Evidence-based guideline update: Plasmapheresis in neurologic disorders

Abstract

# {#article-title-2} To the Editor: I have dedicated my professional career to caring for patients with chronic and debilitating neurologic diseases and have come to appreciate and respect the meaning of the Hippocratic Oath statement “First do no harm.” The American Academy of Neurology (AAN) guideline update on plasmapheresis in neurologic disorders1 is inaccurate and may cause harm to patients. I have successfully treated more than 100 patients with myasthenia gravis (MG) with therapeutic plasma exchange (TPE) not only for myasthenic crises but also on an ongoing basis (maintenance plasmapheresis) to prevent further worsening. This has allowed me to drastically reduce the use of long-term immunosuppressive drugs in such patients. Insurance companies will now cite these guidelines to deny TPE for such patients. Just as it is unnecessary to conduct a double-blind, placebo-controlled study to justify ongoing insulin therapy for diabetic patients, there should be no need to do such a study in MG. The pathogenesis of MG2 itself lends support to the use of long-term TPE, which unequivocally removes pathogenic circulating antibodies. With reference to secondary or chronic progressive multiple sclerosis (MS), the authors' interpretation of our trial study is erroneous.3 This study, heralded by Dr. George Ellison4 as “an exemplary study for others to match or exceed,” showed a significant ( p < 0.007) improvement in disability in the TPE group over the placebo group. A long-term follow-up study5 in 200 chronic progressive patients confirmed the earlier report and further identified the clinical characteristics of those who should respond to TPE. In light of this report, it would be impossible to provide TPE to patients with secondary progressive MS, in whom there are data to show efficacy when conventional therapies have failed. As the organization that represents those who care for patients with chronic and debilitating …