Answers to the Questions asked by the Participants during Asia Pacific Clinical Expert Meeting on Therapeutic Plasma Exchange in the Management of Refractory Central and Peripheral Nervous System Diseases on 23rd Sep'20

Disclaimer: The content provides general information for educational purposes only and is based on the physician’s individual clinical experience. Please refer to relevant clinical guidelines to make informed treatment decisions on a particular disease state.
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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)