Multiple sclerosis (MS) is a chronic autoimmune disease affecting the central nervous system, where the immune system mistakenly attacks the myelin sheath that insulates nerve fibers. For most people with MS, disease-modifying therapies and intravenous corticosteroids help manage relapses. But in a subset of patients, a severe relapse does not respond to steroids – and in these cases, plasmapheresis for multiple sclerosis may be considered as a second-line intervention.
Also called therapeutic plasma exchange (TPE), plasmapheresis removes harmful antibodies and inflammatory factors from the blood, potentially allowing the nervous system to begin recovering from an acute, steroid-refractory attack.
What Causes Steroid-Refractory MS Relapses
In MS, activated immune cells breach the blood-brain barrier and trigger inflammatory damage to myelin. In certain patients – particularly those with type II pathological pattern or neuromyelitis optica spectrum disorder (NMOSD) – antibodies directly attack the myelin or astrocytes and contribute heavily to tissue damage.
When high-dose IV methylprednisolone fails to reverse neurological symptoms, clinicians look for additional options. The presence of antibody-mediated pathology may explain why some patients respond to plasma exchange while others do not. Research has shown that patients with specific pathological patterns – particularly those involving antibody and complement deposits – are more likely to respond to plasmapheresis treatment for multiple sclerosis (Keegan et al., Lancet, 200567102-4)).
How Does Plasmapheresis Work for Multiple Sclerosis
Plasmapheresis involves withdrawing blood, separating plasma from blood cells, removing the plasma (which contains antibodies and inflammatory mediators), and returning the cells with replacement fluid such as albumin or fresh frozen plasma. In acute MS relapses, the goal is to rapidly reduce the circulating levels of pathogenic antibodies and immune complexes that may be driving demyelination.
The procedure is typically performed five to seven times over ten to fourteen days. Each session lasts approximately two to three hours. Patients usually remain awake and may experience mild symptoms such as fatigue, tingling, or a temporary drop in blood pressure during the exchange.
It is important to note that plasmapheresis treatment for multiple sclerosis is not a disease-modifying treatment. It is used specifically for the acute phase of a severe relapse and does not slow the long-term course of MS.
What the Evidence Shows
The landmark evidence for plasma exchange in MS comes from a randomized double-blind, sham-controlled trial conducted by Weinshenker and colleagues at the Mayo Clinic. This study found that 42% of patients who received active plasma exchange experienced moderate-to-marked neurological improvement in their steroid-refractory attack, compared with only 6% who received the sham procedure (Weinshenker et al., Ann Neurol., 199946:6%3C878::AID-ANA10%3E3.0.CO;2-Q)).
A later study found that patients with antibody-mediated demyelinating pathology had better responses to plasma exchange than those with other pathological patterns, further supporting the importance of patient selection (Magaña et al., Arch Neurol., 2011).
Based on this body of evidence, the American Academy of Neurology issued a guideline update supporting the use of plasmapheresis for multiple sclerosis and other neurologic disorders with evidence of antibody-mediated pathology (Cortese et al., Neurology, 2011).
Who May Be a Candidate
Not all MS patients require plasmapheresis, and not all benefit. Plasma exchange is generally considered when:
- A severe relapse has produced significant neurological disability
- High-dose IV corticosteroids have not provided adequate improvement after 5–7 days
- The relapse involves loss of vision, motor function, balance, or speech
- There is clinical reason to suspect antibody-mediated pathology
Clinicians also consider plasma exchange in neuromyelitis optica spectrum disorder (NMOSD) and acute disseminated encephalomyelitis (ADEM), which often involve strong antibody-mediated attacks that may respond better to plasma exchange than to steroids alone.
What to Expect Before, During, and After Treatment
Before: A full medical evaluation and neurological assessment help determine whether plasmapheresis is appropriate. Blood tests, imaging, and a review of prior treatments are standard.
During: Each session takes approximately 2–3 hours and is conducted while the patient is awake. Access is established via a central catheter or large peripheral IV. Vital signs and lab values are monitored throughout.
After: Some patients notice improvement within or shortly after the treatment course. Others may take additional weeks to see the full benefit. Disease-modifying therapy for MS continues during and after plasmapheresis.
Frequently Asked Questions
Is plasmapheresis effective for all types of MS?
Plasmapheresis appears most effective in patients with antibody-mediated demyelination, particularly those with type II MS pathology or NMOSD. Patients with primary progressive MS or T-cell-dominant pathology may respond less predictably.
How many sessions of plasma exchange are needed for MS?
A standard course typically involves five to seven sessions performed every other day over approximately two weeks. The number may be adjusted based on clinical response and the treating clinician’s judgment.
When should plasmapheresis be started after an MS relapse?
Earlier intervention is generally thought to be associated with better outcomes. Most experts consider plasma exchange when steroid therapy has failed to produce meaningful improvement after approximately one week in severe relapses.
Are there risks associated with plasmapheresis for MS?
The procedure carries risks including temporary drops in blood pressure, risk of infection at the access site, and mild electrolyte changes. Serious complications are uncommon when the procedure is performed in experienced clinical settings with appropriate monitoring.
Key Takeaways
- Plasmapheresis for multiple sclerosis is a second-line intervention for severe, steroid-refractory relapses
- It removes harmful antibodies and inflammatory proteins from the bloodstream
- A landmark randomized trial showed 42% of patients improved with plasma exchange vs. 6% with sham treatment
- Patients with antibody-mediated (type II) demyelinating pathology appear to respond most consistently
- A standard course involves 5–7 sessions over about two weeks
- AAN guidelines support its use in appropriate neurological demyelinating disease presentations
To learn more about plasmapheresis therapy and plasma exchange available through Ways2Well, schedule a consultation with our medical team to discuss whether this approach may be appropriate for your situation.
References
- Weinshenker BG, O’Brien PC, Petterson TM, et al. “A randomized trial of plasma exchange in acute central nervous system inflammatory demyelinating disease.” Ann Neurol. 1999;46(6):878–886. DOI: https://doi.org/10.1002/1531-8249(199912)46:6%3C878::AID-ANA10%3E3.0.CO;2-Q46:6%3C878::AID-ANA10%3E3.0.CO;2-Q)
- Keegan M, König F, McClelland R, et al. “Relation between humoral pathological changes in multiple sclerosis and response to therapeutic plasma exchange.” Lancet. 2005;366(9485):579–582. DOI: https://doi.org/10.1016/S0140-6736(05)67102-467102-4)
- Cortese I, Chaudhry V, So YT, et al. “Evidence-based guideline update: Plasmapheresis in neurologic disorders.” Neurology. 2011;76(3):294–300. DOI: https://doi.org/10.1212/WNL.0b013e318207b1f6
- Magaña SM, Keegan BM, Weinshenker BG, et al. “Beneficial plasma exchange response in central nervous system inflammatory demyelination.” Arch Neurol. 2011;68(7):870–878. DOI: https://doi.org/10.1001/archneurol.2011.34
Author: Ways2Well Editorial Team
Reviewed by: Scientific Advisory Board member