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Therapeutic plasma exchange vs conventional treatment with intravenous high dose steroid for neuromyelitis optica spectrum disorders (NMOSD): a systematic review and meta-analysis

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Abstract

Background

Therapeutic plasma exchanges (TPE) has been recommended for neuromyelitis optica spectrum disorders (NMOSD) as a rescue therapy after nonresponding from the high-dose steroid and as an early therapy in severe attacks. We performed a systematic review to evaluate whether therapeutic plasma exchange (TPE) is better than conventional intravenous methylprednisolone (IVMP) in neuromyelitis optica spectrum disorders (NMOSD) patients.

Methods

Systematic search was conducted in five databases: PubMed, Embase, Scopus, Web of Science, and CENTRAL for randomized controlled trials and observational studies of TPE compared to intravenous steroid in NMOSD patients with neurological or visual outcomes in English without publication date restriction. Quality assessment was performed using ROB2 and ROBINS-I. The meta-analysis was done using a random-effects model. Pooled risk ratio (RR) or mean difference with a 95% CIs of efficacy outcomes included the Expanded Disability Status Scale (EDSS), visual acuity, and LogMAR were measured.

Results

Of 3439 potential studies, seven were included in the systematic review (1211 attacks; 433 patients) and three studies were included in the meta-analysis. Compared to high dose steroid alone, the add-on TPE increases a chance for the returning of EDSS to baseline at discharge (RR 3.02, 95% CI 1.34–6.81) and last follow-up (RR 1.68, 95% CI 1.01–2.79) as well as improves visual acuity at last follow-up.

Conclusion

TPE as an add-on therapy to high-dose steroid injection during an acute attack in NMOSD patients is associated with returning to baseline EDSS at discharge and last follow-up, and a trend to have a lower disability at 6–12 months.

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Availability of data and material

All data of this work (abstracts, reviewed articles, data entry spreadsheet, and statistical analysis) will be available to qualified investigators on request.

Abbreviations

AQP4:

Aquaporin-4

AQP4-Ab:

Aquaporin-4 autoantibody

ASFA:

American Society of Apheresis

CNS:

Central nervous system

EDSS:

Expanded Disability Status Scale

GEE:

Generalized estimating equation

HD-S:

High dose steroid

IA:

Immunoadsorption

IVMP:

Intravenous methylprednisolone

LETM:

Longitudinally extensive transverse myelitis

LogMAR:

Logarithm of the minimum angle of resolution

MS:

Multiple sclerosis

MY:

Myelitis

NMO:

Neuromyelitis optica

NMOSD:

Neuromyelitis optica spectrum disorders

ON:

Optic neuritis

OR:

Odds ratio

PLEX:

Plasma exchange

ROBINS-I:

Risk of Bias In Non-randomized Studies of Interventions

RR:

Risk ratio

SD:

Standard deviation

TM:

Transverse myelitis

TPE:

Therapeutic plasma exchange

VA:

Visual acuity

References

  1. Fujihara K, Misu T, Nakashima I, Takahashi T, Bradl M, Lassmann H (2012) Neuromyelitis optica should be classified as an astrocytopathic disease rather than a demyelinating disease. Clin Exp Neuroimmunol 3:58–73

    Article  CAS  Google Scholar 

  2. Ratelade J, Asavapanumas N, Ritchie AM, Wemlinger S, Bennett JL, Verkman AS (2013) Involvement of antibody-dependent cell-mediated cytotoxicity in inflammatory demyelaination in a mouse model of neuromyelitis optica. Acta Neuropathol 126:699–709

    Article  Google Scholar 

  3. Sharma R, Fischer M, Bauer J, Felts P, Smith K, Misu T (2010) Inflammation induced by innate immunity in the central nervous system leads to primary astrocyte dysfunction followed by demyelination. Acta Neuropathol 120:223–236

    Article  CAS  Google Scholar 

  4. Fukazawa T, Kikuchi S, Niino M et al (2004) Attack-related severity: a key factor in understanding the spectrum of idiopathic inflammatory demyelinating disorders. J Neurol Sci 225:71–78

    Article  CAS  Google Scholar 

  5. Wingerchuk D, Lennon V, Lucchinetti C, Pittock S, Weinshenker B (2007) The spectrum of neuromyelitis optica. Lancet Neurol 6:805–815

    Article  CAS  Google Scholar 

  6. Kawachi I, Lassmann H (2017) Neurodegeneration in multiple sclerosis and neuromyelitis optica. J Neurol Neurosurg Psychiatry 88:137–145

    Article  Google Scholar 

  7. Weinshenker B, O'Brien PC, Petterson T et al (1999) A randomized trial of plasma exchange in acute central nervous system inflammatory demyelinating disease. Ann Neurol 46:878–886

    Article  CAS  Google Scholar 

  8. Aungsumart S, Apiwattanakul M (2017) Clinical outcomes and predictive factors related to good outcomes in plasma exchange in severe attack of NMOSD and long extensive transverse myelitis: case series and review of the literature. Mult Scler Relat Disord 13:93–97

    Article  Google Scholar 

  9. Bonnan M, Valentino R, Olindo S, Mehdaoui H, Smadja D, Cabre P (2009) Plasma exchange in severe spinal attacks associated with neuromyelitis optica spectrum disorder. Mult Scler 15:487–492

    Article  CAS  Google Scholar 

  10. Kim W, Kim S, Huh S, Kim H (2012) Brain abnormalities in neuromyelitis optica spectrum disorder. Mult Scler Int 2012:735486

    PubMed  PubMed Central  Google Scholar 

  11. Kleiter I, Gahlen A, Borisow N et al (2015) Neuromyelitis optica: evaluation of 871 attacks and 1,153 treatment courses. Ann Neurol 79:206–216

    Article  Google Scholar 

  12. Lim Y, Pyun S, Kang B, Kim J, Kim K (2013) Factors associated with the effectiveness of plasma exchange for the treatment of NMO-IgG-positive neuromyelitis optica spectrum disorders. Mult Scler 19:1216–1218

    Article  Google Scholar 

  13. Merle H, Olindo S, Jeannin S et al (2012) Treatment of optic neuritis by plasma exchange (add-on) in neuromyelitis optica. Arch Ophthalmol 130:858–862

    Article  Google Scholar 

  14. Srisupa-Olan T, Siritho S, Kittisares K, Jitprapaikulsan J, Sathukitchai C, Prayoonwiwat N (2018) Beneficial effect of plasma exchange in acute attack of neuromyelitis optica spectrum disorders. Mult Scler Relat Disord 20:115–121

    Article  Google Scholar 

  15. Watanabe S, Nakashima I, Misu T, Miyazawa I, Shiga Y, Fujihara K (2007) Therapeutic efficacy of plasma exchange in NMO-IgG-positive patients with neuromyelitis optica. Multiple Sclerosis 13:128–132

    Article  CAS  Google Scholar 

  16. Padmanabhan A, Connelly-Smith L, Aqui N et al (2019) Guidelines on the use of therapeutic apheresis in clinical practice - evidence-based approach from the writing committee of the American society for apheresis: the eighth special issue. J Clin Apher 34:171–354

    Article  Google Scholar 

  17. Reeves H, Winters J (2014) The mechanisms of action of plasma exchange. Br J Haematol 164:342–351

    Article  CAS  Google Scholar 

  18. Rahmlow MR, Kantarci O (2013) Fulminant demyelinating diseases. Neurohospitalist 3:81–91

    Article  Google Scholar 

  19. Wingerchuk D, Lennon V, Pittock S, Lucchinetti C, Weinshenker B (2006) Revised diagnostic criteria for neuromyelitis optica. Neurology 66:1485–1489

    Article  CAS  Google Scholar 

  20. Wingerchuk D, Banwell B, Bennett J, Cabre P, Carroll W, Chitnis T (2015) International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology 85:177–189

    Article  Google Scholar 

  21. Sterne J, Savović J, Page M et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:i4898

    Article  Google Scholar 

  22. Sterne J, Hernán M, Reeves B et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomized studies of interventions. BMJ 355:i4919

    Article  Google Scholar 

  23. Kurtzke J (1983) Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Neurology 33:1444–1452

    Article  CAS  Google Scholar 

  24. Abboud H, Petrak A, Mealy M, Sasidharan S, Siddique L, Levy M (2016) Treatment of acute relapses in neuromyelitis optica: steroids alone versus steroids plus plasma exchange. Mult Scler 22:185–192

    Article  CAS  Google Scholar 

  25. Song W, Qu Y, Huang X (2019) Plasma exchange: an effective add-on treatment of optic neuritis in neuromyelitis optica spectrum disorders. Int Ophthalmol 39:2477–2483

    Article  Google Scholar 

  26. Songthammawat T, Srisupa-Olan T, Siritho S, Kittisares K, Jitprapaikulsan J, Sathukitchai C (2019) A pilot study comparing treatments for severe attacks of neuromyelitis optica spectrum disorders: Intravenous methylprednisolone (IVMP) with add-on plasma exchange (PLEX) versus simultaneous IVMP and PLEX. Mult Scler Relat Disord 38:101506

    Article  Google Scholar 

  27. Bonnan M, Cabre P (2012) Plasma exchange in severe attacks of neuromyelitis optica. Mult Scler Int 2012:787630

    PubMed  PubMed Central  Google Scholar 

  28. Schröder A, Linker R, Gold R (2009) Plasmapheresis for neurological disorders. Expert Rev Neurother 9:1331–1339

    Article  Google Scholar 

  29. Barnes PJ, Adcock IM (2009) Glucocorticoid resistance in inflammatory diseases. Lancet 373:1905–1917

    Article  CAS  Google Scholar 

  30. Saadoun S, Waters P, Bell B, Vincent A, Verkman A, Papadopoulos M (2010) Intra-cerebral injection of neuromyelitis optica immunoglobulin G and human complement produces neuromyelitis optica lesions in mice. Brain 133:349–361

    Article  Google Scholar 

  31. Kim S, Kim W, Huh S, Lee K, Jung I, Kim H (2013) Clinical efficacy of plasmapheresis in patients with neuromyelitis optica spectrum disorder and effects on circulating anti-aquaporin-4 antibody levels. J Clin Neurol 9:36–42

    Article  Google Scholar 

  32. Chanson J-B, Alame M, Collongues N et al (2013) Evaluation of clinical interest of anti-aquaporin-4 autoantibody follow up in neuromyelitis optica. Clin Dev Immunol 2013:146219

    Article  Google Scholar 

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Acknowledgements

We are grateful to the staff of Bumrungrad Clinical Research Center for their administrative and technical support.

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None.

Author information

Authors and Affiliations

  1. Neuroscience Center, Bumrungrad International Hospital, Bangkok, Thailand

    Sasitorn Siritho & Krit Pongpirul

  2. Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

    Sasitorn Siritho

  3. Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand

    Tanawin Nopsopon & Krit Pongpirul

  4. Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Krit Pongpirul

Authors
  1. Sasitorn Siritho
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  2. Tanawin Nopsopon
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  3. Krit Pongpirul
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Contributions

All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: SS, TN, KP. Acquisition, analysis, or interpretation of data: SS, TN. Drafting of the manuscript: SS, TN, KP. Critical revision of the manuscript for important intellectual content: SS, KP. Statistical analysis: TN, KP. Administrative, technical, or material support: KP. Supervision: SS, KP.

Corresponding author

Correspondence to Krit Pongpirul.

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Conflicts of interest

S. Siritho serves as a speaker honoraria from Merck Serono, Pacific Healthcare (Thailand), Menarini (Thailand), Biogen Idec, UCB (Thailand), Eisai Inc, Sanofi-Aventis, Terumo BCT and Novartis. No other disclosures were reported. T. Nopsopon reports no disclosures. K. Pongpirul reports no disclosures.

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The manuscript does not contain clinical studies or patient data.

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Siritho, S., Nopsopon, T. & Pongpirul, K. Therapeutic plasma exchange vs conventional treatment with intravenous high dose steroid for neuromyelitis optica spectrum disorders (NMOSD): a systematic review and meta-analysis. J Neurol 268, 4549–4562 (2021). https://doi.org/10.1007/s00415-020-10257-z

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  • DOI: https://doi.org/10.1007/s00415-020-10257-z

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