Background <p>Tocilizumab is effective in neuromyelitis optica spectrum disorder (NMOSD). It remains unclear when to initiate or discontinue tocilizumab treatment. We aimed to compare the efficacy of early versus escalation tocilizumab treatment in patients with NMOSD.</p> Methods <p>A retrospective study of 41 patients with NMOSD who received regular tocilizumab administration was conducted. The early tocilizumab group comprised patients who started tocilizumab after their first attack, while the escalation group included patients who initially received empirical disease-modifying drugs (DMDs) and later escalated to tocilizumab after relapses. Tocilizumab was administered at 8&#xa0;mg/kg with routine infusions at 4-week intervals. The primary outcome was improvement in the extended disability status scale (EDSS) score at months 3, 6, and 12 during the follow-ups. An additional secondary outcome was annualised relapse rate (ARR).</p> Results <p>The early tocilizumab treatment group showed reduced median EDSS scores at 3, 6 months, with no further reduction at 12 months. The escalation treatment group showed reduced EDSS score at 6 months, with no further reduction at 12 months. The Inter-group analysis showed the early tocilizumab treatment group had significantly lower EDSS scores at 3, 6, and 12 months compared to the escalation treatment group. The ARR was not different at 36 months. Additionally, no difference of ARR was observed in those who were transferred to low-dose rituximab.</p> Conclusions <p>Early use of tocilizumab reduces the degree of disability compared to escalation treatment in NMOSD, with no much differences on relapse rate. Low-dose rituximab may be a feasible candidate switching from tocilizumab.</p>