Immunomodulation 2Saturday, October 13, 2007, 15:30 - 17:00
Sustained long-term improvement in disability with plasma exchange in patients with worsening multiple sclerosis: results of a 25-year follow-up studyB. Khatri, M. McQuillen, S. Tarima, M. Dukic, J. Kramer (Milwaukee, Palo Alto, USA)
Background: Plasma exchange (PE) is an effective therapy for Multiple Sclerosis (MS) patients (pts) who continue to worsen despite cortico-steroid therapy (CST) (Weinshenker B et al, Ann Neurol, 1999). A double blind controlled study proved PE to be significantly effective in reversing disability in chronic progressive MS patients (Khatri et al, Neurology, 1985). This study reports long-term follow-up results in pts with worsening MS treated with PE over the past 25 years at our center.
Methods: Worsening MS pt having failed CST were offered PE. Verification of worsening on Extended Disability Status Scale (EDSS) by at least one step by the insurance carriers was crucial in their authorization of PE. Authorized pts received weekly PE for 10 weeks and then in a declining frequency until clinically stabilized. Temporary radial artery catheterization, femoral vein catheterization or peripheral venous access was used for vascular access.
Results: 271 pts received PE. Age range 19-70, median 41: duration of disease 1-36 years, median 7; severity of disease (EDS) 3-9.5, median 6.5; 74% female; number of PE 3-227, median 20. Peripheral venous access was adequate in 70% of pts and temporary radial artery or femoral vein catheterization in the rest. None required indwelling central line placement for vascular access.
Improvement in disability with PE occurred in 217 of the 271 pts (p < 0.0001). Ten percent of the pts improved by 2.5 steps on EDSS, 25% by 1.5, 50% by one and the rest less than one. This improvement was well sustained at 6-year follow up (p < 0.001) and stabilized during the years 7 to 9. From years 10-25, the pts started to worsen on EDSS but at a much slower pace than prior to PE (0.07 EDSS decline per year post PE vs. 2.6 per year prior to PE). This difference was significant, p < 0.001. Clinical predictors of better response to PE were greater magnitude of worsening 2 years prior to PE ( p<0.001) and duration of disease less than 7.8 years (p<0.001) A total of 8709 PE procedures were well tolerated without any major side effects.
Conclusion: PE can bring about significant and long lasting improvement in disability in worsening MS pts. PE is safe. The large number and types of MS pts selected, the magnitude of improvement and most importantly, the duration for which the improvement persisted, highlights the importance of our findings.