Cost-minimisation analysis of plasma exchange versus IVIg in the treatment of autoimmune neurological conditions

Transforming care: Patient insights on neurology-led peripheral plasma exchange service

BACKGROUND AND OBJECTIVES

Therapeutic plasma exchange (TPE) is a highly efficacious treatment for a wide range of antibody-mediated neuroimmunological disorders. Practical difficulties of TPE via membrane filtration, which requires central venous access, have limited its use for neurology patients. The development of centrifugal plasma exchange (cTPE) machines has enabled treatment via peripheral venous access. We set up a neurology-led ambulatory day case peripheral plasma exchange service at the Wessex Neuroscience Centre in 2019 via cTPE machines. This study aims to evaluate the service based on patients' experience and satisfaction.

MATERIALS AND METHOD

We retrospectively collected data for patients who received cTPE in our centre over a 20-month period. We designed a patient survey that included 15 questions based on Likert grading system. Patients were either given a QR code or were contacted by volunteers from the hospital to complete the questionnaire over the phone.

RESULTS

47 out of the 72 eligible patients participated in the survey. All survey questions received a positive response of 80 % and above, with responses in the range of 90 %. All patients who completed the survey commented that they would recommend this service.

CONCLUSION

cTPE machines enable plasma exchange via peripheral venous access allowing treatment for ambulatory day case patients. This study provides evidence confirming the positive patient experience with cTPE services at the Wessex Neurosciences Centre and highlights the importance of establishing neurology-led cTPE units to deliver effective treatment for neuroimmunology patients.

Miller Fisher Syndrome as a Stroke Mimic: A Case Report

Guillain-Barre syndrome (GBS) is a heterogeneous autoimmune disorder characterized by peripheral neuropathy, often triggered by preceding infections or vaccinations. It encompasses several clinical variants, including the rare Miller Fisher Syndrome (MFS), distinguished by ophthalmoplegia, ataxia, and areflexia. Diagnosis is challenging due to varied presentations and potential overlap with other neurological conditions. We present a case of a 42-year-old male initially suspected to have a stroke when he presented with unilateral loss of sensation and dysarthria. He was later diagnosed with MFS after his condition progressed and he developed generalized weakness, ophthalmoplegia, ataxia, and areflexia. Despite initial stability, his condition deteriorated, requiring intensive care. Early recognition and treatment, such as intravenous immunoglobulin (IVIg) and plasmapheresis, are critical for improving outcomes in GBS and its variants. This case underscores the importance of clinical suspicion and appropriate diagnostic strategies in managing these complex neurological disorders.

Disease burden, healthcare resource utilisation, and treatment patterns in patients with newly diagnosed myasthenia gravis in England: A retrospective cohort study

BACKGROUND

Myasthenia gravis (MG), a chronic and unpredictable autoimmune disease, is associated with multiple comorbidities and high disease burden.

OBJECTIVE

To assess the disease burden, healthcare resource utilisation (HCRU), and treatment patterns of patients with newly diagnosed MG in England.

METHODS

Data from Clinical Practice Research Datalink GP practices linked to the Hospital Episode Statistics database were used. Eligible patients had ≥1 diagnostic code for MG, with the first MG diagnostic code recorded between 01 January 2010 and 31 December 2019. Non-MG controls were selected if they had no recorded MG diagnosis and ≥12 months of data. Controls were matched for age, sex and GP practice in a maximum ratio of 5:1.

RESULTS

Mean follow-up duration was 2.8 and 3.1 years for the MG and non-MG cohorts, respectively. In the MG cohort, 56% of patients were male, with a mean age of 67 years at baseline. Incidence rates of all comorbidities assessed during follow-up were higher in the MG cohort than in controls. Almost two-thirds of MG patients experienced ≥1 myasthenic exacerbation during follow-up; incidence rates (95% confidence interval) of MG exacerbations and crises were 50.0 (44.7-55.9) and 1.3 (0.8-2.0) per 100 person-years, respectively. Visits to non-neurology specialists and outpatient clinics were the most common instances of HCRU overall, each being more frequent in the MG cohort than for controls. In the first year of follow-up, acetylcholinesterase inhibitors (AChEIs) and corticosteroids were used by 56.0% and 50.2% of MG patients, respectively; the use of AChEIs declined thereafter.

CONCLUSIONS

Despite treatment, there is a high disease burden for patients with newly diagnosed MG in England, with high rates of MG exacerbation and HCRU use. Thus, there is a need for targeted treatments with sustained efficacy and improved safety to adequately manage MG symptoms and reduce MG-related disease burden.

Therapeutic Approach to Autoimmune Neurologic Disorders

OBJECTIVE

Autoimmune neurologic disorders encompass a broad category of diseases characterized by immune system attack of the central, peripheral, or autonomic nervous systems. This article provides information on both acute and maintenance immunotherapy used to treat autoimmune neurologic disorders as well as a review of symptomatic management and special considerations when caring for patients with these diseases.

LATEST DEVELOPMENTS

Over the past 20 years, more than 50 antibodies have been identified and associated with autoimmune neurologic disorders. Although advances in diagnostic testing have allowed for more rapid diagnosis, the therapeutic approach to these disorders has largely continued to rely on expert opinion, case series, and case reports. With US Food and Drug Administration (FDA) approval of biologic agents to treat neuromyelitis optica spectrum disorder (NMOSD) and myasthenia gravis as well as ongoing clinical trials for the treatment of autoimmune encephalitis, the landscape of immunotherapy options continues to expand. Consideration of the unique pathogenesis of individual autoimmune neurologic disorders as well as the mechanism of action of the diverse range of treatment options can help guide treatment decisions today while evidence from clinical trials informs new therapeutics in the future.

ESSENTIAL POINTS

Recognizing patients who have a clinical history and examination findings concerning for autoimmune neurologic disorders and conducting a thorough and directed imaging and laboratory evaluation aimed at ruling out mimics, identifying specific autoimmune syndromes, and screening for factors that may have an impact on immunotherapy choices early in the clinical course are essential to providing optimal care for these patients. Providers must consider immunotherapy, symptomatic treatment, and a multidisciplinary approach that addresses each patient's unique needs when treating patients with autoimmune neurologic disorders.

A retrospective observational study on characteristics, treatment patterns, and healthcare resource use of patients with myasthenia gravis in England

Background

There are limited data on the real-world healthcare resource use (HCRU) and management costs of myasthenia gravis (MG) in England.

Objective

This study aims to assess the burden of disease for patients with MG in England.

Design

A retrospective, observational cohort study of adult patients diagnosed with MG, using data from the Hospital Episode Statistics data warehouse.

Methods

Patients with a first-ever recorded diagnosis of MG between 30 June 2015 and 30 June 2020 were followed up until 30 June 2021 or death, whichever occurred first. Post-diagnosis patient characteristics, treatment patterns, HCRU, and costs were described. Costs were evaluated using National Health Service reference costs.

Results

A total of 9087 patients with a median follow-up time of 2.9 years (range, 1.7-4.3 years) were included. The mean age at diagnosis was 66.5 years and 53% of the patients were male. A large proportion of patients (72.8%) were admitted as inpatients during follow-up with a mean number of 1.3 admissions. Patients hospitalized for MG-related complications spent a mean of 9.7 days per patient-year in the hospital. During follow-up, 599 (6.6% of the total cohort) and 163 (1.8%) patients had a record of rescue therapy with intravenous immunoglobulin (IVIg) and plasma exchange (PLEX), respectively. Rituximab was administered to 81 (0.9%) patients and 268 (2.9%) patients underwent thymectomy. In those patients receiving rescue therapy or rituximab, >10% received at least three cycles of the same treatment. The average annual cost of hospital admissions across all patients treated with IVIg, PLEX, and rituximab were £907,072, £689,979, and £146,726, respectively.

Conclusion

A majority of MG patients required hospitalization or accident and emergency attendance, resulting in high HCRU and costs. A subset of patients required rescue therapy (including IVIg and PLEX), rituximab administration, ventilation, or thymectomy.

Clinical features, treatments, their impact, and quality of life for Myasthenia Gravis patients in Australia

This survey provides an update on the experience of Myasthenia Gravis (MG) patients in Australia. Items were drawn from the 2011 Australian Survey and a 2019 US survey allowing for comparative discussion of survey findings. Patients were recruited through the Myasthenia Alliance Australia. Following consent, patients completed an online survey using REDCap software. Questions included demographics, clinical features, treatment side-effects and quality of life (QOL) scales. Samples for completion of survey sections ranged from N = 242-280 representing a power level of over 80%. Female and seronegative patients reported a significantly greater symptom load, earlier disease onset, longer time to diagnosis, more MG exacerbations, treatment side-effects, and poorer QOL. For exacerbation management there was a higher rate of oral corticosteroid use (66%), a lower use of Intravenous Immunoglobulin (IVIg, 47%) and particularly, Therapeutic Plasma Exchange (TPE, 4.5%) within this sample. Although steroid induced side-effects were rarer (9-34%), a comparatively high use of corticosteroids was reported for current and overall treatments including those for MG crises (52-83%). Common treatment side-effects reported by 57-85% of patients, included fatigue, weight gain, a decrease in the ability to fight infections, gastrointestinal symptoms, and muscle weakness. The impact of MG on daily activities and QOL was considerable, but those who had a thymectomy reported better QOL. The survey identified areas for potential practice improvement in MG treatments (corticosteroids, IVIg, TPE), particularly for exacerbation management, and review is recommended. Further research on gender and antibody status differentials regarding clinical features is required.

Therapeutic Plasma Exchange in Certain Immune-Mediated Neurological Disorders: Focus on a Novel Nanomembrane-Based Technology

Therapeutic plasma exchange (TPE) is an efficient extracorporeal blood purification technique to remove circulating autoantibodies and other pathogenic substances. Its mechanism of action in immune-mediated neurological disorders includes immediate intravascular reduction of autoantibody concentration, pulsed induction of antibody redistribution, and subsequent immunomodulatory changes. Conventional TPE with 1 to 1.5 total plasma volume (TPV) exchange is a well-established treatment in Guillain-Barre Syndrome, Chronic Inflammatory Demyelinating Polyradiculoneuropathy, Neuromyelitis Optica Spectrum Disorder, Myasthenia Gravis and Multiple Sclerosis. There is insufficient evidence for the efficacy of so-called low volume plasma exchange (LVPE) (<1 TPV exchange) implemented either by the conventional or by a novel nanomembrane-based TPE in these neurological conditions, including their impact on conductivity and neuroregenerative recovery. In this narrative review, we focus on the role of nanomembrane-based technology as an alternative LVPE treatment option in these neurological conditions. Nanomembrane-based technology is a promising type of TPE, which seems to share the basic advantages of the conventional one, but probably with fewer adverse effects. It could play a valuable role in patient management by ameliorating neurological symptoms, improving disability, and reducing oxidative stress in a cost-effective way. Further research is needed to identify which patients benefit most from this novel TPE technology.

Therapeutic plasma exchange for myasthenia gravis, Guillain-Barre syndrome, and other immune-mediated neurological diseases, over a 40-year experience

BACKGROUND

Therapeutic plasma exchange (TPE) was first used in neurology in the 1980s for myasthenia gravis (MG) and Guillain-Barré syndrome (GBS). Indications have since grown. Fear of complications with this treatment modality limit its use.

RESEARCH DESIGN & METHODS

A study of patients undergoing TPE for neurological diseases (1981-2020) in a University Hospital in Madrid, Spain. Clinical indications, complications, procedure number, apheresis technique and replacement fluids were prospectively recorded and retrospectively analyzed. Historical trends were studied.

RESULTS

 159 patients (48.69 ±18.15 years, 54.3% females) underwent TPE using central-venous catheter and replacement fluid albumin. We performed 1207 procedures over 189 cycles (6.4 ±3.8 procedures/cycle). Most patients underwent TPE for category I-II indications, mainly GBS and MG (77.7%). Complication rate was low (3.9% procedures), mostly hypotensive/vasovagal reactions (55.3%) and vascular access-related complications (38.3%). Most were mild-moderate (92.9%), permitting TPE completion, and somewhat more frequent during the first procedure (38.3%) and after periods of little TPE use. GBS patients were more prone to complications than MG patients (6.5% vs. 1.2%,p<0.001) mainly hypotensive/vasovagal reactions (3.7% vs. 1.0%,p=0.008).

CONCLUSIONS

TPE is well-tolerated with low complication rate (<4% procedures), mainly hypotensive/vasovagal reactions. Patients with GBS seem more prone to them than MG patients. Acquaintance with this technique seems necessary.