Will plasma exchange (plex) remove steroids and should steroids be administered post-procedure?

Plasma Exchange and Steroid Administration

Plasma exchange does not meaningfully remove steroids, and steroids should be administered concurrently with plasma exchange, not after the procedure. 1, 2

Steroid Removal During Plasma Exchange

• Steroids are not significantly removed by plasma exchange because corticosteroids like methylprednisolone and prednisone have high protein binding and tissue distribution, making them relatively resistant to removal during the procedure 1
• The primary concern with plasma exchange is removal of large molecules like immunoglobulins, rituximab, and IVIG—not small molecule drugs like corticosteroids 2
• This is fundamentally different from biologics: rituximab must be given 48-72 hours after plasma exchange because the procedure removes the drug, but this timing concern does not apply to steroids 1, 2

Timing of Steroid Administration with Plasma Exchange

Steroids should be given concurrently with plasma exchange, not sequentially after:

• High-dose pulse corticosteroids (methylprednisolone 1g daily for 3-5 days) should be administered in conjunction with plasma exchange for severe autoimmune conditions, particularly ANCA-associated vasculitis with severe renal involvement or diffuse alveolar hemorrhage 1, 3
• The standard approach is to continue or initiate corticosteroids while performing plasma exchange sessions over 7-14 days 1
• In ANCA vasculitis specifically, the KDIGO 2023 guidelines support plasma exchange for patients with serum creatinine >500 μmol/L requiring dialysis, with concurrent glucocorticoid therapy 1

Clinical Protocol

For severe autoimmune conditions requiring plasma exchange:

• Initiate or continue oral prednisolone 0.5-1 mg/kg/day (maximum 60-80 mg/day) or pulse IV methylprednisolone 500-1000 mg daily for 3-5 days 1
• Perform 5-7 plasma exchange sessions over 10-14 days 1, 2
• Do not delay steroid administration waiting for plasma exchange to complete—both therapies work synergistically 3
• After plasma exchange completion, continue oral steroid taper according to disease-specific protocols 1

Critical Timing Considerations for Other Medications

While steroids can be given concurrently, other medications require specific timing:

• IVIG must be given AFTER plasma exchange is complete, never before, as plasma exchange will remove the immunoglobulin 3, 2, 4
• Rituximab should be administered 48-72 hours after the last plasma exchange session to avoid removal of the drug 1, 2
• Cyclophosphamide infusions should be given immediately after individual plasma exchange sessions 1

Common Pitfalls

• Do not withhold steroids during plasma exchange thinking they will be removed—this delays necessary immunosuppression 1, 3
• Do not give IVIG before or during plasma exchange—this wastes expensive therapy as it will be removed 3, 2
• Plasma exchange can remove clotting factors and cause coagulation defects, requiring monitoring, but this does not affect steroid pharmacokinetics 2
• The combination of plasma exchange with immunosuppressants increases infection risk, requiring prophylactic measures for opportunistic infections 1, 2