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Hiew FL, Thit WM, Alexander M, Thirugnanam U, Siritho S, Tan K, Mya Aye SM, Ohnmar O, Estiasari R, Yassin N, Pasco PM, Keosodsay SS, Trong Nghia HT, Islam MDB, Wong SK, Lee S, Chhabra A, Viswanathan S. Consensus recommendation on the use of therapeutic plasma exchange for adult neurological diseases in Southeast Asia from the Southeast Asia therapeutic plasma exchange consortium. J Cent Nerv Syst Dis 2022; 13:11795735211057314. [PMID: 35173510 PMCID: PMC8842418 DOI: 10.1177/11795735211057314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/12/2021] [Indexed: 11/30/2022] Open
Abstract
Therapeutic plasma exchange (TPE) is an effective and affordable treatment option in most parts of Southeast Asia (SEA). In 2018, the SEA TPE Consortium (SEATPEC) was established, consisting of regional neurologists working to improve outcome of various autoimmune neurological diseases. We proposed an immunotherapeutic guideline prioritizing TPE for this region. We reviewed disease burden, evidence-based treatment options, and major guidelines for common autoimmune neurological disorders seen in SEA. A modified treatment algorithm based on consensus agreement by key-opinion leaders was proposed. Autoimmune antibody diagnostic testing through collaboration with accredited laboratories was established. Choice of first-line immunotherapies (IVIg/corticosteroid/TPE) is based on available evidence, clinicians’ experience, contraindications, local availability, and affordability. TPE could be chosen as first-line therapy for GBS, CIDP, MG (acute/short term), IgG, A paraproteinemic neuropathy, and NMDAR encephalitis. Treatment is stopped for acute monophasic conditions such as GBS and ADEM following satisfactory outcome. For chronic immune disorders, a therapy taper or long-term maintenance therapy is recommended depending on the defined clinical state. TPE as second-line treatment is indicated for IVIg or corticosteroids refractory cases of ADEM, NMOSD (acute), MG, and NMDAR/LGI1/CASPR2/Hashimoto’s encephalitis. With better diagnosis, treatment initiation with TPE is a sustainable and effective immunotherapy for autoimmune neurological diseases in SEA.
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Affiliation(s)
- Fu Liong Hiew
- Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
- Dr Fu Liong Hiew, Physician and Neurologist, Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia Jalan Pahang, Wilayah Persekutuan Kuala Lumpur 50586, Malaysia.
| | - Win Min Thit
- University of Medicine 1, Yangon, Myanmar
- Yangon General Hospital/University of Medicine 1, Yangon, Myanmar
| | - Mathew Alexander
- Brunei Neuroscience Stroke and Rehabilitation Centre, Pantai Jerudong Specialist Centre, Brunei Darussalam
| | | | - Sasitorn Siritho
- Division of Neurology, Faculty of Medicine, Siriraj Hospital, Bumrungrad International Hospital, Bangkok, Thailand
| | - Kevin Tan
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | | | - Ohnmar Ohnmar
- University of Medicine 1, Yangon, Myanmar
- Yangon General Hospital/University of Medicine 1, Yangon, Myanmar
| | - Riwanti Estiasari
- Department of Neurology, Cipto Mangunkusumo Hospital/Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | | | | | | | | | - MD Badrul Islam
- Laboratory Sciences and Services Division (LSSD), The International Centre for Diarrhoeal Disease, Dhaka, Bangladesh
| | - Sing Keat Wong
- Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Shirley Lee
- Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
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Rolfes L, Pfeuffer S, Ruck T, Melzer N, Pawlitzki M, Heming M, Brand M, Wiendl H, Meuth SG. Therapeutic Apheresis in Acute Relapsing Multiple Sclerosis: Current Evidence and Unmet Needs-A Systematic Review. J Clin Med 2019; 8:jcm8101623. [PMID: 31590282 PMCID: PMC6832170 DOI: 10.3390/jcm8101623] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 12/13/2022] Open
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.
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Affiliation(s)
- Leoni Rolfes
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Steffen Pfeuffer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Michael Heming
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Marcus Brand
- Department of Internal Medicine D, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
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Ohkubo A, Okado T, Miyamoto S, Goto K, Yamamoto M, Maeda T, Itagaki A, Seshima H, Kurashima N, Sohara E, Uchida S, Rai T. Removal Characteristics of Immunoadsorption With the Immusorba TR-350 Column Using Conventional and Selective Plasma Separators. Ther Apher Dial 2016; 20:360-7. [DOI: 10.1111/1744-9987.12467] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Atsushi Ohkubo
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Tomokazu Okado
- Department of Nephrology; Tokyo Medical and Dental University; Tokyo Japan
| | - Satoko Miyamoto
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Keigo Goto
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Motoki Yamamoto
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Takuma Maeda
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Ayako Itagaki
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Hiroshi Seshima
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Naoki Kurashima
- Medical Engineering Center; Medical Hospital of Tokyo Medical and Dental University; Tokyo Japan
| | - Eisei Sohara
- Department of Nephrology; Tokyo Medical and Dental University; Tokyo Japan
| | - Shinichi Uchida
- Department of Nephrology; Tokyo Medical and Dental University; Tokyo Japan
| | - Tatemitsu Rai
- Department of Nephrology; Tokyo Medical and Dental University; Tokyo Japan
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Schröder A, Linker RA, Gold R. Plasmapheresis for neurological disorders. Expert Rev Neurother 2014; 9:1331-9. [DOI: 10.1586/ern.09.81] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Trebst C, Bronzlik P, Kielstein JT, Schmidt BMW, Stangel M. Immunoadsorption therapy for steroid-unresponsive relapses in patients with multiple sclerosis. Blood Purif 2011; 33:1-6. [PMID: 22086365 DOI: 10.1159/000332397] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 08/29/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) in steroid-unresponsive relapses of patients with multiple sclerosis (MS) is an established therapy with response rates of up to 70%. Immunoadsorption (IA) specifically removes immunoglobulins from the patient's plasma. It is hypothesized that IA therapy might be better tolerated than and as effective as TPE in the treatment of MS relapses. Experiences with IA therapy of steroid-unresponsive MS relapses are limited. METHODS We report our experiences with IA therapy in a series of 10 patients with steroid-unresponsive MS relapses. RESULTS A marked to moderate clinical response with clear gain of function was observed in 66% of our patients. IA therapy was well tolerated. CONCLUSIONS IA therapy is an effective and well-tolerated therapeutic option for steroid-unresponsive MS relapses.
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Affiliation(s)
- Corinna Trebst
- Department of Neurology, Hannover Medical School, Hannover, Germany. trebst.corinna @ mh-hannover.de
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Carter CJ. Epstein-Barr and other viral mimicry of autoantigens, myelin and vitamin D-related proteins and of EIF2B, the cause of vanishing white matter disease: massive mimicry of multiple sclerosis relevant proteins by the Synechococcus phage. Immunopharmacol Immunotoxicol 2011; 34:21-35. [PMID: 21486137 DOI: 10.3109/08923973.2011.572262] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The Epstein-Barr virus expresses proteins containing numerous short consensi (identical pentapeptides at least, or longer gapped consensi) that are identical to those in 16 multiple sclerosis autoantigens or in the products of multiple sclerosis susceptibility genes. Other viruses implicated in multiple sclerosis also display such mimicry and the Synechococcus phage was identified as a novel and major contributor to this phenomenon. Cyanobacteria hosts of Synechococcus phage favor temperate climes, in line with multiple sclerosis distribution, and bacterial and phage ecology accords closely with multiple sclerosis epidemiology. Bovine, ovine or canine viral proteins were also identified as autoantigen homologues, in line with epidemiological data linking multiple sclerosis to cattle density, sheep contact and dog ownership. Viral proteins align with known autoantigens, other myelin and vitamin D-related proteins and the translation initiation factor EIF2B, which is implicated in vanishing white matter disease. These data suggest that the autoantigens in multiple sclerosis, which causes demyelination in animal models, may be generated by antibodies raised to viral protein homologues. Multiple autoantibodies may cause multiple sclerosis via protein knockdown and immune activation. Their selective removal may be of clinical benefit as already suggested by promising results using plasmapheresis or immunoadsorption in certain multiple sclerosis patients.
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Affiliation(s)
- C J Carter
- PolygenicPathways, Saint Leonards-on-sea, East Sussex, UK.
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Moldenhauer A, Haas J, Wäscher C, Derfuss T, Hoffmann KT, Kiesewetter H, Salama A. Immunoadsorption patients with multiple sclerosis: an open-label pilot study. Eur J Clin Invest 2005; 35:523-30. [PMID: 16101673 DOI: 10.1111/j.1365-2362.2005.01518.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Immunoadsorption (IA) is occasionally applied in patients with acute relapses of multiple sclerosis (MS). This pilot study was undertaken to determine whether IA might help in secondary progressive and relapsing-remitting multiple sclerosis. DESIGN IA was performed at 1-week intervals in 12 patients with secondary progressive or relapsing-remitting MS. These patients had an extended disability status scale (EDSS) score of 4.5-7 and an EDSS increase of 0.5 within 6 months before inclusion in the study despite conventional drug therapy. The change in the EDSS and that in the MS functional composite (MSFC) score, which consisted of quantitative tests of arm function, ambulation, visual acuity and cognition, served as the primary outcome variables, which were measured at baseline and at 3, 6 and 12 months. Changes in quality of life and cerebral lesions by magnetic resonance imaging (MRI) were also assessed at baseline and after the last immunoadsorption (month 3). RESULTS A significant reduction of the median EDSS change was observed after the treatment period, which reversed 3 months after the immunoadsorptions had been stopped. Ten of 12 patients remained stable during the first year of follow-up with no significant changes of the MSFC scores. No significant changes in magnetic resonance imaging T2-hyperintense brain lesions or in the number of gadolinium-positive lesions and in the patients' quality of life were observed. Western blot analyses demonstrated a reduction of serum myelin-specific antibodies, which were collected in the adsorber eluates. CONCLUSIONS Removal of immunoglobulins, including myelin-specific antibodies by immunoadsorption, seems to delay disease progression as defined by EDSS, MSFC and MRI, while the patients' quality of life did not deteriorate.
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Abstract
Given our current knowledge, there is a need for the early institution of immunomodulatory therapy, especially for patients with poor prognostic factors (motor and cerebellar symptoms, frequent disease exacerbations, and a high level of activity on magnetic resonance imaging ). Patients who progress despite immunomodulatory therapy should be reevaluated in terms of diagnosis, development of neutralizing antibodies, or compliance. If a patient has a partial response to immunomodulatory therapy but his or her disease, as assessed by clinical and MRI criteria, remains very active, every effort should be made to modify disease progression by searching for an immunosuppressive therapy regimen before irreversible and considerable disability has accumulated. For the majority of patients, multiple sclerosis (MS) is a chronic condition. Therefore, until a curative treatment has been developed, the available repertoire of immunosuppressive or immunomodulatory treatments should be assessed with respect to the possibility of long-term use. This is particularly important for new immunosuppressive drugs, such as cladribine or mitoxantrone, or for invasive procedures, such as total lymphoid irradiation or autologous bone marrow transplantation. For the latter treatments, experience with long-term administration is not available or the potential side effects (eg, cardiotoxicity with mitoxantrone) limit the cumulative dose. These considerations may limit long-term administration and thus the general usefulness of some drugs. Even with proven efficacy, we need to define the next step once treatment has to be discontinued. We should also address whether exacerbating disease by discontinuing an effective therapy is a potential hazard. What other therapeutic options remain once the current treatment is discontinued? Answers are not readily available at the moment, but the question should influence our decisions in the selection of traditional, well-studied or new, potentially promising therapies.
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