Consensus recommendation on the use of therapeutic plasma exchange for adult neurological diseases in Southeast Asia from the Southeast Asia therapeutic plasma exchange consortium

Abstract

Therapeutic plasma exchange (TPE) is an effective and affordable treatment option in most parts of Southeast Asia (SEA). In 2018, the SEA TPE Consortium (SEATPEC) was established, consisting of regional neurologists working to improve outcome of various autoimmune neurological diseases. We proposed an immunotherapeutic guideline prioritizing TPE for this region. We reviewed disease burden, evidence-based treatment options, and major guidelines for common autoimmune neurological disorders seen in SEA. A modified treatment algorithm based on consensus agreement by key-opinion leaders was proposed. Autoimmune antibody diagnostic testing through collaboration with accredited laboratories was established. Choice of first-line immunotherapies (IVIg/corticosteroid/TPE) is based on available evidence, clinicians’ experience, contraindications, local availability, and affordability. TPE could be chosen as first-line therapy for GBS, CIDP, MG (acute/short term), IgG, A paraproteinemic neuropathy, and NMDAR encephalitis. Treatment is stopped for acute monophasic conditions such as GBS and ADEM following satisfactory outcome. For chronic immune disorders, a therapy taper or long-term maintenance therapy is recommended depending on the defined clinical state. TPE as second-line treatment is indicated for IVIg or corticosteroids refractory cases of ADEM, NMOSD (acute), MG, and NMDAR/LGI1/CASPR2/Hashimoto’s encephalitis. With better diagnosis, treatment initiation with TPE is a sustainable and effective immunotherapy for autoimmune neurological diseases in SEA.

Facilities, selection, outcome measurement, and limitations of therapeutic plasma exchange for neuroimmunological disorders: The South East Asian survey study

“…Common challenges with TPE in this region are the high cost, limited access to TPE, and lack of trained personnel. These findings are supported by Fu et al 28 and Hiew et al 14 TPE can be reimbursed in only a few centers. Most expenses aside from the equipment and accessories are attributable to colloid replacement solution, mainly albumin, which cannot be reimbursed.…”

“…In the absence of universal TPE procedural consensus for an acute demyelinating event, neurologists justify the timing of TPE initiation, monitoring and assessment tools, and proper time to discontinue TPE by their own real-world experience and guided by either national, international guidelines or best evidence-based practices by American Society for Aphersis (ASFA), 11 American Academy of Neurology (AAN), 12 Peripheral Nerve Society, 13 or SEATPEC. 14 For an acute attack of NMOSD, most agree to perform TPE after the patient shows non-responsiveness to IVMP treatment. Additionally, about half believe in doing TPE earlier as a first-line treatment in severe acute NMOSD attacks.…”

“…All experts endorse performing TPE for an acute attack of NMOSD and MG crisis. In the absence of universal TPE procedural consensus for an acute demyelinating event, neurologists justify the timing of TPE initiation, monitoring and assessment tools, and proper time to discontinue TPE by their own real‐world experience and guided by either national, international guidelines or best evidence‐based practices by American Society for Aphersis (ASFA), 11 American Academy of Neurology (AAN), 12 Peripheral Nerve Society, 13 or SEATPEC 14 …”