1. Plasmapheresis Treatment for Myasthenia Gravis
Richard J. Barohn, MD
Chair, Department of Neurology
Gertrude and Dewey Ziegler Professor of Neurology
University Distinguished Professor
Vice Chancellor for Research
University of Kansas Medical Center
Kansas City, KS

2. Plasmapheresis for MG
Directly removes humoral factors such as autoantibodies, immune complexes, complement and other nonspecific inflammatory mediators
Remove 3-6 liters of plasma over several hours. Replace with albumin or purified protein fraction (PPF).
Indications for MG:
crises
pre-thymectomy
severe MG (not in crises) when initiating or increasing oral immunosuppressive drugs
chronic Rx

3. Early Reports of Plasmapheresis for MG
Dau PC, Lindstrom JM, Cassel CK, Denys EH, Shev EE, Spitler LE: Plasmapheresis and immunosuppressive drug therapy in myasthenia gravis. N Engl J Med 297:1134, 1977
5 pts
Newsom-Davis J, Pinching AJ, Vincent A, Wilson SG: Function of circulating antibody to acetylcholine receptor in myasthenia gravis: Investigation by plasma exchange. Neurology 28(3): , 1978
8 pts
Newsom-Davis J, Wilson SG, Vincent A et al: Long term effects of repeated plasma exchange in myasthenia gravis. Lancet 1:464, 1979
13 pts
Olarte MR, Schoenfeldt RS, Penn AS et al: Effect of plasmapheresis in myasthenia gravis, Ann NY Acad Sci 377:725, 1981
21 pts
Keesey J, Buffkin D, Kebo D, et al: Plasma exchange alone as therapy for myasthenia gravis. Ann NY Acad Sci 377:729, 1981
3 pts

4. MG: Plasma Exchange First successful reports in late 1970’s
Antibody levels fall but response does not correlate with starting titers
Improvement occurs in days
Improvement may be seen even if serum antibody is absent
All small case series
No randomized trial done against placebo or no PE

5. Plasmaphresis vs. IVIG For MG
Gajdos et al, Ann Neurol 1997
87 pts with MG exacerbation
Randomized: 3 PT vs. 3 or 5 IVIG 0.4 gm/kg
Endpoint – Myasthenic muscular score day 15
Results – Equal improvements with both Rx:
PE + 18 pts
IVIG points
p = 0.65
Fewer side effects with IVIG (1) vs. PE (8)

6. Comparison of IVIg & Plex in MG Barth, et al Neurology 2011;76
84 pts to IVIg 1g/kg/d x 2 days
Or PE x 5
QMG > 10.5 and “worsening”
Improved: 69% IVIg and 65% PE
Conc: IVIg & PE both effective Rx

7. Pheresis for MG: Recommendation: Level U (Unknown)
Neurology 2011;76:

8. Plasmapheresis Rx for MG
HOW MUCH?
4-6 Exchanges of 3-5 Liters of Plasma
Can be Daily or QOD
However, No Exact Science For # Exchanges or Amount Removed in MG
Often Depends on How Pt Tolerates PE and How Much Can Be Removed

9. Plasmapheresis Rx for MG
LIMITATIONS
Trained technician
Equipment
IV Access - Often Requires Large Double-Lumen Catheter
Complications: Pneumothorax, Hypotension, Sepsis, Pulmonary Embolism
Expensive
Benefit Lasts Several Weeks

10. Plasmapheresis: The Problem of Access
Periph IV hard to access
Chron IJ line – 1 mo to 12 mo infection
Ports
We tried Vortex Dx
Can’t take pressure
AV fistulas
Clot
Cosmetic

11. A-V Fistulas for Pheresis