Chronic long-interval plasma exchange in myasthenia gravis

Clinical experience with maintenance therapeutic plasma exchange in refractory generalized myasthenia gravis

BACKGROUND

Despite the availability of several immunomodulatory therapies, about 20% of myasthenia gravis (MG) patients remain refractory to conventional treatments. There is limited evidence to support the use of maintenance therapeutic plasma exchange (TPE) therapy for refractory generalized MG.

METHODS

Retrospective chart review of 14 patients with refractory generalized MG treated for 12 months with maintenance TPE therapy. Outcome measures were myasthenia gravis composite (MGC) score, myasthenia gravis activities of daily living (MG-ADL), number of acute exacerbations, medication changes, and adverse events. Data were collected at 3 monthly intervals for 12 months before and after initiation of TPE therapy.

RESULTS

Clinically meaningful reductions in mean MG-ADL (>2 points) (mean MG-ADL score: 9.9 ± 0.5; 12-month pre-TPE to 5.2 ± 0.9; 12-month post-TPE) and MGC (>3 points) (mean MGC score: 25.2 ± 1.6; 12-month pre-TPE to 11.7 ± 1.4; 12-month post-TPE) were observed at 3 months following initiation of TPE and were maintained up to 12 months in all patients. After 12 months of TPE therapy, all patients had a significant reduction in daily prednisone and pyridostigmine use. Patients previously on IVIG or rituximab therapy were successfully weaned off both treatments. There was a significant reduction in acute MG exacerbations; 7.8 ± 1.1 mean exacerbations/patient (12-month pre-TPE) to 2 ± 1.1 mean exacerbations/patient (12-month post-TPE).

CONCLUSION

Over a period of 12 months, maintenance TPE therapy improved MG-ADL, and MGC with decreased immunosuppressant requirement, while being well-tolerated.

Therapeutic plasma exchange in neurological diseases: Eleven years experience at a tertiary care center in Turkey

Therapeutic plasma exchange (TPE) is an apheresis procedure in which plasma is separated from the blood cellular components ex vivo, allocated, and replaced with another plasma or a plasma-replacing fluid. This study aimed to define the rate of complications and determine TPE distribution in various neurological diseases. Our study is a retrospective analysis of neurologic diseases requiring TPE between 2008 and 2019 that were selected using the medical records of neurology departments and apheresis units database. We performed 1459 TPE procedures on 207 patients between 2008 and 2019. TPE Procedure is most frequently applied in patients with Myasthenia-Gravis syndrome (34.7%). The complication ratio was 1.6% from a total of 1459 TPE procedures. The most commonly specified adverse event was allergic reactions 11 (5.3%), followed by hypotension 6 (2.9%). TPE was safe and tolerable, with manageable complications in experienced hands.

Treatment of Acquired Autoimmune Myasthenia Gravis: a Topic Review

We propose a new approach to staging the disease based on clinical and immunological response to treatment. We oppose clinical remission to immunological remission and define total clinical remission as the goal of therapy. We describe the use, side effects and indications of established therapies. Acetycholine esterase inhibitors are only a symptomatic treatment as is plasma exchange. Usefulness and limits of thymectomy, corticosteroids and immunosuppressants are described here. Their goal is to reduce the auto-immune process. Long-term hazards from these medications are described and methods to reduce their potential risks are suggested. We suggest the number of patients having life threatening complications while undergoing aggressive immunosuppression can be reduced by a systematic approach to follow-up. In the second part of this review article, adapting management to specific situations is emphasized in refractory disease, respiratory failure, neonatal and juvenile forms of the disease. The special situation of seronegative myasthenia is discussed.

Therapeutic plasma exchange in the treatment of myasthenia gravis

AIM

The aim of this study was to analyze the retrospective experience related to the indication, complication and outcome of Therapeutic Plasma Exchange (TPE) in Myasthenia gravis (MG). It is a well known autoimmune disease characterized by antibodies against the acetylcholine receptor (anti-ACHR) on the post synaptic surface of the motor end plate. Plasma exchange is the therapeutic modality well established in MG with a positive recommendation based on strong consensus of class III evidence.

MATERIALS AND METHODS

A total of 35 patients of MG were submitted to a total of 41 cycles and 171 session of TPE. It was performed using a single volume plasma exchange with intermittent cell separator (Hemonetics) by Femoral or central line access and schedule preferably on alternate day interval. Immediate outcome was assessed shortly after each session and overall outcome at discharge.

RESULTS

Total of 110 patients of MG who were admitted to our hospital during the study period of two years. 35 (31.8%) patients had TPE performed with mean age of 32 years (M:F = 2:1). The mean number of TPE session was 4.2 (SD±1.2), volume exchange was 2215 ml (SD±435); overall incidence of adverse reaction was 21.7%. All patients had immediate benefits of each TPE cycle. Good acceptance of procedure was observed in 78.3% of patients.

CONCLUSION

TPE may be considered as one of the treatment options especially in developing countries like ours as it is relatively less costly but as effective for myasthenic crisis as other modalities.

Intravenous immunoglobulin for myasthenia gravis

BACKGROUND

Myasthenia gravis is an autoimmune disease in which autoantibodies interfere with neuromuscular transmission. As with other autoimmune diseases, people with myasthenia gravis would be expected to benefit from intravenous immunoglobulin (IVIg). This is an update of a review first published in 2003 and last updated in 2007.

OBJECTIVES

To examine the efficacy of IVIg for treating exacerbations of myasthenia gravis or for chronic myasthenia gravis.

SEARCH METHODS

We searched the Cochrane Neuromuscular Disease Group Specialized Register (11 October 2011), CENTRAL (2011, Issue 3), MEDLINE (January 1966 to September 2011) and EMBASE (January 1980 to September 2011) using 'myasthenia gravis' and 'intravenous immunoglobulin' as the search terms.

SELECTION CRITERIA

All randomised controlled trials (RCTs) or quasi-RCTs in which IVIg was compared with no treatment, placebo or plasma exchange, in people with myasthenia gravis.

DATA COLLECTION AND ANALYSIS

One review author extracted the data and two others checked these data. For methodological reasons, no formal meta-analysis was performed.

MAIN RESULTS

We identified seven RCTs. These trials differ in inclusion criteria, comparison with alternative treatment and outcomes. In a trial comparing IVIg with placebo, including 51 participants with myasthenia gravis worsening, the mean difference (MD) in quantitative myasthenia gravis score (QMGS) (MD 95% CI) after 14 days was: -1.60 (95% CI - 3.23 to 0.03) this result being borderline statistically significant in favour of IVIg. In an unblinded study of 87 participants with exacerbation comparing IVIg and plasma exchange there was no difference in myasthenic muscle score (MMS) after 15 days (MD -1.00; 95% CI -7.72 to 5.72). In a study of 84 participants with worsening myasthenia gravis there was no difference in change in QMGS 14 days after IVIg or plasma exchange (MD -1.50; 95% CI -3.43 to 0.43). In a study of 12 participants with moderate or severe myasthenia gravis, which was at high risk of bias from skewed allocation, the mean fall in QMGS both for IVIg and plasma exchange after four weeks was significant (P < 0.05). A study with 15 participants with mild or moderate myasthenia gravis found no difference in change in QMGS 42 days after IVIg or placebo (MD 1.60; 95% CI -1.92 to 5.12). A study included 33 participants with moderate exacerbations of myasthenia gravis and showed no difference in change in QMGS 14 days after IVIg or methylprednisolone (MD -0.42; 95% CI -1.20 to 0.36). All these three smaller studies were underpowered. The last trial, including 168 people with exacerbations, showed no evidence of superiority of IVIg 2 g/kg over IVIg 1 g/kg on the change of MMS after 15 days (MD 3.84; 95% CI -0.98 to 8.66). Adverse events due to IVIg were moderate (fever, nausea, headache), self-limiting and subjectively less severe than with plasma exchange (although, given the available data, no statistical comparison was possible). Other than where specific limitations are mentioned the trials were generally at low risk of bias.

AUTHORS' CONCLUSIONS

In exacerbation of myasthenia gravis, one RCT of IVIg versus placebo showed some evidence of the efficacy of IVIg and two did not show a significant difference between IVIg and plasma exchange. Another showed no significant difference in efficacy between 1 g/kg and 2 g/kg of IVIg. A further, but underpowered, trial showed no significant difference between IVIg and oral methylprednisolone. In chronic myasthenia gravis, there is insufficient evidence from RCTs to determine whether IVIg is efficacious.

Intravenous immunoglobulin for myasthenia gravis

BACKGROUND

Myasthenia gravis is an autoimmune disease in which autoantibodies interfere with neuromuscular transmission. As with other autoimmune diseases, people with myasthenia gravis would be expected to benefit from intravenous immunoglobulin (IVIg).

OBJECTIVES

The objective of this review was to examine the efficacy of intravenous immunoglobulin for treating exacerbations of myasthenia gravis or for chronic myasthenia gravis.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease GroupTrials Register (April 2007) and MEDLINE (January 1966 to May 2007) using 'myasthenia gravis' and 'intravenous immunoglobulin' as the search terms.

SELECTION CRITERIA

We included all randomised or quasi-randomised trials in which intravenous immunoglobulin was compared with no treatment, placebo or plasma exchange, in people with myasthenia gravis.

DATA COLLECTION AND ANALYSIS

One review author extracted the data and two others checked these data and the source from which they were derived. For methodological reasons, no formal meta-analysis was performed.

MAIN RESULTS

We identified six randomised controlled trials, all of which investigated short-term benefit. A trial of IVIg compared with placebo including 51 patients provided evidence for the effectiveness of IVIg in myasthenia gravis worsening. A study of 87 participants with exacerbation found no statistically significant difference between immunoglobulin and plasma exchange after two weeks. A study of 12 participants with moderate or severe myasthenia gravis treated in a crossover design trial found no statistically significant difference in the efficacy of immunoglobulin and plasma exchange after four weeks. A study with 15 participants with mild or moderate myasthenia gravis found no statistically significant difference in efficacy of IVIg and placebo after six weeks. A study included 33 participants with moderate exacerbations of myasthenia gravis and showed no statistically significant difference in the efficacy of IVIg and methylprednisolone. The last trial including 173 people with myasthenia gravis exacerbations, showed no superiority of IVIg 1 g/kg on two consecutive days over IVIg 1 g/kg on a single day.

AUTHORS' CONCLUSIONS

In exacerbation of myasthenia gravis, one randomised controlled trial of IVIg versus placebo demonstrated the efficacy of IVIg and another did not show a significant difference between IVIg and plasma exchange. Another showed no significant difference in efficacy between 1 g/kg and 2 g/kg of IVIg. A further, but underpowered, trial showed no significant difference between IVIg and oral methylprednisolone. In chronic myasthenia gravis, there is insufficient evidence from randomised trials to determine whether IVIg is efficacious. More research is needed to determine whether IVIg reduces the need for corticosteroids as suggested by two case series.

Intravenous immunoglobulin for myasthenia gravis

BACKGROUND

Myasthenia gravis is an autoimmune disease in which autoantibodies interfere with neuromuscular transmission. As with other autoimmune diseases, people with myasthenia gravis would be expected to benefit from intravenous immunoglobulin.

OBJECTIVES

The objective of this review was to examine the efficacy of intravenous immunoglobulin for treating exacerbations of myasthenia gravis or for chronic myasthenia gravis.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group trials register (March 2005) and MEDLINE (January 1966 to March 2005) using 'myasthenia gravis' and 'intravenous immunoglobulin' as the search terms.

SELECTION CRITERIA

We included all randomised or quasi-randomised trials in which intravenous immunoglobulin was compared with no treatment, placebo or plasma exchange, in people with myasthenia gravis.

DATA COLLECTION AND ANALYSIS

One author extracted the data and the two others checked these data and the source from which they were derived. For methodological reasons, no formal meta-analysis was performed.

MAIN RESULTS

We identified five randomised controlled trials, all of which investigated short-term benefit. The first study of 87 participants with exacerbation found no statistically significant difference between immunoglobulin and plasma exchange after two weeks. The second study of 12 participants with moderate or severe myasthenia gravis treated in a crossover design trial found no statistically significant difference in the efficacy of immunoglobulin and plasma exchange after four weeks. The third study with 15 participants with mild or moderate myasthenia gravis found no statistically significant difference in efficacy of intravenous immunoglobulin and placebo after six weeks. The fourth study terminated early. It included 33 participants with moderate exacerbations of myasthenia gravis and showed no statistically significant difference in the efficacy of intravenous immunoglobulin and methylprednisolone. The fifth trial including 173 people with myasthenia gravis exacerbations, showed no superiority of intravenous immunoglobulin 1 g/kg on two consecutive days over intravenous immunoglobulin 1 g/kg on a single day.

AUTHORS' CONCLUSIONS

In severe exacerbations of myasthenia gravis, one randomised controlled trial did not show a significant difference between intravenous immunoglobulin and plasma exchange. Another showed no significant difference in efficacy between 1 g/kg and 2 g/kg of intravenous immunoglobulin. A further trial showed no significant difference between intravenous immunoglobulin and oral methylprednisolone. In chronic myasthenia gravis, there is insufficient evidence from randomised trials to determine whether intravenous immunoglobulin is efficacious. More research is needed to determine whether intravenous immunoglobulin reduces the need for steroids as suggested by two case series.

Plasmapheresis in the treatment of myasthenia gravis: retrospective study of 26 patients

We analyzed the experience of Unicamp Clinical Hospital with plasma exchange (PE) therapy in myasthenia gravis (MG). About 17.8 % of a totality of MG patients had PE performed: 26 cases, 19 women and seven men. The mean age-onset of MG was 28 years, extremes 11 and 69. Minimum deficit observed in the group was graded IIb (O & G) or IIIa (MGFA scale). One patient had prethymectomy PE. In seven the procedures were performed due to myasthenic crisis and in 18 patients due to severe myasthenic symptoms or exacerbation of previous motor deficit. Two patients were also submitted to chronic PE considering refractoriness to other treatments. Twenty-six patients had 44 cycles of PE and 171 sessions. The mean number of sessions was 3.9 (SD ± 1.4) each cycle; median 5, extremes 2 and 6. The mean time by session was 106,5 minutes (SD ± 35.2); median 100.5 (extremes of 55 and 215). The mean volume of plasma exchanged in each session was 2396 ml (SD ± 561); median 2225 (extremes 1512 and 4500). Side effects occurred: reversible hypotension (seven cases), mild tremor or paresthesias (seven cases). Infection and mortality rates due to PE were zero. All patients had immediate benefit of each PE cycle and usually they also received prednisone or other immunosuppressors. Good acceptance of the procedure was observed in 80.7% of patients.

Therapeutic plasma exchange: an underutilized therapeutic modality?

Since its clinical availability approximately 25 years ago, therapeutic plasma exchange (TPE) has become recognized as appropriate primary therapy for many diverse medical conditions. In some aspects TPE has been constrained in its use according to schedules of efficacy. Expansion of TPE to other indications is likely once attention is focused on its ability to enable patients to avoid potentially toxic pharmacologic interventions if employed as a chronic therapy, and especially when it is accepted that adjunctive use, not only a curative role, is a valuable use of this therapeutic modality.

Plasma exchange for myasthenia gravis

BACKGROUND

Myasthenia gravis is an autoimmune disease mediated by auto-antibodies direct against the nicotinic receptor for acetylcholine. Patients would be expected to benefit from plasma exchange. Non-randomised studies suggest that plasma exchange is beneficial in the short term.

OBJECTIVES

To examine the efficacy of plasma exchange in the short and long term treatment of myasthenia gravis.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group register (searched 17 July 2002) and MEDLINE (January 1966 to June 2002) for randomised controlled trials using myasthenia gravis as the search term. We checked the bibliographies in reports of randomised trials and contacted one author to identify additional published or unpublished data.

SELECTION CRITERIA

Types of studies: All randomised or quasi-randomised studies.

TYPES OF PARTICIPANTS

All patients with myasthenia gravis who were diagnosed by an internationally accepted definition. Types of intervention: Treatment with plasma exchange alone or combined with steroids or immunosuppressive drugs. Types of outcome measures:

PRIMARY OUTCOME MEASURE

~bullet~patients treated for exacerbation: change in a specific muscle score after plasma exchange; ~bullet~patients treated for chronic myasthenia gravis: change in a functional scale.

SECONDARY OUTCOME MEASURES

~bullet~patients treated for exacerbation: change in a functional scale and percentage weaned from mechanical ventilation; ~bullet~patients treated for chronic myasthenia gravis: percentage in remission by the end of one year after first plasma exchange; ~bullet~adverse events.

DATA COLLECTION AND ANALYSIS

One author extracted the data and the two others checked them. Since there was only one trial no formal meta-analysis was required.

MAIN RESULTS

We identified one randomised controlled trial. Improvement in a quantitative muscle score was not significantly greater in patients treated with plasma exchange and prednisone than in patients treated with prednisone alone one month after onset of treatment. More relapses were observed in the plasma exchange and prednisone group in the first year as compared with the prednisone alone group. Problems in recruitment and matching of patients entered into this trial limit the conclusions that can be drawn. On the other hand,experience from many non-randomised studies suggests that plasma exchange is beneficial in myasthenia gravis. Consequently the relative benefits of plasma exchange are still unconfirmed.

REVIEWER'S CONCLUSIONS

There are no adequate randomised controlled trials but many case series report short-term benefit from plasma exchange in myasthenia gravis, especially in myasthenic crisis. There are no adequate randomised controlled trials to determine whether plasma exchange improves the long-term outcome for myasthenia gravis. Further research is need to compare plasma exchange with alternative short-term treatments for myasthenic crisis and to determine the value of long-term plasma exchange for treating myasthenia gravis.

Plasmapheresis in myasthenia gravis. A survey

Plasmapheresis plays an important role in the acute management of patients with severe myasthenia gravis. Although plasmapheresis is now in use for more than 20 years, some controversies remain about the indication and the place in the therapy. It is generally found that the effect starts one week after the start of PP and lasts about 2-4 weeks after the last exchange; because of this temporary effect use of concomitant immunosuppressive medication is recommended. Compilation of data from 13 large series shows that about 75% of the patients react favourably. The relation between fluctuations of antibodies and the effect of PP is poor; even seronegative patients may improve as well.

Myasthenia gravis

Adult-onset myasthenia gravis is an acquired autoimmune disorder of neuromuscular transmission in which acetylcholine receptor antibodies attack the postsynaptic membrane of the neuromuscular junction. Although the cause of this disease is unknown, the role of immune responses in its pathogenesis is well established. Circulating acetylcholine receptor antibodies are present in 80% to 90% of patients with the generalized form of myasthenia gravis. Most patients have ptosis, diplopia, dysarthria and dysphagia. The weakness and fatigue worsen on exertion and improve with rest. Respiratory muscle and limb weakness are rare at the onset of the disease. For the past two decades, there has been considerable progress in understanding the diagnosis and management of myasthenia gravis. The diagnosis is based on clinical presentation, neurologic examination, and confirmation by means of electrophysiologic testing and immunologic studies. Myasthenia gravis mimics many neuromuscular diseases and even illnesses such as depression and chronic fatigue syndrome. One should always exclude drug-induced myasthenia gravis for all patients. With the introduction of new modalities of treatment, particularly immunosuppressive or immunomodulating drugs, plasma exchange and thymectomy, the morbidity and mortality of myasthenia gravis have decreased dramatically to the point that myasthenia gravis should not be considered as serious a disease as it once was. Although the several therapeutic options are usually effective and have meant independence in daily life to many patients with myasthenia gravis, well-designed, controlled, prospective studies are still lacking.

Myasthenia gravis treatment: twelve years experience on 110 patients

The clinical conditions of 110 patients affected by myasthenia gravis (MG) were followed from two to twelve years. Patients with thymectomy showed a statistically higher percentage of clinical remissions than patients without thymectomy. In patients without clinical remission immunosuppressive drugs were prescribed in different schedule; the greater percentage of pharmacological remissions with less adverse effects was obtained with administration of prednisone 50-75 mg/die initially, than gradually reduced to smaller dosage in alternate day, associated to azathioprine. Plasmapheresis, performed in six cases not responders to immunosuppressive drugs, always showed a positive and even prolonged effect.