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neuro.mogad.v1PRODUCTION
neuro.mogad.v1

Myelin Oligodendrocyte Glycoprotein-Antibody Associated Disease (MOGAD)

neurologychronicsubacuteadultpediatricpregnancy
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm MOGAD per Banwell 2023 criteria (PMID 36706773) — MOG-IgG+ (live CBA) with ≥1 core clinical event + supporting MRI features + exclusion of alternatives (AQP4-IgG negative; HSV PCR negative if cortical encephalitis phenotype)

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MOGAD phenotype assigned + monophasic vs relapsing tier

Patient inputs (16)

Distinguish from NMOSD-AQP4+ — different DMT; AQP4-IgG via CBA; mutually exclusive in 99% (Wingerchuk 2015 PMID 26092914)

Cortical encephalitis MOGAD overlaps differential with HSV encephalitis (route to neuro.encephalitis.hsv.v1) — HSV PCR + VZV + enterovirus + autoimmune AE panel MANDATORY

Bimodal — pediatric peak (5-10 y) presents ADEM-like; adult peak (30s-40s) presents ON + myelitis + cortical encephalitis (Banwell 2023 PMID 36706773)

Post-infectious / post-vaccination MOGAD recognized (often ADEM-phenotype pediatric) — document precipitant

70% monophasic with single attack + recovery; 15-30% relapsing — DMT decision driven by course (Banwell 2023 PMID 36706773; PMID 33219036)

MOG-IgG via LIVE cell-based assay (live cell CBA) — gold standard; fixed cell CBA acceptable; ELISA NOT acceptable (false positives); clear positive titer (low-titer borderline) (Banwell 2023 PMID 36706773)

STAT MRI brain + orbits + cord with gad; MOG-IgG-typical: bilateral ON (often longitudinally extensive optic nerve); fluffy peripheral cord lesion (conus prone); ADEM-like multifocal; cortical encephalitis FLAIR hyperintensity (Banwell 2023 PMID 36706773)

Cervical + thoracic cord with gad — MOGAD myelitis often conus + central gray matter; some longitudinally extensive ≥3 segments (overlap with NMOSD pattern)

CSF — pleocytosis (often >50 cells); protein elevated; OCB usually NEGATIVE (vs MS 90%+ positive); intrathecal MOG-IgG (CSF-MOG) supports MOGAD if serum borderline (Banwell 2023 PMID 36706773)

Cortical encephalitis MOGAD — seizure + AMS + FLAIR cortical hyperintensity; AED initiation + EEG

Severe ON baseline VA + steroid response trajectory drives PLEX trigger

Required before DMT initiation in reproductive-age females

Rituximab / B-cell depletion pre-screen

Cortical encephalitis differential — autoimmune encephalitis panel (NMDAR / LGI1 / CASPR2 / GAD65 / GABA-B / AMPA)

MOGAD slightly female predominant (~3:2 adult); pediatric balanced (Banwell 2023 PMID 36706773)

MOGAD comorbid autoimmunity less common than NMOSD; document if SLE/Sjögren/thyroid/RA

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationalsevereclassic_bilateral_optic_neuritis_mogad
    Bilateral simultaneous ON with severe vision loss + good steroid response — adult MOGAD typical (Banwell 2023 PMID 36706773)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_transverse_myelitis_mogad
    Acute TM with MOG-IgG+ — conus prone, central gray matter, longitudinally extensive variable (Banwell 2023 PMID 36706773)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_adem_phenotype_mogad
    Pediatric encephalopathy + multifocal demyelination + MOG-IgG+ — most common pediatric MOGAD presentation (~60% pediatric ADEM have MOG)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebrainstem_mogad
    Brainstem MOGAD with characteristic lesion (oculomotor, ataxia, dysphagia, dysarthria)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecortical_encephalitis_mogad
    Cortical encephalitis MOGAD — seizures + FLAIR cortical hyperintensity (newer recognition; Banwell 2023 PMID 36706773)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_disease_15_30pct_relapsing
    Relapsing MOGAD ≥2 events ≥3 mo apart — 15-30% of MOGAD; initiate chronic DMT (Banwell 2023 PMID 36706773; rituximab PMID 33219036)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_mogad
    Pregnancy in MOGAD — postpartum relapse risk; IVIG safer than PLEX in pregnancy; eculizumab not indicated (not NMOSD); rituximab Cat C
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildmonophasic_course_70pct
    Monophasic MOGAD — single event with recovery; no relapse in 12+ mo; do NOT over-treat with chronic DMT (Banwell 2023 PMID 36706773)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

MOGAD acute pulse + course-driven chronic Rx (Banwell 2023 PMID 36706773; PMID 27793206; rituximab PMID 33219036)
axis: mogad_acute_and_chronic_treatmentstep 1 - Step 1 — Acute IV methylprednisolone (often dramatically steroid-responsive; ~80% remit; PMID 27793206)
Selected step "Step 1 — Acute IV methylprednisolone (often dramatically steroid-responsive; ~80% remit; PMID 27793206)" — Acute MOGAD core event (ON / myelitis / ADEM / cortical encephalitis / brainstem / cerebral) with neuro deficit
  • methylprednisolone
    first line
    corticosteroid_pulse
    1 g IV daily × 3-5 d adult (30 mg/kg/d × 3-5 d pediatric, max 1 g/d) • IV • daily × 3-5 d (max: 5 g cumulative)
    triggers: acute_mogad_relapse
    First-line acute pulse; MOGAD highly steroid-responsive (~80% remit); MOG-IgG sample BEFORE steroid if feasible (Banwell 2023 PMID 36706773)
    rxcui 6902
  • prednisone
    add on
    corticosteroid_oral_taper
    60 mg PO daily × 2 wk then taper over 8-12 wk (SLOW) • PO • daily slow taper
    triggers: post_pulse_taper_mogad
    MOGAD prone to REBOUND on rapid taper — slow 8-12 wk oral taper recommended after IV pulse; this is distinguishing feature vs MS-flare
    rxcui 8640

outpatient playbook — drug actions (7)

  1. 1. rituximab (relapsing)
    1 g IV × 2 doses then q6 mo • IV • q6 mo
    trigger: Relapsing MOGAD ≥2 events ≥3 mo apart
    PMID 33219036; HBV/VZV/TB pre-screen
  2. 2. IVIG monthly maintenance
    0.4-1 g/kg IV monthly • IV • monthly
    trigger: Relapsing pediatric MOGAD or pregnancy
    Banwell 2023 recommended pediatric
  3. 3. azathioprine (oral steroid-sparing)
    2-3 mg/kg PO daily • PO • daily
    trigger: Relapsing oral preference
    TPMT + CBC + LFT monitoring
  4. 4. mycophenolate mofetil
    1 g PO BID titrate • PO • BID
    trigger: AZA-intolerant relapsing
    CONTRAINDICATED pregnancy
  5. 5. tocilizumab (refractory)
    162 mg SC weekly OR 8 mg/kg IV q4 wk • SC/IV • weekly/monthly
    trigger: Refractory relapsing MOGAD
    IL-6R antagonist off-label
  6. 6. observation only (monophasic)
    no DMT • n/a • n/a
    trigger: Monophasic confirmed >12 mo no relapse
    Do not over-treat (70% monophasic)
  7. 7. levetiracetam (post-cortical encephalitis)
    1000-1500 mg PO BID • PO • BID
    trigger: Seizure post-cortical encephalitis
    Long-term AED management

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: MOG-IgG positive (live cell-based assay) with ≥1 core clinical event per Banwell 2023 (PMID 36706773); Bilateral simultaneous ON with severe vision loss + good steroid response — adult MOGAD typical (Banwell 2023 PMID 36706773); Acute TM (often conus involvement, short or long-segment; MOG-IgG+ pivot from TM engine).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Myelin Oligodendrocyte Glycoprotein-Antibody Associated Disease (MOGAD)** (neuro.mogad.v1).
Phenotype framing: MOGAD ON / MOGAD TM / MOGAD ADEM-phenotype / MOGAD cortical encephalitis / MOGAD brainstem / NMOSD-AQP4 (pivot) / MS (McDonald 2017) / HSV/VZV encephalitis (pivot) / autoimmune AE (anti-NMDAR/LGI1) / ADEM without MOG / paraneoplastic / sarcoid / SLE / Behçet
Scope: Confirm MOGAD per Banwell 2023 criteria (PMID 36706773) — MOG-IgG+ (live CBA) with ≥1 core clinical event + supporting MRI features + exclusion of alternatives (AQP4-IgG negative; HSV PCR negative if cortical encephalitis phenotype)

No severity triggers fired against current inputs.

Plan

Regimen axis: **MOGAD acute pulse + course-driven chronic Rx (Banwell 2023 PMID 36706773; PMID 27793206; rituximab PMID 33219036)** — step "Step 1 — Acute IV methylprednisolone (often dramatically steroid-responsive; ~80% remit; PMID 27793206)".
1. methylprednisolone 1 g IV daily × 3-5 d adult (30 mg/kg/d × 3-5 d pediatric, max 1 g/d) IV daily × 3-5 d (corticosteroid_pulse, first line) — First-line acute pulse; MOGAD highly steroid-responsive (~80% remit); MOG-IgG sample BEFORE steroid if feasible (Banwell 2023 PMID 36706773)
2. prednisone 60 mg PO daily × 2 wk then taper over 8-12 wk (SLOW) PO daily slow taper (corticosteroid_oral_taper, add on) — MOGAD prone to REBOUND on rapid taper — slow 8-12 wk oral taper recommended after IV pulse; this is distinguishing feature vs MS-flare

Setting playbook (outpatient) — Primary MS-NMO-MOGAD clinic — comprehensive MOGAD management q3-6 mo with relapse surveillance + MRI + DMT + comorbidity + pregnancy + pediatric developmental surveillance (Banwell 2023 PMID 36706773)
3. rituximab (relapsing) 1 g IV × 2 doses then q6 mo IV q6 mo — Relapsing MOGAD ≥2 events ≥3 mo apart (PMID 33219036; HBV/VZV/TB pre-screen)
4. IVIG monthly maintenance 0.4-1 g/kg IV monthly IV monthly — Relapsing pediatric MOGAD or pregnancy (Banwell 2023 recommended pediatric)
5. azathioprine (oral steroid-sparing) 2-3 mg/kg PO daily PO daily — Relapsing oral preference (TPMT + CBC + LFT monitoring)
6. mycophenolate mofetil 1 g PO BID titrate PO BID — AZA-intolerant relapsing (CONTRAINDICATED pregnancy)
7. tocilizumab (refractory) 162 mg SC weekly OR 8 mg/kg IV q4 wk SC/IV weekly/monthly — Refractory relapsing MOGAD (IL-6R antagonist off-label)
8. observation only (monophasic) no DMT n/a n/a — Monophasic confirmed >12 mo no relapse (Do not over-treat (70% monophasic))
9. levetiracetam (post-cortical encephalitis) 1000-1500 mg PO BID PO BID — Seizure post-cortical encephalitis (Long-term AED management)

Non-pharmacologic actions:
- PT/OT referral for gait + ADL
- Pediatric developmental surveillance + early intervention
- Neuropsych eval if cortical encephalitis residua
- Mental health referral if PHQ-9 ≥10
- Ophthalmology q3-6 mo if ON history
- Pre-DMT vaccinations (live MMR/VZV 4-6 wk before B-cell depletion)
- Bone health (DEXA, vitamin D)
- Pregnancy planning + postpartum surveillance

AVOID / contraindication checks:
- MOG_IgG_via_LIVE_CBA_not_ELISA (ELISA = false positives)
- Send_MOG_IgG_BEFORE_steroid_if_feasible (titer lowered by steroid)
- Slow_8_to_12_wk_oral_prednisone_taper_to_prevent_rebound (MOGAD rebound risk distinguishing feature)
- Do_NOT_initiate_chronic_DMT_after_monophasic_event (70% monophasic; risk benefit unfavorable)
- AVOID_typical_MS_DMTs_in_MOGAD (limited data; possible harm signal)
- HSV_PCR_MANDATORY_if_cortical_encephalitis_phenotype (HSV mimic = different Rx)
- HBV_VZV_TB_screen_before_rituximab
- Mycophenolate_CONTRAINDICATED_in_pregnancy
- Cyclophosphamide_CONTRAINDICATED_in_pregnancy
- IVIG_aseptic_meningitis_thromboembolism_warning
- Pediatric_dosing_methylpred_30_mg_per_kg_per_d_max_1g

Monitoring

Regimen monitoring:
- Daily neuro exam during acute admission
- Visual acuity q-day if ON
- EEG continuous if cortical encephalitis with seizures
- CBC + CD19/CD20 + IgG q3-6 mo on rituximab
- LFT + CBC monthly first 6 mo on AZA/MMF
- MOG-IgG persistence at 6-12 mo (correlates relapse risk; not for diagnosis)
- Annual MRI brain + orbits + cord (relapsing course; surveillance only for monophasic)
- Ophthalmology q3-6 mo if ON
- Pediatric neurodevelopmental surveillance if pediatric ADEM-phenotype
- Pregnancy / postpartum surveillance
- AED levels + LFT if on long-term AED post-cortical encephalitis

Setting (outpatient) monitoring:
- Annual MRI brain + orbits + cord (relapsing) or surveillance (monophasic)
- CBC + LFT q3-6 mo on DMT
- IgG annually on rituximab
- MOG-IgG at 6-12 mo
- Pregnancy intent each visit
- AED level if applicable

Follow-up plan: Rehab (PT/OT/SLP); ophthalmology q3-6 mo if ON; neuropsych if cortical encephalitis or ADEM-phenotype (cognitive deficits); pediatric developmental surveillance if pediatric ADEM; AED management if seizure history; pregnancy planning + postpartum surveillance; MS-NMO-MOGAD specialty clinic q3-6 mo
- Close-out criterion: Long-term plan + specialty referrals documented

Monitoring phase: Daily neuro exam during acute admission; EEG monitoring if cortical encephalitis; CBC + CD19/CD20 + IgG q3-6 mo on rituximab; LFT + CBC on AZA/MMF; MOG-IgG persistence at 6-12 mo (high-titer persistence correlates relapse risk); annual MRI brain + cord + orbits

Disposition

Current setting: outpatient — Primary MS-NMO-MOGAD clinic — comprehensive MOGAD management q3-6 mo with relapse surveillance + MRI + DMT + comorbidity + pregnancy + pediatric developmental surveillance (Banwell 2023 PMID 36706773)

Disposition criteria:
- Continue indefinite MS-NMO-MOGAD clinic q3-6 mo
- Admit for acute relapse with deficit
- Discharge from chronic DMT after 5 y stable on monophasic surveillance

Escalation triggers (move to higher acuity):
- Breakthrough relapse on DMT → consider switch (rituximab → tocilizumab or IVIG-monthly)
- New ON / myelitis / encephalitis → ED + steroid pulse
- IgG <500 + recurrent infection on rituximab → IVIG / pause
- Pregnancy confirmed → MS-NMO + MFM coordination
- New seizure → AED titrate + EEG

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Bilateral simultaneous ON with severe vision loss + good steroid response — adult MOGAD typical (Banwell 2023 PMID 36706773)
- [SEVERE] Acute TM with MOG-IgG+ — conus prone, central gray matter, longitudinally extensive variable (Banwell 2023 PMID 36706773)
- [SEVERE] Pediatric encephalopathy + multifocal demyelination + MOG-IgG+ — most common pediatric MOGAD presentation (~60% pediatric ADEM have MOG)

Citations

- Banwell 2023 MOGAD diagnostic criteria (PMID 36706773) + autoimmune mimics review (PMID 34664709) + MOGAD acute treatment (PMID 27793206) + rituximab MOGAD (PMID 33219036) [PMID:36706773](https://pubmed.ncbi.nlm.nih.gov/36706773/)
- Cited evidence (PMID 34664709) [PMID:34664709](https://pubmed.ncbi.nlm.nih.gov/34664709/)
- Cited evidence (PMID 26092914) [PMID:26092914](https://pubmed.ncbi.nlm.nih.gov/26092914/)
- Cited evidence (PMID 30785074) [PMID:30785074](https://pubmed.ncbi.nlm.nih.gov/30785074/)
- Cited evidence (PMID 33219036) [PMID:33219036](https://pubmed.ncbi.nlm.nih.gov/33219036/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Banwell 2023 MOGAD diagnostic criteria (PMID 36706773) + autoimmune mimics review (PMID 34664709) + MOGAD acute treatment (PMID 27793206) + rituximab MOGAD (PMID 33219036) — PMID:36706773
  • Cited evidence (PMID 34664709) — PMID:34664709
  • Cited evidence (PMID 26092914) — PMID:26092914
  • Cited evidence (PMID 30785074) — PMID:30785074
  • Cited evidence (PMID 33219036) — PMID:33219036