IMPORTANCE: Neuromyelitis optica (NMO - including NMO spectrum disorders 
[NMOSD]) is a devastating disease. Eighty-three percent of patients with 
transverse myelitic (TM) attacks and 67% of patients with optic neuritis (ON) 
attacks have no or a partial recovery.
OBSERVATIONS: Up until recently, there was no proven agent to treat to prevent 
relapses. The neuro-immunological community had a dearth of indicated agents for 
NMOSD. We now have three agents indicated for the treatment of NMO including 
(eculizumab [Soliris®]), an anti-C5 complement inhibitor, satralizumab 
(ENSRYNG®), a monoclonal antibody against the IL-6 receptor (IL-6R) that blocks 
B cell antibody production and inebilizumab (Uplinza®), a monoclonal antibody 
that binds to the B-cell surface antigen CD19 with subsequent B and plasmablast 
cell lymphocytolysis with decreasing antibody production. Autologous 
hematopoietic stem cell bone marrow transplantation (AHSCBMT) has also been 
used. How do we sequence NMO therapies with the understanding of the acuteness 
and severity of the disease, the individual mechanism of action (MOA) and 
rapidity of onset of action, onset of efficacy and long-term safety of each 
agent?
CONCLUSIONS AND RELEVANCE: We might suggest the following sequence - 1st line 
using eculizumab for rapid efficacy and stabilization without effect on the 
acquired immune system followed by satrilizumab (long term immunomodulation). 
Reserve inebilizumab (immunosuppressant) for breakthrough disease and salvage 
the severe with AHSCBMT. In NMO, control the complement, transition to 
modulation, and reserve suppression - and salvage the severe with AHSCBMT.