Beneficial effects of plasmapheresis before thymectomy on the outcome in myasthenia gravis

Effectiveness and safety of therapeutic plasma exchange in neurological diseases: An 11-year report from a tertiary care center

BACKGROUND

Therapeutic plasma exchange has been a well-known treatment method for many years and is widely available. It leads to the improvement of neurological symptoms in autoimmune neurological diseases by the removal of antibodies. The aim of this study was to present therapeutic plasma exchange responses and procedure-related adverse events in patients with autoimmune neurological diseases based on our 11-year experience.

METHOD

A retrospective evaluation was conducted on adult patients who underwent a therapeutic plasma exchange procedure due to neurological diseases between January 2013 and January 2024. Data were gathered from electronic and written hospital and apheresis unit records.

RESULTS

A total of 265 patients underwent 1274 procedures with a preliminary diagnosis of autoimmune neurological disease. Five patients were excluded from the analysis due to their final diagnoses. The most common clinical indications were Guillain-Barré syndrome (45.4%), myasthenia gravis (26.1%), and multiple sclerosis (19.2%). The overall response rate was 81.3%, with 21.7% exhibiting a complete response and 59.6% demonstrating a partial response. With the exception of one patient (hypertensive crisis), no complications necessitating the termination of the procedure were observed. The most prevalent complication was an easily manageable allergic reaction.

CONCLUSION

Therapeutic plasma exchange has been demonstrated to be an efficacious and safe treatment option in autoimmune neurological diseases, with a favorable overall response rate and a manageable mild-to-moderate side effect profile.

Successful Emergency Management of a Dog with Ventilator-Dependent Acquired Myasthenia Gravis with Immunoadsorption

A one-year-old, female intact Samoyed, 12.5 kg, was presented with coughing for 2 weeks, progressive appendicular and axial muscle weakness, megaesophagus and labored breathing for 5 days. There was no improvement with standard treatment. Acquired myasthenia gravis was suspected and the dog was referred with increasing dyspnea. At presentation, the dog showed a severely reduced general condition, was non-ambulatory and showed abdominal and severely labored breathing. A marked hypercapnia (PvCO2 = 90.1 mmHg) was present in venous blood gas analysis. The serum anti-acetylcholine receptor antibody test was consistent with acquired myasthenia gravis (2.1 nmol/L). The dog was anesthetized with propofol and mechanically ventilated with a Hamilton C1 ventilator. Immunoadsorption was performed with the COM.TEC® and ADAsorb® platforms and a LIGASORB® adsorber to eliminate anti-acetylcholine receptor antibodies. Local anticoagulation was performed with citrate. Treatment time for immunoadsorption was 1.5 h with a blood flow of 50 mL/min. A total plasma volume of 1.2 L was processed. Further medical treatment included intravenous fluid therapy, maropitant, esomeprazole, antibiotic therapy for aspiration pneumonia and neostigmine 0.04 mg/kg intramuscularly every 6 h for treatment of acquired myasthenia gravis. Mechanical ventilation was stopped after 12 h. A percutaneous gastric feeding tube was inserted under endoscopic control on day 2 for further medical treatment and nutrition. A second treatment with immunoadsorption was performed on day 3. Again, a total plasma volume of 1.2 L was processed. Immediately after this procedure, the dog regained muscle strength and was able to stand and to walk. After 6 days, the dog was discharged from the hospital. This is the first report of immunoadsorption for emergency management of a dog with acute-fulminant acquired myasthenia gravis. Immunoadsorption may be an additional option for emergency treatment in dogs with severe signs of acquired myasthenia gravis.

Global prevalence of myasthenia gravis and the effectiveness of common drugs in its treatment: a systematic review and meta-analysis

BACKGROUND

Myasthenia gravis is a neuromuscular autoimmune disorder characterized by weakness and disability in the voluntary muscles. There have been several preliminary studies on the epidemiology of myasthenia gravis in different parts of the world and the effectiveness of common drugs in its treatment, but there has been no comprehensive study of the efficacy of common drugs in the treatment of myasthenia gravis. Therefore, this study aimed to determine the epidemiology of myasthenia gravis globally and the effectiveness of common drugs in its treatment using systematic review and meta-analysis.

METHODS

Research studies were extracted from IranDoc, MagIran, IranMedex, SID, ScienceDirect, Web of Sciences (WoS), ProQuest, Medline (PubMed), Scopus and Google Scholar based on Cochran's seven-step guidelines using existing keywords extracted in MeSH browser. The I2 test was used to calculate the heterogeneity of studies, and Begg and Mazumdar rank correlation tests were used to assess publication bias. Data were analyzed using Comprehensive Meta-Analysis software (Version 2).

RESULTS

In the search for descriptive studies based on the research question, 7374 articles were found. After deleting articles unrelated to the research question, finally, 63 articles with a sample size of 1,206,961,907 people were included in the meta-analysis. The prevalence of MG worldwide was estimated to be 12.4 people (95% CI 10.6-14.5) per 100,000 population. For analytical studies on the effectiveness of common myasthenia gravis drugs, 4672 articles were found initially, and after removing articles unrelated to the research question, finally, 20 articles with a sample size of 643 people in the drug group and 619 people in the placebo group were included in the study. As a result of the combination of studies, the difference between the mean QMGS score index after taking Mycophenolate and Immunoglobulin or plasma exchange drugs in the group of patients showed a significant decrease of 1.4 ± 0.77 and 0.62 ± 0.28, respectively (P < 0.01).

CONCLUSION

The results of systematic review of drug evaluation in patients with myasthenia gravis showed that Mycophenolate and Immunoglobulin or plasma exchange drugs have positive effects in the treatment of MG. It also represents the positive effect of immunoglobulin or plasma exchange on reducing SFEMG index and QMGS index and the positive effect of Mycophenolate in reducing MG-ADL index, SFEMG and Anti-AChR antibodies index. In addition, based on a meta-analysis of the random-effect model, the overall prevalence of MG in the world is 12.4 people per 100,000 population, which indicates the urgent need for attention to this disease for prevention and treatment.

Therapeutic Plasma Exchange in Myasthenia Gravis: A Systematic Literature Review and Meta-Analysis of Comparative Evidence

Background: Patients with Myasthenia Gravis (MG) can be treated acutely with therapeutic plasma exchange (TPE) or intravenous immune globulin (IVIG). To date, there is no definitive understanding of which of the two treatments is more effective and safer. The purpose of this study was to systematically review the literature on the comparative efficacy and safety of TPE to other available treatments for MG. Methods: A systematic literature search for studies published between 1997 and 2017 was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using two database sources, MEDLINE (through the PubMed database) and Cochrane Library. Results: The search strategy resulted in 535 articles whose abstracts were reviewed. Among these, 165 full texts articles were reviewed for eligibility and 101 articles were excluded. Of the 165 articles, 64 articles were included for a systematic literature and 11 articles for a meta-analysis. Conclusions: This systematic literature review and meta-analysis of treatment options showed that there was a higher response rate with TPE than IVIG in acute MG patients and patients undergoing thymectomy. There was no difference in mortality between the two treatment options. Our findings highlight the need for additional randomized clinical trials in these patients with MG.

Perioperative Approach in a Patient with Myasthenia Gravis

Background: Myasthenia gravis is an autoimmune neuromuscular disorder that causes the destruction and overall decrease in functional acetylcholine receptors at the neuromuscular junction. The resultant respiratory and cardiovascular implications are a primary cause of mortality; therefore, a complete and comprehensive understandings of this disorder is vital for the anesthesia provider. Anesthesia management in myasthenia gravis is a great challenge for all anesthesiologists. In this disease, even small doses of muscle relaxants could lead to delayed recovery for respiratory muscles. Case report: We present the case of a 38 years old woman (weight 87 kg) diagnosed with Myasthenia Gravis, which symptoms has worsened recently. The case demonstrates the anesthetic challenges involved, with a focus on the overall approach, pharmacologic considerations, physiological changes, and an emphasis on preoperative operative and post-operative optimization. Conclusion: Thymectomy is a common procedure performed in cases of myasthenia gravis (MG) with a thymoma or general MG that does not improve with medical therapy. During anesthesia the use of propofol or sevoflurane with opioids without the use of any neuromuscular blocking agents has been used with success.

Case Series: Clinical Impact of Plasmapheresis and Thymectomy on Early-Onset Myasthenia Gravis

Thymectomy is a common procedure performed in cases of myasthenia gravis (MG) with a thymoma or general MG that does not improve with medical therapy. This procedure is usually preceded by plasmapheresis to prevent the occurrence of myasthenic crisis and improve clinical outcome after thymectomy. Early-onset MG has a different phenotype than late-onset MG. So far, the effectiveness of plasmapheresis followed by thymectomy in early-onset MG remains unclear because of the conflicting results of previous studies. We present 5 early-onset MG patients who underwent plasmapheresis followed by thymectomy in the 2007–2020 period. Follow-up was done 1 year after thymectomy. We describe clinical features and postoperative data and evaluate the clinical outcome after thymectomy. Muscle strength was assessed by the Medical Research Council scale. Evaluation of clinical stage before and after thymectomy were carried out with the modified Osserman classification. All patients showed improvement (100%) in the clinical grade of the modified Osserman classification: 3 patients were in the complete remission category and 2 patients were in the improved category. All patients with general weakness experienced improvement in muscle strength at the 1-year evaluation.

Reappraisal of Oral Steroid Therapy for Myasthenia Gravis

Treatment with oral corticosteroids at high doses with an escalation and de-escalation schedule is effective against myasthena gravis (MG). In fact, the use of corticosteroids has led to a reduction in mortality to below 10% after the 1960s. However, long-term use of oral steroids above a certain dosage level is known to cause a number of problems. In 2014, the Japanese clinical guidelines for MG proposed that the first goal in MG treatment (treatment target) should be set at minimal manifestations (MM) with oral prednisolone (PSL) 5 mg/day or below, and that treatment strategies should strive to attain this level as rapidly as possible. In 2015, a multicenter, cross-sectional study revealed that higher PSL dose and longer PSL treatment do not ensure better outcome. In the absence of good response, the PSL dose should be decreased by combining with modalities such as plasma exchange/plasmapheresis and intravenous immunoglobulin (fast-acting treatments). In 2018, we conducted a multicenter, cross-sectional study in a large population of Japanese patients with generalized MG, aiming to elucidate the correlation between oral PSL regimens and achievement of treatment goals. The ORs for low vs. high dose to achieve treatment goals at 1, 2, and 3 years were 10.4, 2.75, and 1.86, respectively, whereas the corresponding ORs for low vs. medium dose were 13.4, 3.99, and 4.92. Early combination with fast-acting therapy (OR 2.19 at 2 years, 2.11 at 3 years) or combination with calcineurin inhibitors (OR 2.09 at 2 years, 2.36 at 3 years) were also positively associated with achieving treatment goals. These results indicate that early combination of low-dose PSL regimens with other therapies is the key for early achievement of treatment goals in generalized MG. However, even with this regimen, ~35% of patients did not achieve the treatment target after 3 years. These results suggest the limitation of the current oral corticosteroid therapy. We need to develop new treatment options to increase the rate of satisfactory outcome.

Clinical usefulness of prethymectomy plasmapheresis in patients with myasthenia gravis: a systematic review and meta-analysis

OBJECTIVES

Our goal was to evaluate, through a systematic review, the efficacy of plasmapheresis in the preoperative preparation of the patient for a thymectomy for the treatment of myasthenia gravis.

METHODS

MEDLINE, Embase, LILACS, Scopus and CENTRAL databases were searched. The following outcomes were evaluated: myasthenic crisis, mortality, pneumonia, bleeding, use of mechanical ventilation, length of hospital stay and intensive care unit (ICU) stay. RevMan 5.3 software provided by the Cochrane Collaboration was used for the meta-analysis.

RESULTS

The total number of patients evaluated in the 7 included studies was 360. Plasmapheresis during the preoperative period did not decrease the myasthenic crisis [risk ratio (RR) 0.36, 95% confidence interval (CI) 0.08-1.66; I2 = 44%; 5 studies, 243 patients]. There was also no change in the mortality rate (RR 0.7, 95% CI 0.11-4.62; I2 = 0%; 3 studies, 172 patients) or pneumonia cases (RR 0.28, 95% CI 0.07-1.09; I2 = 27%; 5 studies, 272 patients). Bleeding was greater in patients who underwent plasmapheresis (mean difference 34.34 ml; 95% CI 24.93-43.75; I2 = 0%). We evaluated the following outcomes: need for mechanical ventilation, hospital stay, ICU stay and mechanical ventilation, but these outcomes were not adequate to perform the meta-analysis due to the high heterogeneity among the studies. Subgroup analysis showed that plasmapheresis performed during the preoperative period in patients with severe disease (Osserman III and IV) decreased the myasthenic crisis postoperatively (RR 0.12, 95% CI 0.02-0.65; I2 = 63%).

CONCLUSIONS

Plasmapheresis may reduce the myasthenic crisis during the postoperative period in patients with severe disease but may produce little or no difference in patients with mild clinical expression of the disease.

Role of complement and potential of complement inhibitors in myasthenia gravis and neuromyelitis optica spectrum disorders: a brief review

The complement system is a powerful member of the innate immune system. It is highly adept at protecting against pathogens, but exists in a delicate balance between its protective functions and overactivity, which can result in autoimmune disease. A cascade of complement proteins that requires sequential activation, and numerous complement regulators, exists to regulate a proportionate response to pathogens. In spite of these mechanisms there is significant evidence for involvement of the complement system in driving the pathogenesis of variety of diseases including neuromyelitis optica spectrum disorders (NMOSD) and myasthenia gravis (MG). As an amplification cascade, there are an abundance of molecular targets that could be utilized for therapeutic intervention. Clinical trials assessing complement pathway inhibition in both these conditions have recently been completed and include the first randomized placebo-controlled trial in NMOSD showing positive results. This review aims to review and update the reader on the complement system and the evolution of complement-based therapeutics in these two disorders.

Plasma exchange in neurological disease

Plasma exchange is a highly efficient technique to remove circulating autoantibodies and other humoral factors rapidly from the vascular compartment. It was the first effective acute treatment for peripheral disorders such as Guillain-Barré syndrome and myasthenia gravis before intravenous immunoglobulin became available. The recent recognition of rapidly progressive severe antibody-mediated central nervous system disorders, such as neuromyelitis optica spectrum disorders and anti-N-methyl-D-aspartate-receptor encephalitis, has renewed interest in using plasma exchange for their acute treatment also. In this review we explain the principles and technical aspects of plasma exchange, review its current indications, and discuss the implications for its provision in the UK.

Perioperative management in myasthenia gravis: republication of a systematic review and a proposal by the guideline committee of the Japanese Association for Chest Surgery 2014

Thymectomy is regarded as a useful therapeutic option for myasthenia gravis (MG), though perioperative management in MG patients is largely empirical. While evidence-based medicine is limited in the perioperative management of MG patients, treatment guidelines are required as a benchmark. We selected issues faced by physicians in clinical practice in the perioperative management of extended thymectomy for MG, and examined them with a review of the literature. The present guidelines have reached the stage of consensus within the Japanese Association for Chest Surgery.

Preoperative plasmapheresis for elective thymectomy in myasthenia patient: is it necessary?

Background. Role of plasmapheresis before thymectomy remains controversial. The aim of this study is to determine the peri-operative and post-operative outcome of a thymectomy between performing and not performing a pre-operative plasmaphreresis. Patients and Methods. A retrospective chart review study was conducted in Chiang Mai University Hospital between January 2006 and December 2011. There were 86 myasthenia patients divided into two groups; Preoperative plasmapheresis group (PPG) and no preoperative plasmapheresis group (NPPG). The primary outcome involved post-operative extubation and the secondary outcome included post-operative complications, 28 day mortality and length of hospital stay. Results. Eighty-six patients were enrolled in this study. The number of patients who had a history of myasthenic crisis at any time or within one month in the PPG was significantly more than those in the NPPG. Muscle power and forced expiratory vital capacity in the NPPG was higher than that in the PPG. The postoperative extubation rate was similar in both groups. After controlling for the propensity score, there were no statistically significant differences in both of primary and secondary outcomes. Conclusion. The results of this study shows no significant differences between both groups in all outcomes, therefore the pre-operative plasmaphresis is not necessary for elective thymectomy.

A decrease in the percentage of CD3+ cells is correlated with clinical improvement during plasmapheresis in patients with myasthenia gravis

Plasmapheresis not only removes circulating antibodies but also modulates cellular immunity, including lymphocyte subsets. To investigate the effect of double-filtration plasmapheresis (DFPP) on the ratio of lymphocyte subsets in patients with myasthenia gravis (MG), we examined the percentages of B-cells, T-cells, T helper (Th) cells, T suppressor (Ts) cells, natural killer (NK) cells, NKT cells, and Th/Ts ratio before and after a single DFPP session and after a course of DFPP. A total of 26 patients were recruited; their peripheral blood lymphocyte subsets were assayed using flow cytometry. After a single session of DFPP treatment, the percentages of T-cells (P = 0.0200), Th cells (P = 0.0178), and the Th/Ts ratio (P = 0.0309) decreased significantly, whereas the percentage of NK cells (P = 0.0007) increased significantly. More importantly, after one course of DFPP treatment, the reduced clinical quantitative MG (QMG) score was correlated with the decrease of the percentage of T-cells (r = 0.5005, P = 0.0092). Fourteen thymectomized MG patients had decreased percentages of T-cells (P = 0.0304) and Th cells (P = 0.0444), whereas they had increased NK cells (P = 0.0197) after a single DFPP session. Here, transiently decreased percentages of T-cells after the full DFPP course could enhance the effectiveness of plasmapheresis for MG patients.

Current and emerging treatments for the management of myasthenia gravis

Myasthenia gravis is an autoimmune neuromuscular disorder. There are several treatment options, including symptomatic treatment (acetylcholinesterase inhibitors), short-term immunosuppression (corticosteroids), long-term immunosuppression (azathioprine, cyclosporine, cyclophosphamide, methotrexate, mycophenolate mofetil, rituximab, tacrolimus), rapid acting short-term immunomodulation (intravenous immunoglobulin, plasma exchange), and long-term immunomodulation (thymectomy). This review explores in detail these different treatment options. Potential future treatments are also discussed.

Evidence-based guideline update: Plasmapheresis in neurologic disorders: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology

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.

RESULTS AND RECOMMENDATIONS

Plasmapheresis is established as effective and should be offered in severe acute inflammatory demyelinating polyneuropathy (AIDP)/Guillain-Barré syndrome (GBS) and in the short-term management of chronic inflammatory demyelinating polyneuropathy (Class I studies, Level A). Plasmapheresis is established as ineffective and should not be offered for chronic or secondary progressive multiple sclerosis (MS) (Class I studies, Level A). Plasmapheresis is probably effective and should be considered for mild AIDP/GBS, as second-line treatment of steroid-resistant exacerbations in relapsing forms of MS, and for neuropathy associated with immunoglobulin A or immunoglobulin G gammopathy, based on at least one Class I or 2 Class II studies (Level B). Plasmapheresis is probably not effective and should not be considered for neuropathy associated with immunoglobulin M gammopathy, based on one Class I study (Level B). Plasmapheresis is possibly effective and may be considered for acute fulminant demyelinating CNS disease (Level C). There is insufficient evidence to support or refute the use of plasmapheresis for myasthenia gravis, pediatric autoimmune neuropsychiatric disorders associated with streptococcus infection, and Sydenham chorea (Class III evidence, Level U).

Juvenile myasthenia gravis: three case reports and a literature review

Juvenile myasthenia gravis is a rare disorder acquired in childhood, representing 10% to 15% of all cases of myasthenia gravis. Like the adult form, it is generally characterized by an autoimmune attack on acetylcholine receptors at the neuromuscular junction. Most patients present with ptosis, diplopia, and fatigability. More advanced cases may also have bulbar problems and limb weakness. Left untreated, the disease may progress to paralysis of the respiratory muscles. Early recognition of this disease helps avoid unnecessary testing, prevent undue parental anxiety, and stop the progression of symptoms. Here, we relate the clinical course and current status of 3 patients with juvenile myasthenia gravis, discuss the disease in general, and review current treatment modalities.

Myasthenic crisis

Myasthenic crisis is a life-threatening medical emergency requiring early diagnosis and respiratory assistance. It can affect between one-fifth and one-third of all patients with generalized autoimmune myasthenia gravis. Myasthenic crisis is to be distinguished from other causes of acute neuromuscular paralysis which in most cases, can be achieved clinically. High dose corticosteroids in combination with plasma exchange or immunoglobulin are the cornerstone of treatment for this fully reversible cause of neuromuscular paralysis.