Ehler J, Koball S, Sauer M, Mitzner S, Hickstein H, Benecke R, Zettl UK. PLoS One. 2015 Aug 5;10(8):e0134583. doi: 10.1371/journal.pone.0134583. eCollection 2015.
Objectives :Experience with therapeutic plasma exchange (TPE) for acute relapses in clinically isolated syndrome (CIS) or multiple sclerosis (MS) patients has been derived from small and inhomogeneous patient populations so far. In the present study, we retrospectively evaluated features associated with TPE response in a larger cohort of CIS and MS patients with acute worsening of disease.
Participants: Ninety CIS and MS patients with acute relapses or acute worsening of symptoms were firstly treated with TPE. The population consisted of 62 women and 28 men with a median age of 38 years (range 18–69 years).
Outcome Measures Primary endpoint was the clinical response to TPE, focused on the functional improvement of the target neurologic deficit. Secondary endpoint was an improvement in expanded disability status scale (EDSS) scoring.
Results A clinical response to TPE was observed in 65 out of 90 patients (72.2%), with marked improvement in 18 (20.0%) and moderate improvement in 47 out of 90 patients (52.2%). The median EDSS was reduced from 3.75 before to 3.0 after TPE (p = 0.001). Response to TPE was significantly more frequent in patients with relapsing courses of disease (CIS, RR-MS, p = 0.001), no disease modifying drugs (p = 0.017), gadolinium-positive (Gd+) MRI lesions (p = 0.001) and EDSS ≤ 5.0 before TPE (p = 0.014). In the multiple logistic regression analysis only the detection of Gd+ MRI lesions was significantly altered (p = 0.004).
Conclusion Clinical response to TPE was achieved in the majority of our patients. We identified clinical and diagnostic features in CIS and MS relapses that might be helpful to identify patients responding to TPE. Gd+ MRI lesions before treatment were the best predictor of the response to TPE in our cohort.
As a clinician this paper challenges our current thinking of managing MS, at least in the early stages. It’s a retrospective study, but without a doubt plasma exchange appears to be superior to steroids as a treatment option (see figure below). The Gd+ suggests that maybe this would be an option in patients with relapses.
So what would be the proof of concept for plasma exchange? If you believe that MS has miasma/scourge of nasties floating around in your blood, then cleansing the body of this makes sense. This would include things like myelin targeting antibodies, cytokines, heat shock proteins, complement etc.
Logistically, it would be a nightmare to set up. Steroids trump this by being relatively safe (aside from avascular necrosis of the hip), having an oral option and the IV version which can be given by district nurses at home if required. Conversely, plasma exchange is unlicensed, expensive and can kill you (secondary to line infection and sepsis, too much fluid being removed, drop in clotting factors, STD’s etc.).
Nonetheless, I would consider it an option in tumefactive MS where the presentation is ghastly, with reduced conscious level, seizures, aphasia (inability to talk) etc. As our experience/success rates improve – diversifying into CIS and RRMS (for relapses) should be on the cards.
Glucocorticosteroid treatment and therapeutic plasma exchange in clinically isolated syndrome and multiple sclerosis patients. A) Response to glucocorticosteroid treatment in CIS and MS patients. B) Response to therapeutic plasma exchange in CIS and MS patients. C) Different responses to therapeutic plasma exchange in CIS and MS patients. D) Development of medianEDSS values during therapeutic plasma exchange. * p = 0.01 (CIS versus SP-MS), ** p = 0.002 (RR-MS versus SP-MS), *** p = 0.001 (EDSS before versus after TPE).