A pilot study comparing treatments for severe attacks of neuromyelitis optica spectrum disorders: Intravenous methylprednisolone (IVMP) with add-on plasma exchange (PLEX) versus simultaneous ivmp and PLEX.

BACKGROUND: Our previous retrospective study demonstrated that NMOSD patients with an acute attack who did not respond to IVMP alone, however, showed further significant improvement after treatment with PLEX at 6 month-follow-up. OBJECTIVE: To compare the efficacy between treatments with intravenous methylprednisolone (IVMP) with subsequent add-on plasma exchange (PLEX) and a combination of simultaneous IVMP and PLEX in neuromyelitis optica spectrum disorders (NMOSD) patients with a severe acute attack. METHOD: We conducted a prospective, randomized, controlled, pilot study of the treatments for a severe acute attack in NMOSD patients. RESULTS: There were eleven AQP4-positive NMOSD patients in the study. One received only IVMP, five received IVMP with subsequent add-on PLEX treatment, and the other five received simultaneous IVMP and PLEX treatment. The attacks comprised myelitis (57.1%) and optic neuritis (42.9%). Both treatments with IVMP followed by subsequent add-on PLEX when needed (not-respond to IVMP treatment) and a combination treatment of simultaneous IVMP+PLEX from the outset showed clinical improvement measured by EDSS at 6 months follow-up, compared to those at the attacks (p-value = 0.07 in IVMP add-on PLEX group and p-value = 0.05 in IVMP+PLEX group), respectively. Although, a trend of a better outcome stratified by EDSS toward early PLEX initiation with IVMP+PLEX treatment was observed at 6 months follow-up, however not significantly. CONCLUSION: Early treatment with PLEX should be encouraged especially in NMOSD with a severe acute attack.

Beneficial effect of plasma exchange in acute attack of neuromyelitis optica spectrum disorders.

BACKGROUND: Plasma exchange (PLEX) is routinely performed in neuromyelitis optica spectrum disorders (NMOSD) patients with an acute attack who do not respond to corticosteroids treatment. OBJECTIVE: To compare treatment outcomes in NMOSD patients with an acute attack between the two groups. METHODS: We retrospectively studied 67 attacks from 52 NMOSD patients. Outcome measurements using Expanded Disability Status Scale (EDSS), modified Rankin Scale (mRS) were compared. RESULTS: There were 23 IVMP responders, 16 IVMP non-responders refusing PLEX, 12 IVMP non-responders/PLEX responders, and 16 IVMP/PLEX non-responders. The IVMP-responders showed faster improvement since the time of discharge but seemed to have less treatment benefit over time. However, IVMP non-responders/PLEX responders showed continuous and maximum improvement at 6 months (ΔEDSS from nadir: 1 for IVMP-responders vs 0.5 for IVMP non-responders without PLEX vs 2.75 IVMP non-responders/PLEX-responders vs 0.5 IVMP/PLEX non-responders; p = 0.49) and had comparable outcomes to the IVMP-responders (nadir EDSS 8.0 to 5.25 [ΔEDSS = 2.75] vs nadir EDSS 6.5 to 5.0; [ΔEDSS = 1.5], respectively). CONCLUSION: Add - on PLEX treatment in NMOSD patients with an acute attack should be considered in those not responding to IVMP alone.