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. 2016 Feb;22(2):185-92.
doi: 10.1177/1352458515581438. Epub 2015 Apr 28.

Treatment of acute relapses in neuromyelitis optica: Steroids alone versus steroids plus plasma exchange

Hesham Abboud  1 , Alex Petrak  2 , Maureen Mealy  3 , Sarana Sasidharan  3 , Laila Siddique  3 , Michael Levy  3
Affiliations

Treatment of acute relapses in neuromyelitis optica: Steroids alone versus steroids plus plasma exchange

Hesham Abboud et al. Mult Scler. 2016 Feb.

Abstract

Background: Although adding plasma exchange (PLEX) to steroids in severe neuromyelitis optica (NMO) attacks is common practice in steroid-resistant cases, the benefit of this strategy has not been previously quantified.

Objective: The objective of this paper is to compare the efficacy of high-dose intravenous methylprednisolone (IVMP) versus IVMP+PLEX in treatment of acute NMO relapses.

Methods: We conducted a retrospective review of the last 83 NMO admissions to the Johns Hopkins Hospital treated with IVMP alone versus IVMP+PLEX (for steroid-resistant cases). Extended Disability Status Scale (EDSS) score was calculated at baseline, at presentation, at discharge, and on follow-up.

Results: Eighteen NMO relapses (16 patients, 87% female, mean age at relapse: 33.9±23.8, median baseline EDSS 2.5) were treated with IVMP alone and 65 relapses (43 patients, 95% female, mean age at relapse: 43.8±15.7, median baseline EDSS 5.75) were treated with IVMP + PLEX. Sixty-five percent of IVMP + PLEX patients achieved an EDSS equal or below their baseline at follow-up while only 35% of the IVMP-only patients achieved their baseline EDSS on follow-up (odds ratio=3.36, 95% CI 1.0657 to 10.6004, p = 0.0386). PLEX was more effective in improving EDSS in patients on preventive immunosuppressive medications at time of relapse.

Conclusions: PLEX+IVMP are more likely to improve EDSS after NMO relapses compared to IVMP alone, especially in patients taking preventive medications.

Keywords: EDSS; Neuromyelitis optica; acute relapse; plasma exchange; preventive medications; steroids.

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Conflict of interest statement

Conflicts of interest

Hesham Abboud has received an educational grant from Teva Pharmaceuticals unrelated to this study. Dr Levy receives research support from the National Institutes of Health (NIH), Guthy Jackson Charitable Foundation, Viropharma, Acorda, Sanofi, NeuralStem and Genentech, and serves as a consultant for Chugai Pharmaceuticals, GlaxoSmithKline and MedImmune. The other authors have nothing to declare.

Figures

Figure 1
Figure 1
Median EDSS changes in the IVMP-only group: Baseline EDSS of 2.5 rose to 4.5 on presentation and declined to 4 on discharge and remained at 4 at follow-up. EDSS: Expanded Disability Status Scale; IVMP: intravenous methylprednisolone.
Figure 2
Figure 2
Median EDSS changes in the IVMP + PLEX group: Baseline EDSS of 5.75 rose to 7.75 on presentation and declined to 6.5 on discharge and remained at 6.5 at follow-up. EDSS: Expanded Disability Status Scale; IVMP: intravenous methylprednisolone; PLEX: plasma exchange.
Figure 3
Figure 3
Effect of IVMP + PLEX or IVMP + PLEX plus preventive medications on EDSS after relapse compared to presenting EDSS at the time of relapse. The y-axis represents the difference between presenting EDSS and follow-up EDSS within one year. A value higher than zero indicates improvement of follow-up EDSS compared to presenting EDSS. A value of 0 or lower indicates no improvement or worsening EDSS score on follow-up compared to presenting EDSS. EDSS: Expanded Disability Status Scale; IVMP: intravenous methylprednisolone; PLEX: plasma exchange.
Figure 4
Figure 4
Effect of IVMP+PLEX or IVMP + PLEX plus preventive medications on EDSS after relapse compared to baseline. The y-axis represents the difference between baseline EDSS (before relapse) and follow-up EDSS within one year of relapse. A value of 0 or higher indicates improvement of EDSS to baseline or better. A value below 0 indicates worse EDSS score on follow-up compared to baseline. EDSS: Expanded Disability Status Scale; IVMP: intravenous methylprednisolone; PLEX: plasma exchange.
Figure 5
Figure 5
Effect of individual preventive immunosuppressive medications with IVMP + PLEX on EDSS after relapse compared to baseline. The y-axis represents the difference between baseline EDSS (before relapse) and follow-up EDSS within one year of relapse. A value of 0 or higher indicates improvement of EDSS to baseline or better. A value below 0 indicates worse EDSS score on follow-up compared to baseline. EDSS: Expanded Disability Status Scale; IVMP: intravenous methylprednisolone; PLEX: plasma exchange.
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