It should be done at least 24 hours apart to make sure that the IgGs equlibrate between plasma and CNS tissues. (Answering Faculty: Dr Metha Apiwattanakul)

Aggressive clinical course or failure from first or second line drugs. (Answering Faculty: Dr Metha Apiwattanakul)

It depends on the severity of attack and the baseline neurological deficits. Need to be adjust case by case. If the patient has severe relapse, I would prefer PLEX + high dose steroid at the same time. (Answering Faculty: Dr Metha Apiwattanakul)

If they are worsening, it may be that the inflammatory process is on going. It is worth to try. (Answering Faculty: Dr Metha Apiwattanakul)

The repeat PLEX may consider around 2-4 weeks after the first PLEX. There is no RCT yet, but may use the model of treatment fluctuation in GBS. (Answering Faculty: Dr Metha Apiwattanakul)

Yes, the effectiveness of PLEX is independent of serostatus. We should not wait the antibody result as the decision point to do PLEX or not. Reference; [1] M. Bonnan, R. Valentino, S. Debeugny, H. Merle, J.L. Ferge, H. Mehdaoui, P. Cabre, Short delay to initiate plasma exchange is the strongest predictor of outcome in severe attacks of NMO spectrum disorders, Journal of neurology, neurosurgery, and psychiatry 89(4) (2018) 346-351. [2] S. Aungsumart, M. Apiwattanakul, 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 (2017) 93-97. (Answering Faculty: Dr Metha Apiwattanakul)

The study from Wisconsin: Induction PLEX 3 times per week x 2 weeks, then 2 times per week x 2 weeks, then once a week for 3-5 weeks, then maintenance with gradual decline once in every 3-12 weeks. Reference; B.O. Khatri, J. Kramer, M. Dukic, M. Palencia, W. Verre, Maintenance plasma exchange therapy for steroid-refractory neuromyelitis optica, J Clin Apher 27(4) (2012) 183-92. (Answering Faculty: Dr Metha Apiwattanakul)

Yes, especially VA worse than 20/200. (Answering Faculty: Dr Metha Apiwattanakul)

I would prefer to have patient hydrated either orally or IV fluid, and slow the inlet flow to 50-55 ml/mins. (Answering Faculty: Dr Metha Apiwattanakul)

No specific time frame, may be use the AQP4 model; Less than 3-4 weeks. (Answering Faculty: Dr Metha Apiwattanakul)

I would rely on the physical examination rather than the MRI. If the VA is worse than 20/200 after the high dose steroid, I will go further with PLEX (You may consider do PLEX + steroid in case of severe attach such as no light perception). (Answering Faculty: Dr Metha Apiwattanakul)

After high dose steroid, I will gradual tapering steroid from high dose to maintenance dose and add on Azathioprine at the same time. (Answering Faculty: Dr Metha Apiwattanakul)

Not yet. (Answering Faculty: Dr Metha Apiwattanakul)

Usually not, but there is some case report that there may be some benefit though. (Answering Faculty: Dr Metha Apiwattanakul)

Myasthenia Muscular Score (Answering Faculty: Dr Vinay Goyal)

I prefer IVIG over PLEX in severe sepsis and multiorgan faliure. Reference; Sanders et al, 2016 (Answering Faculty: Dr Vinay Goyal)

I observe if the patient can swallow in the morning without taking pyridostigmine, then I’m sure the patient is improving, and Plasma Exchange is working. (Answering Faculty: Dr Vinay Goyal)

I have no experience in giving maintenance therapy to MG patients. Padmanabhan et al., 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, recommends Plasma Exchange in long term treatment of MG. (Answering Faculty: Dr Vinay Goyal)

Yes. Half life of IVIG is approx. 21 days and is plasma bound. Admistration of plama exchange before 21 days will wash out IVIG. (Answering Faculty: Dr Vinay Goyal)

The information given is limited. I would prefer giving IVIG to curtail this period. (Answering Faculty: Dr Vinay Goyal)

NO. I stop anticholinestrase only when patient is on ventilator. (Answering Faculty: Dr Vinay Goyal)

Based on my experience for myasthenia crisis, plasma exchange is an critical therapeutic modality and should be used as and when possible. (Answering Faculty: Dr Vinay Goyal)

Approx. 21 days. (Answering Faculty: Dr Vinay Goyal)

In our center we don't check IgA in all the patients. (Answering Faculty: Dr Vinay Goyal)

Based on my experience, in severe Myasthenia Crisis, approximately 20-40% need more than five plasma exchanges. (Answering Faculty: Dr Vinay Goyal)

It is not an absolute contrindication. This could be due to mulitple factors: Labile blood pressure due to compromised haemodynamics and requirement of inotropic support, potential catheter related infection, removal of antibitics and other essential drugs in the plasma. Ref: Rimmer E, Houston BL, Kumar A, Abou-Setta AM, Friesen C, Marshall JC, Rock G, Turgeon AF, Cook DJ, Houston DS, Zarychanski R. The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis. Crit Care. 2014 Dec 20;18(6):699. doi: 10.1186/s13054-014-0699-2. PMID: 25527094; PMCID: PMC4318234. (Answering Faculty: Dr Fu Liong Hiew)

I have no experiece in this. (Answering Faculty: Dr Fu Liong Hiew)

Risk is low. I have not come across with this complication myself due to TPE. In fact, some patients receiving TPE had thromboembolism due to other compounding factors e.g immobilisation and underlying malignancy. Ref: Mokrzycki MH, Balogun RA. Therapeutic apheresis: a review of complications and recommendations for prevention and management. J Clin Apher 2011;26(5):243-8. doi: 10.1002/jca.20303. Epub 2011 Sep 5. (Answering Faculty: Dr Fu Liong Hiew)

We performed PLEX only after the patient tested negative for SARS-CoV-2 on two separate throat swabs. (Answering Faculty: Dr Ashwin Pinto)

Not necessarily - vaccination is likely to lead to a different immune response to that generated by infection. (Answering Faculty: Dr Ashwin Pinto)

We gave IV methylprednisolone first line and then added PLEX as the patient had not had a good repsonse to IVMP. (Answering Faculty: Dr Ashwin Pinto)

This will depend on the clinical state of the patient and the indication for PLEX. (Answering Faculty: Dr Ashwin Pinto)

Probably by removal of humoral factors although whether anti-MOG antibodies are pathogenic is unclear. (Answering Faculty: Dr Ashwin Pinto)

Yes - no evidence of restricted diffusion on DWI. (Answering Faculty: Dr Ashwin Pinto)

I plan to treat with oral prednsiolone for six months then re-test antibody status. (Answering Faculty: Dr Ashwin Pinto)

We gave PLEX daily for this patient. (Answering Faculty: Dr Ashwin Pinto)

I plan to treat with oral prednsiolone for six months then re-test antibody status. (Answering Faculty: Dr Ashwin Pinto)

The clinical presentation is not typical of anti-GFAP - no fever, only mild CSF changes and no myelitis. Difficult to ignore the anti-MOG antibodies but I agree the antibody may be a marker of autoimmunity rather than directly pathogenic. (Answering Faculty: Dr Ashwin Pinto)

We use PLEX in MG for patients on maximal medical therapy with steroids and a steroid sparing agent who have on-going symptoms. (Answering Faculty: Dr Ashwin Pinto)