When is plasma exchange recommended for joint issues in autoimmune diseases like rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE)?

Plasma Exchange in Autoimmune Joint Diseases

Plasma exchange is generally not recommended for joint issues in autoimmune diseases like rheumatoid arthritis or systemic lupus erythematosus, and should be reserved only for specific life-threatening manifestations. 1

Indications for Plasma Exchange in Autoimmune Diseases

Not Recommended for:

• Joint manifestations in RA or SLE: The 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline specifically recommends against using plasma exchange for systemic autoimmune rheumatic disease progression after first-line therapy 1
• Routine management of arthritis: No evidence supports plasma exchange for the management of joint symptoms in autoimmune diseases

Potential Indications (Life-Threatening Conditions Only):

1. Rapidly Progressive Interstitial Lung Disease (RP-ILD):

   • May be considered as salvage therapy in specific circumstances
   • Only recommended as an add-on to monotherapy or dual combination therapy in non-MDA-5 RP-ILD 1
   • Not recommended as first-line therapy

2. Severe SLE Manifestations (not joint-related):

   • Diffuse alveolar hemorrhage (DAH) 2
   • Refractory neuropsychiatric lupus 2, 3
   • Thrombotic thrombocytopenic purpura 3
   • Catastrophic antiphospholipid syndrome 3, 4
   • Hyperviscosity syndrome and cryoglobulinemia 3

Implementation Considerations

Timing and Administration:

• When used for salvage therapy in RP-ILD:
  • Should be added to existing immunosuppressive regimens
  • Important timing consideration: Avoid administering plasma exchange shortly after rituximab or IVIG to prevent removal of these therapies 1

Efficacy and Evidence Quality:

• Evidence supporting plasma exchange is limited to small observational studies 1
• Very low certainty of evidence for all recommendations regarding plasma exchange 1
• One retrospective study showed improvement in 62.12% of patients with severe autoimmune disease manifestations treated with plasma exchange 2

Risks and Complications:

• Main complications include:
  • Hemorrhage 2
  • Catheter-related infections 4
  • Urinary infections 4
  • Hospital-acquired pneumonia 4
• Potential for "rebound" phenomenon after discontinuation, though not consistently observed 5

Treatment Algorithm for Joint Issues in RA/SLE

For joint manifestations in RA or SLE, follow evidence-based approaches:

1. First-line therapies:

   • Conventional DMARDs (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) 1
   • Continue these medications through surgical procedures if needed 1

2. For inadequate response:

   • Biologic DMARDs (TNF inhibitors, rituximab, abatacept)
   • JAK inhibitors (tofacitinib, baricitinib, upadacitinib)

3. For severe refractory disease:

   • Consider rituximab for refractory manifestations, particularly effective for hematologic issues 6
   • Cyclophosphamide for severe disease not responding to other therapies 6
   • IVIG may be considered before plasma exchange 7

Key Takeaway

Plasma exchange should not be used for joint manifestations in autoimmune diseases. It should be reserved only for specific life-threatening conditions when conventional therapies have failed, and even then, only in specialized centers with experience in this procedure.