Treatment of FLAMES Subtype of MOGAD

Acute Treatment

High-dose intravenous methylprednisolone (1000 mg daily for 3-5 days) should be initiated immediately upon diagnosis of FLAMES MOGAD, followed by a slow oral prednisone taper (starting at 1 mg/kg/day) over 2-3 months to prevent early relapses 1
For severe attacks or inadequate response to steroids, plasma exchange (5-7 exchanges) or immunoadsorption should be implemented early, and intravenous immunoglobulin (IVIG) at 2 g/kg divided over 2-5 days is an alternative for patients who cannot undergo plasma exchange 1, 2

Regular clinical assessments every 3-6 months to evaluate treatment response and detect early signs of relapse are recommended 1

MOG-IgG serum concentrations vary with disease activity (higher during attacks) and treatment status (lower during immunosuppression), so timing of testing is important, and if MOG-IgG testing is negative but MOGAD is still suspected, re-testing during acute attacks, treatment-free intervals, or 1-3 months after plasma exchange/IVIG is recommended 2, 3

CSF analysis typically shows neutrophilic pleocytosis or white cell count >50/μl, which can mimic CNS infection, and medications with known risk of worsening neurological symptoms should be avoided 4, 5, 6

Stopping steroids too quickly, as MOGAD has a high risk of flare-ups after steroid cessation, and treating as multiple sclerosis, as some MS disease-modifying therapies might be ineffective or potentially harmful in MOGAD 1, 7