Therapeutic Apheresis in Acute Relapsing Multiple Sclerosis: Current Evidence and Unmet Needs—A Systematic Review

Abstract

Multiple sclerosis (MS) is the most abundant inflammatory demyelinating disorder of the central nervous system. Despite recent advances in its long-term immunomodulatory treatment, MS patients still suffer from relapses, significantly contributing to disability accrual. In recent years, apheresis procedures such as therapeutic plasma exchange (TPE) and immunoadsorption (IA) have been recognized as two options for treating MS relapses, that do not respond to standard treatment with corticosteroids. TPE is already incorporated in most international guidelines, although evidence for its use resulted mostly from either case series or small unblinded and/or non-randomized trials. Data on IA are still sparse, but several studies indicate comparable efficacy between both apheresis procedures. This article gives an overview of the published evidence on TPE and IA in the treatment of acute relapses in MS. Further, we outline current evidence regarding individual outcome predictors, describe technical details of apheresis procedures, and discuss apheresis treatment in children and during pregnancy.

Comparing Plasma Exchange to Escalated Methyl Prednisolone in Refractory Multiple Sclerosis Relapses

“…For statistical analysis we applied FSS-based stratification as proposed by Conway and colleagues, which stratifies treatment responses based on peak-and recovery-FSS distances into "good/full", "partial", or "worst/no" recovery [16]. We show a modified matrix, as previously used, with outcome stratification in Figure S1 [17]. The outcomes were evaluated after treatment completion and at follow-up (3 months after discharge).…”

Therapeutic Plasmapheresis with Albumin Replacement in Alzheimer’s Disease and Chronic Progressive Multiple Sclerosis: A Review

“…Possible adverse reactions to PP are mainly related to vascular access, the use of replacement fluids, and the need for anticoagulation [16]. When manifested, the most commonly reported adverse effects observed in patients with immune-mediated neurological disorders are paraesthesias and/or cramps and hypotension [17].…”

“…The utility of this procedure includes the removal of antibodies, alloantibodies, immune complexes, monoclonal proteins, toxins and cytokines, and it involves the replenishment of a specific plasma factor containing 5% albumin. PP has been successfully used in several immune-mediated neurological disorders, including Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, and myasthenia gravis [14][15][16][17][18]. Less common neurological diseases in which plasmapheresis has afforded beneficial effects are paraneoplastic polyneuropathies, neuromyelitis optica (also known as Devic's disease), motor neuron disease, polymyositis, and multifocal motor neuropathy [18].…”

“…In the case of MS, eliminating pathogenic humoral factors from the blood [14], including suspected auto-antibodies directed against the myelin sheath, is needed in some patients with steroid refractory relapses [15], or in patients that develop neutralizing antibodies to interferon-beta (IFN-β), which are associated with reduced bioactivity and efficacy of IFN-β [19,20]. There is extensive literature related to the use of plasma exchange in relapsing and remitting multiple sclerosis, and its use as a temporary treatment of acute relapses in steroid-unresponsive MS patients has been recently reviewed [15,16]. For this reason, the aim of the review does not include the studies on the relapsing and remitting form of MS (the most common form of the disease).…”

“…For this reason, the aim of the review does not include the studies on the relapsing and remitting form of MS (the most common form of the disease). In addition, MS patients with chronic progressive (including primary progressive and secondary progressive) forms of the disease present several humoral factors related to its progression [16,[21][22][23][24]. In a therapeutic plasmapheresis (plasma exchange), a volume of circulating plasma is extracted to eliminate toxic compounds, and is usually substituted by a 5% albumin solution, or occasionally by fresh frozen plasma (from donors) to replace the plasma volume removed, and thereby maintain the volemia [15,22,25].…”