Sequential intermittent therapeutic plasma exchange: A possible induction and maintenance therapy in the management of adult patients with neuromyelitis optica spectrum disorder

Abstract

Evidence on the benefits of intermittent therapeutic plasma exchange (TPE) as maintenance therapy in neuromyelitis optica spectrum disorder (NMOSD) is limited. This study explores the possible effectiveness of sequential intermittent therapeutic plasma exchange (SITPE), a novel TPE protocol in the management of adult NMOSD patients. Through retrospective review of medical records in Kuala Lumpur Hospital, Malaysia, NMOSD patients who underwent SITPE, namely, an induction phase of monthly cycle of TPE (1 cycle = five exchange sessions) for three cycles with or without a subsequent maintenance phase of three‐monthly cycle of TPE for three cycles, were included in this controlled historical cohort study. We explored their serial improvements in Expanded Disability Status Scale (EDSS), limb power, visual acuity, and annualized relapse rate following SITPE initiation. Statistical significance was set at P < .05. Fifteen adults (mean age: 35.4 years, mean disease duration: 9.5 years, 73% female, 87% AQP4‐IgG positive) with corticosteroid‐refractory attacks were included. Upon SITPE initiation, significant improvements in EDSS and limb motor power for up to 12 months, in addition to significant improvements in visual acuity for up to 6 months, were recorded. Significant reduction in annualized relapse rates for up to 2 years was documented. These improvements were not significantly influenced by age groups, gender, or presence of cord atrophy. Notably, adverse events of SITPE were infrequent and manageable. Sequential intermittent therapeutic plasma exchange as induction and maintenance therapy may improve the disease outcomes and prevent relapses in adult NMOSD patients with severe, corticosteroid‐refractory attacks.

Therapeutic plasma exchange for optic neuritis attacks in patients with neuromyelitis optica spectrum disorders

“…There was a low frequency of complications with the most frequent being low fibrinogen levels before each session given the very‐high intention of daily therapy. However, hypofibrinogenemia impedes daily therapy administration even though the intention of prescription is achieving a shorter hospital stay and is not associated with higher infection rates or better response rates 27,28 …”

“…However, hypofibrinogenemia impedes daily therapy administration even though the intention of prescription is achieving a shorter hospital stay and is not associated with higher infection rates or better response rates. 27,28 F I G U R E 1 VOS with methylprednisolone and TPE Among the factors that predict response in the VOS score as an outcome, the age at TPE showed a negative relationship and severe initial VOS was associated with the response to TPE. There was no association of previous immunosuppressive management with the response to TPE.…”

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice – Evidence‐Based Approach from the Writing Committee of the American Society for Apheresis: The Ninth Special Issue

“…In the majority, 5 procedures were performed on average for acute exacerbation (range 2-10) (Abboud, 2016;Ipe, 2020). Maintenance TPE every 2 to 12 weeks performed for several years after taper of gradually declining TPE frequency showed varying degrees of improvement and reduction in the number of NMOSD exacerbations (Khatri, 2012;Visvanathan, 2021).…”

Therapeutic efficacy and safety of plasmapheresis in elderly patients with neuromyelitis optica spectrum disorder: a single-center observational study

“…Because NMOSD-related optic neuritis appears refractory to PLEX, or response is delayed especially in the elderly, PLEX should begin earlier or combined sequentially with other initial treatment. 26 , 27 …”