Influenza vaccination in patients with optic neuromyelitis optica Recently, neurologists in South Korea published an article in the European Journal of Neurology in which they examined antibody production in blood drawn from people on the optic neuromyelitis optica spectrum, multiple sclerosis, and healthy individuals before, during, and after influenza (N1H1) vaccination, and analyzed them for comparison. Sixteen of these patients were being treated with rituximab, five were being treated with buyomethylphenidate (primaquine), six with azathioprine (Imuran), and eight with interferon beta. FINDINGS: Patients treated with rituximab had severely disrupted humoral immunity and lower geometric mean titers of antibody production, although vaccination itself was relatively safe. Antibody production was not affected by vaccination with hepatitis B surface antigen, measles and tetanus vaccines during treatment. Note: In demyelinating patients, the flu is often a trigger for disease relapse. Theoretically, influenza vaccination induces the production of antibodies in the body to prevent colds and reduce relapses. However, the “bystander effect” of vaccination itself can cause relapses, and can trigger demyelinating diseases, such as disseminated encephalomyelitis, even in healthy individuals. Large-scale clinical studies in Europe and the United States on influenza vaccination in patients with multiple sclerosis have long been published and concluded that vaccination does not increase the relapse rate of the disease. In my opinion, patients should weigh the pros and cons of whether or not to get vaccinated. In my scientific articles, examples have been given of patients with multiple sclerosis who were bedridden and incapacitated by vaccination and required round-the-clock care by their families after a 40-year interval of relapse-free, healthy living. There have also been patients who had an attack from rabies vaccination and a relapse from hepatitis B vaccination. Therefore, if you are allergic, it is best to avoid vaccination. Methotrexate for optic neuromyelitis optica spectrum disease A recent issue of the Journal of Neurology, Neurosurgery and Psychiatry published a scientific study by clinical neurologists at the University of Oxford, UK. The aim of the study was to assess whether methotrexate treatment was effective in patients with serum aquaporin-4 positive optic neuromyelitis optica and its spectrum. What are the adverse effects? They reviewed 14 patients treated with methotrexate who were positive for aquaporin-4 and evaluated their annual recurrence rate, Expanded Disability Scale score, and tolerability. The mean duration of patient treatment with methotrexate was 21.5 months. The results showed that the annual relapse rate was 1.39 before methotrexate treatment and decreased to 0.18 after treatment; 43% of patients were relapse-free (64% relapse-free if the first 3 months of dosing and underdose were excluded); 79% of patients had stable or improving disability; and no patients discontinued methotrexate because of adverse effects. Methotrexate is a commonly used drug in clinical practice, especially in the vasculitis spectrum of rheumatology. When used in the optic neuromyelitis optica spectrum, the authors found that it reduced its recurrence rate, stabilized the disease, and was well tolerated by patients. Therefore, it is recommended that methotrexate may be an alternative treatment for patients on the optic neuromyelitis optica spectrum who are not responding to first-line drug therapy, whose disease fluctuates, who cannot tolerate it, or who are financially disadvantaged. Note: Clinical practice demonstrates that each drug must be treated individually, and this is also true for methotrexate. This is because there are case reports in the previous literature of patients with rheumatic diseases who have developed demyelinating encephalopathy as a result of treatment with methotrexate. I agree with the authors that methotrexate should be used in conditions where the outcome of first-line drugs such as azathioprine and buyomethylphenidate is unsatisfactory.