Plasma Exchange Proven as Safe and Effective Therapy for Elders With NMOSD

Weihe Zhang

In a recently published study of elderly and young patients with neuromyelitis optica spectrum disorder (NMOSD), findings showed that plasma exchange (PLEX) is an effective and safe therapy for all ages of the disease, with improvements in neurological and functional outcomes that were similar between groups. Investigators concluded this approach should be considered an option for elders during attacks when initial therapies fail or during severe relapse.

The analysis featured 26 elderly patients with NMOSD aged at least 60 years old and 50 young patients with the disease who received 1 session of PLEX every other day in a neurology ward, for up to 7 sessions, depending on therapeutic efficacy and tolerance. Led by Weihe Zhang, associate professor, China-Japan Friendship Hospital, the study evaluated the clinical efficacy of PLEX through the Expanded Disability Status Scale (EDSS) and visual outcome scale (VOS) scores at 6 months.

Coming into the study, the number of patients with comorbidities in the elderly group (69.2%) was significantly higher than that of the young group (12%; P <.05). Specifically, 9 (34.6%) and 7 (26.9%) patients in the elderly group had hypertension or atherosclerotic cardiovascular disease, respectively, while neither of these were observed in the young group. Diabetes mellitus (DM), recorded in 5 patients in the elder group and 2 in the young group, was also significantly more frequent among elders (P <.05).

At the 6-month follow-up, functional improvement, defined as any reduction in EDSS or VOS score, was found in 24 of 25 (96.0%) elders, an increase from 22 individuals after 1 month of treatment. While 21 of the elderly population received intravenous methylprednisolone (IVMP) as a first therapy, none of them exhibited significant improvements in either of the scores for function until PLEX was given. The percent reduction in VOS score after PLEX (30.1%) was significantly higher than after IVMP/intravenous immunoglobulin (IVIg) (6.3%) therapies at 6 months, but the VOS scores were similar at 1 month (20.0%; cf, 6.3%; P = .08).

The functional improvments seen at 1 and 6 months after PLEX were, "consistent with another study on NMOSDand supports the long-term benefit of PLEX treatment," the study investigators wrote. “In addition, in this study, after failing to respond to initial IVMP/IVIg, lower EDSS and VOS scores showed that the elderly experienced improvement of neurological functions by 6 months after PLEX regardless of attack type (optic neuritis, transverse myelitis, or symptomatic cerebral syndrome)."

READ MORE: Differences in Diagnosis and Prevention Between NMOSD and MS

Marked-to-moderate improvement (MMI), otherwise considered a complete-to-moderate resolution of attack symptoms and a reduction in EDSS or VOS scores by at least 30%, respectively, was found in 15 of the 25 (60.0%) treated elders. Seven of these patients experienced only 1 attack with transverse myelitis before PLEX and showed MMI. In the 7, 21, and 2 elderly patients who experienced attacks with optic neuritis, transverse myelitis, and symptomatic cerebral syndrome, respectively, 2 (28.6%), 14 (66.7%), and 2 (100%) showed MMI at 6 months after PLEX.

In terms of safety, PLEX was generally well tolerated, as more than one-third (34.6%) of elders experienced 12 adverse events (AEs). Eight (72.7%) of these AEs were minor and transient and spontaneously resolved or could be relieved by withholding the PLEX procedure for several days. About one in every 5 patients (19.2%) in the elderly group suffered from transient hypotension at the first session of PLEX, which was significantly higher than that observed in the young group (4.0%; P <.05).

There were 3 noted serious AEs in the elderly group, one of which was severe sepsis, causing the 60-year-old woman to withdraw from treatment. In the other 2 patients, PLEX sessions were prematurely interrupted due to life-threatening heparin-related thrombocytopenia and deep venous thrombosis. Across age groups in the elderly population, there were no trends for incidence in AEs, and no patients died during the PLEX procedure.

REFERENCE
1. Zhang W, Jiao Y, Cui L, et al. Therapeutic efficacy and safety of plasmapheresis in elderly patients with neuromyelitis optica spectrum disorder: a single-center observational study. Therapeutic Advances in Neurol Disord. 2023;16. doi:10.1177/17562864231162420