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NMOSD & C5

In NMOSD, it’s the attacks that lead to life-changing disability

People living with anti-AQP4 antibody-positive NMOSD can experience vision loss, pain, paralysis, and, in rare cases, even premature death1-7

Most anti-AQP4 antibody-positive patients have experienced a relapse4,8

93 percent
  • Nearly 93% of patients with AQP4-lgG+ NMOSD have experienced a relapse, which can cause severe disability and be potentially life-threatening3,9*
  • 73% of NMOSD cases are AQP4-lgG+4,8†

Attacks are unpredictable and tend to be severe and recurrent4,5,10

90 percent
  • A relapse is likely even if a patient is on an IST3
  • Within 5 years of their first attack, 90% of patients with NMOSD have had a relapse,‡ and more than 40% are expected to become blind in at least 1 eye4,5,10§

The consequences of an attack can be permanent

75 percent
  • 75% of patients in 1 study did not fully recover from their first myelitis attack3

There is a high risk of accumulating permanent, irreversible neurological damage and disability with every attack1-3,9,11,12

Activated complement leads to the destruction of astrocytes, chronic inflammation, subsequent demyelination and neuronal death, and the creation of lesions in the CNS.

*A retrospective chart analysis of patients who met 2015 diagnostic criteria for NMOSD seen at any of 5 NMOSD centers worldwide: Johns Hopkins University NMO Clinic (Baltimore, USA), Research Institute and Hospital of National Cancer Center (Goyang, South Korea), John Radcliffe Hospital, University of Oxford (Oxford, UK), NeuroCure Clinical Research Center at Charité University Hospital (Berlin, Germany), and Neuro Clínica (Medellín, Colombia). Local review boards at each site approved the use of human subjects for this analysis, as required.8

†Review conducted by The Walton Centre Neurosciences NHS Trust in Liverpool, United Kingdom. All patients had been seen in this clinic over the last 4 years (after the availability of MOG-IgG testing). 261 unique patients with non-MS/atypical CNS inflammatory conditions attended the clinic and were assessed for NMOSD. All patients were tested for AQP4-IgG.132 cases satisfied the 2015 NMOSD diagnostic criteria.9

‡From a review of 71 patients with NMO evaluated at the Mayo Clinic or hospital between 1950 and 1997.10

§Based on Mayo Clinic records of 140 seropositive adult patients from 2005 to 2011.8

C5 cleavage is an underlying cause of damage in NMOSD

In anti-AQP4 antibody-positive NMOSD, complement activation can lead to astrocyte destruction, chronic inflammation, and, ultimately, physical disability1,3,11,12

Diagram detailing the four steps through which complement activation can cause damage
One
1

Anti-AQP4 antibody binding and complement activation

AQP4-lgG crosses the blood-brain barrier and binds to AQP4 on the surface of astrocyte foot processes, activating the complement cascade.1,13-16

Two
2

Terminal complement activation

The activated complement cascade leads to the cleavage of C5 into C5a and C5b, the key initiation step of terminal complement activation.11,17

Three
3

Terminal complement effects (C5b)

C5b recruits additional complement proteins to form the MAC, leading to astrocyte lysis and cell death.11,13

Four
4

Terminal complement effects (C5a)

Proinflammatory C5a recruits leukocytes, which leads to downstream inflammation, demyelination, and neuronal death.11,18

Appropriate diagnosis and relapse risk reduction are critical for patients with anti-AQP4 antibody-positive NMOSD1-3,9,11,12

Explore the role of complement inhibition in NMOSD

Mechanism of Action

AQP4, aquaporin-4; CNS, central nervous system; IgG, immunoglobulin G; IgG+, immunoglobulin G positive; IST, immunosuppressive therapy; MAC, membrane attack complex; MOG, myelin oligodendrocyte glycoprotein; MS, multiple sclerosis; NHS, National Health Service; NMOSD, neuromyelitis optica spectrum disorder.

IMPORTANT SAFETY INFORMATION INCLUDING BOXED WARNING

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WARNING: SERIOUS MENINGOCOCCAL INFECTIONS

ULTOMIRIS, a complement inhibitor, increases the risk of serious infections caused by Neisseria meningitidis [see Warnings and Precautions (5.1)] Life-threatening and fatal meningococcal infections have occurred in patients treated with complement inhibitors. These infections may become rapidly life-threatening or fatal if not recognized and treated early.

  • Complete or update vaccination for meningococcal bacteria (for serogroups A, C, W, Y, and B) at least 2 weeks prior to the first dose of ULTOMIRIS, unless the risks of delaying ULTOMIRIS therapy outweigh the risk of developing a serious infection. Comply with the most current Advisory Committee on Immunization Practices (ACIP) recommendations for vaccinations against meningococcal bacteria in patients receiving a complement inhibitor. See Warnings and Precautions (5.1) for additional guidance on the management of the risk of serious infections caused by meningococcal bacteria.
  • Patients receiving ULTOMIRIS are at increased risk for invasive disease caused by Neisseria meningitidis, even if they develop antibodies following vaccination. Monitor patients for early signs and symptoms of serious meningococcal infections and evaluate immediately if infection is suspected.

Because of the risk of serious meningococcal infections, ULTOMIRIS is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called ULTOMIRIS and SOLIRIS REMS [see Warnings and Precautions (5.2)].

CONTRAINDICATIONS

  • Initiation in patients with unresolved serious Neisseria meningitidis infection.

WARNINGS AND PRECAUTIONS

Serious Meningococcal Infections

ULTOMIRIS, a complement inhibitor, increases a patient’s susceptibility to serious, life-threatening, or fatal infections caused by meningococcal bacteria (septicemia and/or meningitis) in any serogroup, including non-groupable strains. Life-threatening and fatal meningococcal infections have occurred in both vaccinated and unvaccinated patients treated with complement inhibitors.

Revaccinate patients in accordance with ACIP recommendations considering the duration of ULTOMIRIS therapy. Note that ACIP recommends an administration schedule in patients receiving complement inhibitors that differs from the administration schedule in the vaccine prescribing information. If urgent ULTOMIRIS therapy is indicated in a patient who is not up to date with meningococcal vaccines according to ACIP recommendations, provide antibacterial drug prophylaxis and administer meningococcal vaccines as soon as possible. Various durations and regimens of antibacterial drug prophylaxis have been considered, but the optimal durations and drug regimens for prophylaxis and their efficacy have not been studied in unvaccinated or vaccinated patients receiving complement inhibitors, including ULTOMIRIS. The benefits and risks of treatment with ULTOMIRIS, as well as those associated with antibacterial drug prophylaxis in unvaccinated or vaccinated patients, must be considered against the known risks for serious infections caused by Neisseria meningitidis.

Vaccination does not eliminate the risk of serious meningococcal infections, despite development of antibodies following vaccination.

Closely monitor patients for early signs and symptoms of meningococcal infection and evaluate patients immediately if infection is suspected. Inform patients of these signs and symptoms and instruct patients to seek immediate medical care if they occur. Promptly treat known infections. Meningococcal infection may become rapidly life-threatening or fatal if not recognized and treated early. Consider interruption of ULTOMIRIS in patients who are undergoing treatment for serious meningococcal infection depending on the risks of interrupting treatment in the disease being treated.

ULTOMIRIS and SOLIRIS REMS

Due to the risk of serious meningococcal infections, ULTOMIRIS is available only through a restricted program called ULTOMIRIS and SOLIRIS REMS.

Prescribers must enroll in the REMS, counsel patients about the risk of serious meningococcal infection, provide patients with the REMS educational materials, assess patient vaccination status for meningococcal vaccines (against serogroups A, C, W, Y, and B) and vaccinate if needed according to current ACIP recommendations two weeks prior to the first dose of ULTOMIRIS. Antibacterial drug prophylaxis must be prescribed if treatment must be started urgently, and the patient is not up to date with both meningococcal vaccines according to current ACIP recommendations at least two weeks prior to the first dose of ULTOMIRIS. Patients must receive counseling about the need to receive meningococcal vaccines and to take antibiotics as directed, signs and symptoms of meningococcal infection, and be instructed to carry the Patient Safety Card at all times during and for 8 months following ULTOMIRIS treatment.

Further information is available at www.UltSolREMS.com or 1-888-765-4747.

Other Infections

Serious infections with Neisseria species (other than Neisseria meningitidis), including disseminated gonococcal infections, have been reported.

ULTOMIRIS blocks terminal complement activation; therefore, patients may have increased susceptibility to infections, especially with encapsulated bacteria, such as infections caused by Neisseria meningitidis but also Streptococcus pneumoniae, Haemophilus influenzae, and to a lesser extent, Neisseria gonorrhoeae. Patients receiving ULTOMIRIS are at increased risk for infections due to these organisms, even if they develop antibodies following vaccination.


Thromboembolic Event Management

The effect of withdrawal of anticoagulant therapy during treatment with ULTOMIRIS has not been established. Treatment should not alter anticoagulant management.

Infusion-Related Reactions

Intravenous administration may result in systemic infusion-related reactions, including anaphylaxis and hypersensitivity reactions. In clinical trials, infusion-related reactions occurred in approximately 1 to 7% of patients treated with ULTOMIRIS. These events included lower back pain, drop in blood pressure, limb discomfort, drug hypersensitivity (allergic reaction), dysgeusia (bad taste), and drowsiness. These reactions did not require discontinuation of ULTOMIRIS. If signs of cardiovascular instability or respiratory compromise occur, interrupt ULTOMIRIS infusion and institute appropriate supportive measures.

ADVERSE REACTIONS

Most common adverse reactions in adult patients with NMOSD (incidence ≥10%) were COVID-19, headache, back pain, arthralgia, and urinary tract infection. Serious adverse reactions were reported in 8 (13.8%) patients with NMOSD receiving ULTOMIRIS.

DRUG INTERACTIONS

Plasma Exchange, Plasmapheresis, and Intravenous Immunoglobulins

Concomitant use of ULTOMIRIS with plasma exchange (PE), plasmapheresis (PP), or intravenous immunoglobulin (IVIg) treatment can reduce serum ravulizumab concentrations and requires a supplemental dose of ULTOMIRIS.

Neonatal Fc Receptor Blockers

Concomitant use of ULTOMIRIS with neonatal Fc receptor (FcRn) blockers (e.g., efgartigimod) may lower systemic exposures and reduce effectiveness of ULTOMIRIS. Closely monitor for reduced effectiveness of ULTOMIRIS.

To report SUSPECTED ADVERSE REACTIONS, contact Alexion Pharmaceuticals, Inc. at 1-844-259-6783 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

INDICATION

ULTOMIRIS is indicated for the treatment of adult patients with neuromyelitis optica spectrum disorder (NMOSD) who are anti-aquaporin-4 (AQP4) antibody positive.

Please see full Prescribing Information for ULTOMIRIS, including Boxed WARNING regarding serious and life-threatening or fatal meningococcal infections.

References:

  1. ULTOMIRIS. Prescribing information. Alexion Pharmaceuticals, Inc.
  2. Data on file. Alexion Pharmaceuticals, Inc.
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