied the inclusion criteria. In the MS cohort of 43 patients, treatment duration (mean ± standard deviation (SD)) was 4.10 ± 1.42 years, and the mean dosing interval was 32.61 ± 4.87 weeks. In 44 NMOSD patients, corresponding values were 4.92 ± 2.32 years and 33.87 ± 8.67 weeks. RTX reduced the median annualized relapse rate from 0.55 to 0.00 in MS and from 1.15 to 0.00 in NMOSD (both P < 0.001). The median Expanded Disability Status Scale scores improved from 2.0 to 0.0 in MS (P = 0.006) and from 4.5 to 4.0 in NMOSD (P < 0.001). Four patients maintained dosing intervals exceeding 48 weeks without relapse, and their CD19-positive B-cell proportion remained below 1%. Adverse events occurred in 32.6% of MS patients and 43.2% of NMOSD patients, most commonly infusion reactions (16.3% and 15.9%, respectively) or infections (14.0% and 27.3%, respectively). Leukopenia was documented in 4.7% of MS and 6.8% of NMOSD patients, whereas hypogammaglobulinemia arose only in NMOSD (6.7%); no fatal events were recorded. Conclusions:CD19-guided, extended-interval RTX is associated with relapse control, disability score improvement and favorable tolerability, while potentially lowering infusion frequency and healthcare costs in resource-constrained settings. Nonetheless, repopulation of CD19-positive B cells during prolonged intervals warrants vigilance because it may signal an increased risk of relapse.

Myasthenia gravis, neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) are antibody-mediated neuroimmune disorders that frequently affect women in their reproductive years and require careful treatment planning around pregnancy. Disease exacerbations (for myasthenia gravis) and attacks (for NMOSD and MOGAD) can occur during pregnancy, are common postpartum, and can cause preventable, long-term maternal disability. Many drug labels are conservative or recommend unnecessary prolonged washouts or avoidance of breastfeeding, creating uncertainty for physicians and patients. This Personal View integrates available evidence on conventional immunosuppressants and biological therapies, including complement inhibition, B-cell depletion, and neonatal Fc receptor blockade. Although data on pregnancy safety for newer treatments are few, preliminary data suggest that selected therapies could be continued during pregnancy to maintain disease stability and are compatible with breastfeeding. We offer expert recommendations for therapy choice, infant vaccinations, and fetal and infant monitoring in myasthenia gravis, NMOSD, and MOGAD.

Sleep disturbance is common in aquaporin-4 immunoglobulin G (AQP4-IgG)-positive neuromyelitis optica spectrum disorder (NMOSD), but its clinical and neurobiological correlates remain incompletely characterized; prior studies used single-modality assessments. In this exploratory cross-sectional study we characterized sleep-wake patterns in clinically stable AQP4-IgG-positive NMOSD and explored volume-sleep associations. Patients and controls underwent questionnaires, 7-day wrist actigraphy and structural MRI; intracranial volume-normalized regional volumes and within-patient volume-sleep associations were examined, with Benjamini-Hochberg false discovery rate (FDR) correction. Twenty-four patients and 26 controls were enrolled; 20 patients and 20 database-derived controls contributed MRI. Patients were older than controls (49.7 versus 33.0 years; g = 1.40); analyses were adjusted for age and body mass index (BMI). After adjustment, patients showed longer time in bed (+58 min) and total sleep time (+50 min), whereas sleep efficiency and wake after sleep onset did not differ. Higher BMI was associated with lower sleep efficiency (r = -0.44) and longer sleep onset latency. Subjective sleep disturbance and pain-related quality of life were worse in NMOSD. After FDR correction, volume reductions were observed in bilateral hippocampal molecular-layer subfields and all five corpus callosum segments, with suggestive thalamic reductions; no volume-sleep association survived. Sleep disturbance in clinically stable AQP4-IgG-positive NMOSD was characterized by greater subjective sleep burden and altered sleep-wake timing, with associations observed with clinical and metabolic factors. These hypothesis-generating findings are consistent with a multifactorial pattern of associations and highlight the need for longitudinal studies integrating objective sleep measurement, neuroimaging and biomarkers.

Clinically isolated syndrome (CIS) is the initial clinical presentation that may indicate the development of multiple sclerosis (MS). While significant advancements have been made in the treatment of MS, there remains no definitive consensus on the effective treatment of CIS. Our study aims to evaluate the outcomes of disease-modifying therapies (DMTs) in the progression of CIS to clinically definite multiple sclerosis (CDMS) and to assess their efficacy in the treatment of CIS. A literature search was conducted through March 2024, focusing on immunotherapies that can treat CIS. The control group consisted of patients who received a placebo. The primary outcomes were the number of patients who converted to CDMS over the course of the study and the progression of the severity of disability in patients with MS using the Expanded Disability Status Scale (EDSS). The secondary outcomes included improvement in CIS symptoms based on MRI lesions, including gadolinium-enhancing (GDE) and T2-weighted (T2W) lesions. A total of 9 studies (8 randomized controlled trials and 1 post hoc analysis) included 3,339 patients diagnosed with CIS who received immunotherapy. The patients had a mean age of 31.4 ± 7.8 years and were followed for a mean duration of 35.7 months. Cladribine showed the strongest evidence in lowering CDMS conversion (HR 0.37; 95% CrI 0.23-0.59; SUCRA 85.40 followed by GA (HR 0.50; 95% CrI 0.34-0.73; SUCRA 62.10), IFN beta-1b (HR 0.51; 95% CrI 0.35-0.74; SUCRA 60.60), teriflunomide (HR 0.59; 95% CrI 0.37-0.92; SUCRA 59.20), and IFN beta-1a (HR 0.62; 95% CrI 0.50-0.77; SUCRA 39.50), respectively. DMTs, including cladribine, teriflunomide, IFN beta-1a, IFN beta-1b, and GA, showed evidence of reducing conversion to CDMS compared with placebo. Cladribine and GA showed the strongest evidence for a high probability of reducing CDMS conversion.

BACKGROUND:Therapeutic plasma exchange (TPE) is a cornerstone of therapeutic apheresis across multiple subspecialties. While international registries have described global practice, nationwide data from Thailand are lacking. METHODS:We conducted a 10-year retrospective analysis of all TPE admissions reimbursed under Thailand's Universal Health Coverage scheme (2014-2023). Cases were identified using ICD-9 code 997.1. Demographics, clinical indications, complications, outcomes, and costs were extracted from discharge records. Indications were categorized according to the 2023 American Society for Apheresis (ASFA) guidelines. RESULTS:A total of 5884 admissions were identified. The mean age was 46.4 ± 20.6 years, 58.0% were male, and 13.0% were pediatric. TPE Utilization increased from the mid-200s in 2014 to nearly 900 admissions in 2023. Neurological (28.9%) and nephrological (24.4%) disorders were the leading subspecialties. Systemic lupus erythematosus (12.4%), septic shock (12.1%), and acute inflammatory demyelinating polyradiculoneuropathy (9.1%) were the most frequent disease-specific indications. Nearly three-quarters of procedures were guideline-supported (Category I: 28.6%, Category II: 31.7%), while Category III use was 28.1% in our cohort. In-hospital mortality was 51.6% overall, driven largely by septic shock and acute liver failure, whereas survival exceeded 70% in autoimmune neurologic diseases and transplant recipients. Complications included bleeding (25.5%), transfusion requirements (69.0%), and hypocalcemia (9.7%). The actual cost per admission ranged USD 4000-12000, while reimbursement covered USD 2000-7000. CONCLUSION:This first nationwide analysis of TPE in Thailand highlights increasing utilization, high-cost burden, and important differences from global practice. Strengthening registries, refining coding systems, and developing region-specific guidelines will be critical to optimize outcomes and sustainability.

Objective This systematic review aims to analyze the clinical, laboratory, and imaging characteristics of GFAP astrocytopathy, with attention to differences between Asian and non-Asian populations. Methods We searched PubMed, Embase, and Scopus from inception through June 2025 for case reports, case series, and observational studies involving adult patients with GFAP astrocytopathy. Fifteen studies, including 538 patients, were analyzed. Data on clinical presentations, MRI findings, and laboratory results were extracted and compared across regions. Results We identified a total of 2,272 studies, of which 15 were included in our final analysis, comprising 538 patients. Our analysis identified three main clinical phenotypes: meningoencephalitis (164/371, 44.2%), meningoencephalomyelitis (94/371, 25.3%), and myelitis (26/371, 7.0%). The most common clinical symptoms were headache (186/470, 39.6%), abnormal movements (160/473, 33.8%), fever (172/538, 32.0%), and psychiatric symptoms (111/471, 23.6%). MRI findings frequently showed lesions in the periventricular (85/434, 19.6%) and subcortical regions (80/432, 18.5%). Perivascular and meningeal enhancements represented the most common radiological findings. Laboratory findings revealed positive GFAP antibodies in either serum or CSF. Co-existence of other antibodies in CSF and serum was also observed, most notably anti-AQP4, anti-MOG, and anti-NMDAR. Conclusion GFAP astrocytopathy is characterized by a wide range of clinical and radiological manifestations, most commonly presenting as meningoencephalitis, meningoencephalomyelitis, or myelitis, with meningoencephalitis being the most prevalent clinical syndrome observed in this study. Commonly reported symptoms include headache, fever, abnormal movements, and psychiatric symptoms. The disease exhibits diverse neurological and imaging features. Regional differences suggest that genetics, diagnostic practices, and cultural factors may influence symptom profiles. These findings highlight the need for standardized diagnostic criteria and further research across diverse populations.

BACKGROUND AND OBJECTIVES:Double seronegative NMOSD (DS-NMOSD) lacks approved disease-modifying treatments, and limited data exist on optimal relapse-prevention strategies. In this multicenter, international, retrospective cohort study, we sought to compare the real-world effectiveness of anti-CD20 agents vs nonspecific immunosuppressants as disease-modifying strategies for relapse prevention in DS-NMOSD. METHODS:A retrospective cohort database was constructed using standardized data collection from medical records across collaborating centers in the United States, Brazil, the United Kingdom, Thailand, Turkiye, and China. Patients meeting IPND-2015 NMOSD criteria with negative serum aquaporin-4 and myelin oligodendrocyte glycoprotein antibody testing via cell-based assays and at least 12 months of follow-up were reviewed. The primary outcome was the incidence rate ratio (IRR) of relapses; secondary outcomes included the annualized relapse rate (ARR) and time to relapse. RESULTS:A total of 103 patients with DS-NMOSD met study criteria, with a median follow-up of 6 years. Anti-CD20 therapy was associated with a significantly lower IRR (0.02, 95% CI 0.01-0.04) and ARR (0.17, 95% CI 0.07-0.40) compared with nonspecific immunosuppressants (0.76, 95% CI 0.40-1.43) after adjusting for covariates. Survival analysis demonstrated a prolonged relapse-free interval with anti-CD20 agents. DISCUSSION:Our findings support the use of B-cell depletion as a potentially superior relapse-prevention strategy in DS-NMOSD, highlighting its potential as a first-line therapy. CLASSIFICATION OF EVIDENCE:This study provides Class IV evidence that, in patients with DS-NMOSD, treatment with a DMT reduces relapse incidence rate ratio compared with no treatment and anti-CD20 DMTs are associated with a lower relapse incidence rate ratio compared with nonspecific immunosuppressants.

BACKGROUND:Aquaporin-4-immunoglobulin G-seropositive neuromyelitis optica spectrum disorder (AQP4-IgG+ NMOSD) is a relapse-associated inflammatory disease in which attacks drive irreversible disability. Treatment discontinuation occurs in practice, and data on outcomes after withdrawal are limited. METHODS:We retrospectively reviewed adults with AQP4-IgG+ NMOSD who had discontinued maintenance immunotherapy and had at least 6 months of follow-up. Clinical characteristics, treatment exposure, relapses, and disability outcomes were collected. Relapse-free survival was analysed using the Kaplan-Meier method. RESULTS:Among 292 patients with AQP4-IgG+ NMOSD, 22 met the inclusion criteria. Median age at discontinuation was 48.8 years (interquartile range [IQR] 28.9-65.5) and 19 patients (86.4%) were female. Twelve of 22 patients (54.5%) relapsed after discontinuation, whereas 10 (45.5%) remained relapse-free. The relapse-free probability was 81.0% at 1 year (95% CI, 56.9-92.4), 56.3% at 5 years (95% CI, 32.6-74.5), and 48.2% at 10 years (95% CI, 24.0-68.9). In subgroup analysis, patients who remained relapse-free had lower Expanded Disability Status Scale (EDSS) scores at nadir (4.0 [3.5-4.0] vs 5.0 [4.0-6.0], p = 0.032). EDSS scores worsened in 5 of 12 relapsing patients (41.7%) but in none of the 10 non-relapsing patients; within-group change was significant in the relapse group (p = 0.027). CONCLUSION:Maintenance immunotherapy discontinuation in AQP4-IgG+ NMOSD was associated with a high risk of relapse, frequently resulting in disability worsening. These findings emphasize the need for careful consideration before treatment withdrawal, even among patients with prolonged clinical remission.

This first international multicenter study evaluated pregnancy outcomes and their influence on disease activity in Asian women with myelin oligodendrocyte glycoprotein-antibody-associated disease (MOGAD) meeting the 2023 diagnostic criteria. Among 318 women with adult-onset MOGAD, 23 pregnancies after disease onset in 18 women were analyzed. Pregnancy outcomes were generally favorable, with most infants born healthy. Relapse rates decreased during pregnancy and returned postpartum. Three-quarters of women with previously monophasic disease transitioned to a relapsing course postpartum, although most attacks during and after pregnancy recovered well. These findings suggest that pregnancy can be considered with appropriate clinical monitoring in women with MOGAD.

BACKGROUND:Comorbidities occur in aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (AQP4-NMOSD), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and double seronegative NMOSD (DN-NMOSD), potentially contributing to a less favorable disease course. OBJECTIVES:To characterize comorbidities in AQP4-NMOSD, MOGAD, and DN-NMOSD and assess their association with optic neuritis (ON) outcomes by optical coherence tomography (OCT) in AQP4-NMOSD. METHODS:Four hundred and forty-two participants from the CROCTINO cohort were evaluated for comorbidities. RESULTS:In AQP4-NMOSD patients (n = 360), 43.5% (n = 161) had comorbidities, equally divided between single and multiple. In MOGAD (n = 49), 40.8% had comorbidities, with 75% (n = 15) single and 25% (n = 5) multiple. In DN-NMOSD (n = 33), 36.4% (n = 12) had comorbidities equally split. AQP4-NMOSD patients had more multiple comorbidities (50%, n = 81/161) than MOGAD (25%, n = 5/20, p = 0.03) and more autoimmune disorders (AID) (40.4%, n = 65) than MOGAD (20%, n = 4, p = 0.09) and DN-NMOSD (none, p = 0.004). Cardiovascular comorbidities and related risk factors (CVC/RF) occurred in 34.8% (n = 56) of AQP4-NMOSD, 50% (n = 10) of MOGAD, and 33.3% (n = 4) of DN-NMOSD. Expanded Disability Status Scale was higher in MOGAD (3.0 vs. 2.0, p = 0.006) and DN-NMOSD (5.0 vs. 2.0, p = 0.008) with comorbidities. AQP4-NMOSD patients with CVC/RF had higher ON relapse rates than those with AID (1.06 ± 3.33 vs. 0.49 ± 0.98, p < 0.001). OCT revealed reduced inner nuclear layer thickness in AQP4-NMOSD with comorbidities compared to non-comorbidity (B = -1.52, p = 0.047), more pronounced with CVC/RF (B = -2.96, p = 0.009). CONCLUSION:Comorbidities are frequent in AQP4-NMOSD and MOGAD and are associated with ON frequency and disability. These findings highlight the need for proactive comorbidity management to improve patient care.

OBJECTIVE:To examine the impact of multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and related disorders on employment and income in Thailand. METHODS:This questionnaire-based cross-sectional study was conducted at Siriraj Hospital in 2023-2024. Primary outcomes included sociodemographic characteristics and employment status. Employment-related factors were analyzed using log-binomial regression, focusing on employment loss, reduced work hours, and income loss. RESULTS:This study included 204 participants aged > 18 years old, with 169 (82.8 %) females, a median age of 36.5 (IQR: 27.0-50.25), and a median disease duration of 8.0 years (IQR: 3.25-14.0). Diagnosis included 98 (48.0 %) NMOSD, 71 (34.8 %) MS, 13 (6.4 %) MOGAD, and 22 (10.8 %) other conditions. The average annual salary of 6205.11 USD (IQR: 2872.74-11,490.95) before diagnosis was reduced to 5745.46 USD (IQR: 1,378.91-11,490.95) USD after diagnosis, p = 0.079. Median weekly work hours dropped from 40 (IQR: 10-48) per week by half to 20 (0-40) hours, p < 0.001. Unemployment was reported in 52/184 (28.3 %) patients, 70/185 (37.8 %) experienced reduced work hours, and 60/117 (51.3 %) reported income loss. No association was found between factors and unemployment. Increased age (prevalence ratio [PR] = 1.02, 95 % CI 1.01-1.03, p = 0.050) and total number of attacks (PR= 1.03, 95 % CI 1.01-1.07, p = 0.021) were linked to reduced work hours. Increased pain score was associated with income loss (PR=1.11, 95 % CI: 1.04-1.19, p = 0.001). CONCLUSIONS:The study emphasizes the importance of a holistic approach to managing these diseases. Prioritizing adequate disease management, avoidance, and treatment of disability, relapses, and pain is crucial for mitigating employment-related challenges.

OBJECTIVES:To assess loss of employment, work hours, and wages of people with aquaporin-4 antibody-positive or double-seronegative/antibody status unknown neuromyelitis optica spectrum disorder (NMOSD) internationally. METHODS:An investigator-designed survey was administered to adults ages 18-70 years with NMOSD and distributed by neurologists in 23 countries, July 2022 to September 2023. RESULTS:There were 897 participants (635 aquaporin-4 antibody positive, 262 double-seronegative/untested; 81.4% female, average age 42.5 years, average disease duration 7.6 years, median 2 disease attacks since diagnosis). NMOSD impact was visual loss (34.0% unilateral; 28.2% bilateral), 61.8% with spinal cord disease, 55.6% with pain, 43.6% with fatigue, 38.2% with depressed mood, and 25.0% with gait aid use. In total, 92.6% took immunosuppressive therapy. Employment rates were 62.6% before and 36.3% after NMOSD diagnosis. In a multivariable model, statistically significant independent associations with unemployment in NMOSD were older age (odds ratio (OR) = 0.97, p < 0.001), being female (OR = 0.48, p < 0.001), bilateral visual loss (OR = 0.61, p = 0.02), highest frequency of depressed mood (OR = 0.29, p < 0.001), and walking aid use (OR = 0.38, p < 0.001). DISCUSSION:Approximately 1/3 of people living with NMOSD of potential working age are in the workforce. Unemployment in NMOSD is associated with previously recognized factors but also self-reported low mood, gait aid use, and bilateral visual loss.

ABSTRACT Introduction Optical coherence tomography (OCT)‐derived retina measurements are markers for neuroaxonal visual pathway status. High‐quality OCT scans are essential for reliable measurements, but their acquisition is particularly challenging in eyes with severe visual impairment, as often observed in neuromyelitis optica spectrum disorders (NMOSD). Objective To investigate OCT quality issues in real‐world data from the international Collaborative Retrospective Study on Retinal OCT in Neuromyelitis Optica (CROCTINO). Methods We evaluated the quality of peripapillary and macular OCT scans, using Heidelberg Spectralis SD‐OCT, Carl Zeiss Cirrus HD‐OCT, or Topcon SD‐OCT across 22 centers. Experienced graders applied OSCAR‐IB criteria for OCT quality. Eyes were classified as severely visually impaired or not based on a 1.0 logMAR cut‐off. Quality outcomes were compared using the Chi‐square test. Results A total of 3075 OCT scans (1630 peripapillary, 1445 macular) from 539 people with NMOSD and related conditions were evaluated. Macular scans were rejected more often than peripapillary scans due to quality issues (20.1% vs. 14.5%, p < 0.001). Rejection rates were higher in eyes with severe visual impairment (peripapillary: 28.9%, macular: 41.6%) compared to eyes without severe visual impairment (peripapillary: 10.7%, p < 0.001; macular: 14.6%, p < 0.001). Conclusion Our study revealed that approximately one in six scans was rejected due to low quality, with higher rejection rates in eyes with severe visual impairment. As scan quality can bias quantitative outcomes and artificial intelligence applications, these findings emphasize the unmet need for standardized OCT practices tailored to NMOSD and other conditions involving severe visual impairment.

Serum neurofilament light chain is a notable biomarker for detecting axonal injury and has shown significant potential for clinical applications. Establishing a reference interval and cut-off level is a critical step towards implementing a serum neurofilament light chain in routine clinical practice. In this study, we aimed to establish a reference range of serum neurofilament light chains for the Thai population. Blood samples were collected from healthy Thai adults without a history of neurological diseases and screened at the Siriraj Hospital. The relationship between age, sex and log10-transformed serum neurofilament light chain levels was analysed using linear regression. A crude reference interval was calculated as the 2.5–97.5th percentile values. An age-normative percentile curve for serum neurofilament light chain was derived using the generalized additive model for location, scale and shape. A total of 223 subjects (96 males and 127 females) aged 18–70 years were recruited. Male sex (P = 0.008) and older age (P < 0.001) were significantly associated with higher serum neurofilament light chain levels. A median of the observed serum neurofilament light chain values was 5.8 pg/ml (95% confidence interval 5.4–6.2), ranging from 1.0 to 18.4 pg/ml, with a crude reference interval of 2.3–15.9 pg/ml. The 2.5–97.5th percentile intervals for serum neurofilament light chain by age group were as follows: 20–29 years (n = 57): 1.7–8.7 pg/ml; 30–39 years (n = 58): 2.5–10.6 pg/ml; 40–49 years (n = 59): 3.5–14.3 pg/ml; 50–59 years (n = 37): 4.7–15.8 pg/ml and 60–69 years (n = 12): 4.2–18.2 pg/ml. The age-normative serum neurofilament light chain curve predicted the 97.5th percentile of 8.2, 9.9, 11.7, 14.6 and 19.9 pg/ml for ages 20, 30, 40, 50 and 60, respectively. This study is the first to establish reference values for serum neurofilament light chains in Thailand. The age-normative upper reference curve is closely aligned with observed values and those previously reported in other studies, providing a robust framework for clinical implementation. However, further validation in larger cohorts and among individuals with neurological diseases is warranted.

Background Cladribine Tablets (CladT) have emerged as a potent disease-modifying therapy (DMT) for relapsing multiple sclerosis (Pittock et al., 2019. While their efficacy and safety profiles have been well-documented in Western populations, there is a paucity of region-specific guidelines for their use in the Asia-Pacific context. This manuscript presents a consensus developed by Asia-Pacific experts, aiming to provide practical recommendations for the clinical application of CladT in this region. Methods A steering committee (SC) comprising four multiple sclerosis (Pittock et al., 2019one international and three from the APAC region—led an advisory board and developed 16 clinical questions regarding the practical use of CladT. To address these questions, statements were formulated based on available evidence, expert insights, and perspectives from the SC, along with input from an extended faculty of six MS experts representing in total nine APAC countries. Consensus on the recommendations was established when at least 75 % of respondents rated their agreement between 7 and 9 on a 9-point scale. Results A total of 16 clinical statements were drafted, and consensus was reached on 15 of them. The recommendations covered key aspects of CladT use, including indications for treatment initiation in both treatment-naïve and previously treated patients, strategies for managing disease activity over time, long-term safety considerations, and the role of CladT in special populations. CladT were recognized as an effective high-efficacy therapy for both highly and moderately active RMS, with robust long-term efficacy and safety profiles. It was also identified as a suitable option for patients requiring minimal hospital visits and those with limited access to healthcare facilities. While there was strong agreement on its use in treatment-naïve and early MS patients as well as a switch therapy, no consensus was reached on using CladT as a first-switch option for patients experiencing breakthrough disease on high-efficacy therapies. Recommendations also emphasized the importance of lymphocyte monitoring, appropriate patient selection, and the possibility of additional treatment courses beyond Year 5 in selected cases. Conclusion The consensus encompasses patient selection criteria, therapeutic strategies, monitoring protocols, and safety considerations, tailored to the unique demographic and healthcare landscapes of APAC countries.

Our study focused on assessing disease and pregnancy outcomes in Thai patients with Neuromyelitis Optica Spectrum Disorder (NMOSD), a condition that disproportionately affects women of childbearing age and poses risks to both mother and fetus. We retrospectively analyzed eight NMOSD patients with a total of 10 pregnancies from our central nervous system inflammatory demyelinating diseases (CNS-IDDs) registry. Over a 12-months spanning from before pregnancy to 12 months postpartum, we observed 13 relapses, with a notable 76.92% occurring postpartum. The mean annualized relapse rate (ARR) peaked at 1.2 (SD ± 1.93) during specific postpartum intervals (0-3 and 6-9 months postpartum), significantly increasing from 0.20 (SD ± 0.42) in the 12 months before pregnancy (BP) to 1.00 (SD ± 1.49) during the 12 months postpartum (PP). Disability, assessed using the Expanded Disability Status Scale (EDSS) scores, worsened from 1.56 (SD ± 2.18) before pregnancy to 2.1 (SD ± 2.63) at six months postpartum. Maternal and fetal complications were prevalent, with six out of nine pregnancies experiencing adverse outcomes such as false labor, premature rupture of membranes, postpartum hemorrhage, intrauterine growth restriction, preterm birth, stillbirth, and low birth weight. Based on our findings, azathioprine and rituximab may be suitable treatment options for maintaining therapy throughout pregnancy, particularly in cases of high disease activity. Our study highlights the critical need for comprehensive management strategies for NMOSD patients of childbearing age. Preconception planning and counselling, along with early obstetrical consultation and closely monitored treatments during pregnancy and postpartum, are vital to mitigating pregnancy-related relapses and adverse fetal outcomes in this vulnerable patient population.

AbstractObjectiveTo evaluate the efficacy of rituximab (RTX) in stabilizing disability progression in secondary progressive multiple sclerosis (SPMS).MethodsA systematic review was conducted, encompassing studies from inception to April 2023, utilizing the MEDLINE and EMBASE databases. Inclusion criteria comprised studies with a minimum of 3 SPMS patients receiving intravenous RTX in at least one infusion, with a follow‐up duration of at least 6 months. Primary outcome measures included changes in Expanded Disability Status Scale (EDSS) scores. Mean differences in pre‐ and post‐RTX EDSS scores were analyzed using a random‐effects model. Meta‐regression examined age at RTX initiation, pre‐RTX EDSS scores, disease duration, and outcome reported time as variables. Secondary outcomes assessed changes in the annualized relapse rate (ARR).ResultsThirteen studies, involving 604 SPMS patients, met the inclusion criteria. Following a mean follow‐up of 2 years, the mean difference in EDSS scores (ΔEDSS = EDSSpre‐RTX − EDSSpost‐RTX) was −0.21 (95% CI −0.51 to 0.08, p = 0.16), indicating no significant variation. Multivariable meta‐regression identified significant associations between EDSS score mean difference and pre‐RTX EDSS scores, disease duration at RTX initiation, and outcome reported time. However, age at RTX initiation showed no significant association. Pre‐ and post‐RTX ARR data were available for 245 out of 604 SPMS patients across seven studies, revealing a mean difference in ARR (ΔARR = ARRpre‐RTX − ARRpost‐RTX) of 0.74 (95% CI 0.19–1.29, p = 0.008).InterpretationRTX demonstrates efficacy in reducing relapse frequency and exhibits potential in stabilizing disability progression over a 2‐year follow‐up, particularly among individuals with shorter disease duration.