[Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD): What controversies remain?]

Abstract

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) has emerged as a distinct entity within central nervous system autoimmune demyelinating disorders, clearly differentiated from multiple sclerosis and aquaporin-4 antibody-associated neuromyelitis optica spectrum disorders. Although international diagnostic criteria have been established and the clinical spectrum has broadened, several controversies remain. Serological diagnosis remains a major challenge: not all laboratories use standardized methods, and the interpretation of low or borderline antibody titers is still debated. Furthermore, the prognostic value of serial antibody testing is unclear. The clinical course is also variable. While some patients follow a monophasic course, up to 50% may relapse, and there are no reliable predictors of recurrence. Whether to initiate long-term immunotherapy after a first event, especially in patients with incomplete recovery, remains controversial. Acute and maintenance treatments lack robust, comparative evidence. There is no consensus on the optimal therapeutic strategy, treatment duration, or which patients may benefit most from prolonged immunosuppression. In conclusion, MOGAD is a rapidly evolving field. Clinical decision-making must currently rely on a combination of limited evidence, expert opinion, and individualized patient evaluation.