From the Guidelines
Plasmapheresis is a recommended treatment for myasthenia gravis, particularly in life-threatening situations, as it can provide rapid improvement by removing pathogenic autoantibodies from circulation. According to the most recent guideline evidence 1, plasmapheresis may be considered for life-threatening symptoms, although it is essential to be aware of potential contraindications such as renal failure, hypercoagulable states, sepsis, and haemodynamic instability. The effects of plasmapheresis are typically short-lived, lasting 2-6 weeks, and therefore should be used in conjunction with longer-acting immunotherapies.
Key Considerations
- Plasmapheresis works by removing acetylcholine receptor antibodies and other pathogenic autoantibodies from circulation, providing temporary relief of symptoms.
- The typical regimen consists of 4-6 exchanges over 1-2 weeks, with each session removing approximately 1-1.5 plasma volumes.
- Patients should be closely monitored for complications including hypotension, electrolyte abnormalities, and coagulation disorders.
- Intravenous immunoglobulin (IVIG) at 2g/kg divided over 2-5 days is an alternative when plasmapheresis is unavailable or contraindicated.
Clinical Context
In clinical practice, plasmapheresis is often used in conjunction with other treatments, such as corticosteroids, azathioprine, mycophenolate mofetil, or rituximab, to manage myasthenia gravis. As noted in an earlier study 1, plasma exchange has been shown to lead to clear clinical benefit in patients with myasthenia gravis, highlighting its effectiveness in removing pathogenic autoantibodies. However, the most recent guideline evidence 1 should be prioritized when making treatment decisions.
From the Research
Plasmapheresis for Myasthenia Gravis
- Plasmapheresis is a treatment option for myasthenia gravis (MG), particularly in acute exacerbations, including myasthenic crisis 2.
- It is similarly effective to intravenous immunoglobulin and immunoadsorption in these situations 2.
- The use of plasmapheresis in MG is typically considered when patients are refractory to other treatments or require chronic rescue measures despite ongoing therapy 3.
- There is no direct comparison of plasmapheresis to other immunosuppressive therapies, such as azathioprine or mycophenolate mofetil, in the provided studies.
- However, azathioprine and mycophenolate mofetil are commonly used immunosuppressants in MG treatment, with studies suggesting they can improve patient outcomes 4, 5.
- Symptomatic treatment with acetylcholine esterase inhibition, such as pyridostigmine, is also a common approach in MG management, although it can have side effects 6.
Treatment Options and Effectiveness
- Azathioprine and mycophenolate mofetil have been compared in a prospective cohort study, with results showing no significant difference in clinical outcomes between the two drugs 4.
- Pyridostigmine is effective in symptomatic treatment of MG, but can have side effects, with 91% of patients reporting side effects 6.
- Plasmapheresis, intravenous immunoglobulin, and immunoadsorption are effective in acute exacerbations of MG, but the choice of treatment may depend on individual patient factors and disease severity 2, 3.
Patient Management and Treatment Decisions
- Treatment decisions in MG should be guided by individual patient needs and response to therapy 3, 4.
- A modified treatment algorithm for MG has been proposed, which considers patients who have disease that fails to respond to stepwise approach to therapy, are treatment intolerant, or require chronic rescue measures despite ongoing therapy as treatment refractory 3.
- Emerging therapies, including monoclonal antibody-based therapies, may be considered for treatment-refractory patients 3.