Evidence-based guideline update: Plasmapheresis in neurologic disorders

Abstract

Objective: To reassess the role of plasmapheresis in the treatment of neurologic disorders. Methods:We evaluated the available evidence based on a structured literature review for relevant articles from 1995 through September 2009. In addition, due to revision of the definitions of classification of evidence since the publication of the previous American Academy of Neurology assessment in 1996, the evidence cited in that manuscript was reviewed and reclassified.

Immune Mediated Diseases and Immune Modulation in the Neurocritical Care Unit

“…The standard approach for treating acute attacks is similar to that for the treatment of MS exacerbations and consists of high-dose parenteral corticosteroids followed by a gradual oral corticosteroid taper [45]. Most literature suggests that plasmapheresis is of benefit, and plasmapheresis is generally recommended when corticosteroids are not effective [23,[45][46][47]. The utility of IVIG in the treatment of acute NMO has not been adequately studied.…”

“…Treatment with high-dose parental corticosteroids (followed by an oral taper) is considered to be the standard of care. Plasmapheresis and/or IVIG may be of benefit for patients who fail to respond to corticosteroids [23]. Finally, in both ADEM and AHLE, the brain lesions can be associated with significant edema.…”

“…Limited data suggest that plasmapheresis may be of benefit for patients with ATM that fail to respond to high-dose treatment with corticosteroids [23,85,86]. Outcome from ATM can be predicted by the severity of symptoms at presentation.…”

“…For patients with milder presentations of AIDP/GBS, plasmapheresis should also be considered, but the data to support this recommendation are not as robust. IVIG is a reasonable alternative to plasmapheresis, and the data do not support the superiority of one treatment over another [23,98]. Despite improvement in ICU care and advances in immunotherapy, the mortality in patients with AIDP/GBS are still at least 2 to 3%, and may even approach 10% [88,[101][102][103].…”

“…Based on a single randomized clinical trial (RCT), plasmapheresis may also have some benefit for treating exacerbations in patients with relapsing-remitting disease [23]. Intravenous immune globulin (IVIG) does not appear have any benefit as an adjunct therapy to methylprednisolone in the treatment of MS exacerbations, and generally it is also not recommended [24].…”