Abstract
Multiple sclerosis (MS) is the most abundant inflammatory demyelinating disorder of the central nervous system. Despite recent advances in its long-term immunomodulatory treatment, MS patients still suffer from relapses, significantly contributing to disability accrual. In recent years, apheresis procedures such as therapeutic plasma exchange (TPE) and immunoadsorption (IA) have been recognized as two options for treating MS relapses, that do not respond to standard treatment with corticosteroids. TPE is already incorporated in most international guidelines, although evidence for its use resulted mostly from either case series or small unblinded and/or non-randomized trials. Data on IA are still sparse, but several studies indicate comparable efficacy between both apheresis procedures. This article gives an overview of the published evidence on TPE and IA in the treatment of acute relapses in MS. Further, we outline current evidence regarding individual outcome predictors, describe technical details of apheresis procedures, and discuss apheresis treatment in children and during pregnancy.
Highlights
In multiple sclerosis (MS), the complex interplay between environmental factors and susceptibility genes leads to the development of inflammatory brain lesions defined by oligodendrocyte death and axonal damage, recovery of function and structural repair, post-inflammatory gliosis, and neurodegeneration
The administration of high-dose intravenous methylprednisolone (IVMPS; up to 1000 mg daily) over a period of three to five days usually represents the first step in acute Multiple sclerosis (MS) relapse treatment and has been endorsed by national and international guidelines, ever since a first prospective, randomized trial showed superiority of IVMPS compared to placebo [9,11]
Guidelines have no uniform recommendations on using therapeutic plasma exchange (TPE) or IA in acute steroid-refractory MS relapses. Both procedures are recommended by the German Society of Neurology for escalation treatment of acute relapsing-remitting MS (RRMS) exacerbations not responding to the first IVMPS course [22]
Summary
In multiple sclerosis (MS), the complex interplay between environmental factors and susceptibility genes leads to the development of inflammatory brain lesions defined by oligodendrocyte death and axonal damage, recovery of function and structural repair, post-inflammatory gliosis, and neurodegeneration. Approximately one-quarter of the patient’s clinical improvement is not sufficient after the first course of IVMPS [15] In this context, apart from extending steroid treatment to a higher dose (up to 2000 mg daily for five additional days), apheresis procedures, such as therapeutic plasma exchange (TPE) and immunoadsorption (IA) are considered as an alternative after their proven success in other neurological diseases [16,17,18]. Guidelines have no uniform recommendations on using TPE or IA in acute steroid-refractory MS relapses Both procedures are recommended by the German Society of Neurology for escalation treatment of acute relapsing-remitting MS (RRMS) exacerbations not responding to the first IVMPS course [22]. We here aimed to conduct a review of the published literature that provides a general overview of available evidence using apheresis treatment in inflammatory demyelinating relapses, and in more detail outlines specific treatment-determining aspects
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