What is the role of plasmapheresis in the treatment of myasthenia gravis (MG)?

Updated: Aug 27, 2018
  • Author: Abbas Jowkar, MD; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE  more...
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Answer

Plasmapheresis (plasma exchange) is believed to act by removing circulating humoral factors (ie, anti-AChR antibodies and immune complexes) from the circulation. It is used as an adjunct to other immunomodulatory therapies and as a tool for crisis management. Like IVIg, plasmapheresis is generally reserved for myasthenic crisis and refractory cases. Improvement is noted in a couple of days, but it does not last for more than 2 months.

Plasmapheresis is an effective therapy for MG and is often the initial treatment of choice in myasthenic crisis. Also, it is used to optimize control in preparation for surgery. Improvement in strength may help to achieve rapid postoperative recovery and to shorten the period of assisted ventilation. Long-term regular plasmapheresis on a weekly or monthly basis can be used if other treatments cannot control the disease.

Complications are primarily limited to complications of intravenous (IV) access (eg, central line placement) but also may include hypotension and coagulation disorders (though less commonly). Patients will need careful monitoring of fibrinogen and may need FFB if fibrinogen levels drop to less than 150 mg/dL prior to the next pheresis. There is a risk of hypocalcemia, central-line-associated bloodstream infection (CLABSI), thrombocytopenia, thromboembolism, and heparin-induced thrombocytopenia.

ACE inhibitors must be stopped 24 hrs before treatment and until treatment is completed.

Plasmapheresis is given as 250 mL/Kg total divided every other day over 5-6 exchanges. The onset of action is 1-7 days with maximal effect in 1-3 weeks.


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