Has plasmapheresis been shown to help some psychiatric problems due to Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal (PANDAS) infections?

From the Guidelines

Plasmapheresis is not recommended as a treatment for psychiatric problems associated with PANDAS due to the lack of strong evidence supporting its efficacy and the potential risks associated with the procedure. The concept of PANDAS is still considered a hypothesis and not a proven causal relationship between streptococcal infections and neuropsychiatric disorders 1. While some studies suggest that plasmapheresis may be beneficial in removing harmful antibodies that trigger neuropsychiatric symptoms, the current state of knowledge does not support its routine use as a treatment for PANDAS. The American Heart Association recommends against the use of immunoregulatory therapy, including plasmapheresis, for the treatment of PANDAS due to the lack of evidence and potential risks 1.

Instead, treatment for psychiatric problems associated with PANDAS typically involves the use of psychotropic medications, such as selective serotonin reuptake inhibitors (SSRIs) for obsessive-compulsive disorder and anxiety, and other medications for attention-deficit/hyperactivity disorder (ADHD) and tic disorders 1. The use of these medications is supported by a stronger evidence base and is generally considered safer and more effective than plasmapheresis.

Key considerations in the treatment of PANDAS include:

• The use of psychotropic medications as a first-line treatment for psychiatric symptoms
• The potential benefits and risks of plasmapheresis and other immunoregulatory therapies
• The need for further research to establish a causal relationship between streptococcal infections and neuropsychiatric disorders
• The importance of a comprehensive treatment approach that addresses the physical and emotional needs of patients with PANDAS.

In clinical practice, the decision to use plasmapheresis or other treatments for PANDAS should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances, and in consultation with a qualified healthcare professional. However, based on the current evidence, plasmapheresis is not a recommended treatment for psychiatric problems associated with PANDAS.

From the Research

Plasmapheresis in PANDAS

• Plasmapheresis has been shown to provide lasting improvement in a 27-year-old adult male with PANDAS, in combination with rituximab and ceftriaxone 2.
• A systematic review of treatment options for PANDAS found that plasmapheresis is one of the immunomodulatory interventions that have been introduced as alternative treatments, although the literature on its use is diverse and clinical consensus is lacking 3.
• Another systematic review of treatment options for PANDAS found that there is a paucity of high-level studies regarding this rare disorder, and no hard treatment recommendations can be made, including for plasmapheresis 4.
• The American Academy of Neurology has stated that there is insufficient evidence to support or refute the use of plasmapheresis for PANDAS, based on Class III evidence 5.

Psychiatric Problems in PANDAS

• PANDAS is characterized by a sudden onset of neuropsychiatric disorders, including obsessive-compulsive disorder (OCD) or tic-like symptoms, following a group-A streptococcal infection 2.
• A retrospective study of patients with PANDAS/PANS found that neurological and psychiatric symptoms were present in over 70% of the population, with no significant difference between the two groups 6.
• The study also found that psychotherapy significantly resulted in the most efficacious relief of OCD, reducing stress in patients and their parents 6.