Clinical experience with maintenance therapeutic plasma exchange in refractory generalized myasthenia gravis

Background Despite the availability of several immunomodulatory therapies, about 20% of myasthenia gravis (MG) patients remain refractory to conventional treatments. There is limited evidence to support the use of maintenance therapeutic plasma exchange (TPE) therapy for refractory generalized MG. Methods Retrospective chart review of 14 patients with refractory generalized MG treated for 12 months with maintenance TPE therapy. Outcome measures were myasthenia gravis composite (MGC) score, myasthenia gravis activities of daily living (MG-ADL), number of acute exacerbations, medication changes, and adverse events. Data were collected at 3 monthly intervals for 12 months before and after initiation of TPE therapy. Results Clinically meaningful reductions in mean MG-ADL (>2 points) (mean MG-ADL score: 9.9 +/- 0.5; 12-month pre-TPE to 5.2 +/- 0.9; 12-month post-TPE) and MGC (>3 points) (mean MGC score: 25.2 +/- 1.6; 12-month pre-TPE to 11.7 +/- 1.4; 12-month post-TPE) were observed at 3 months following initiation of TPE and were maintained up to 12 months in all patients. After 12 months of TPE therapy, all patients had a significant reduction in daily prednisone and pyridostigmine use. Patients previously on IVIG or rituximab therapy were successfully weaned off both treatments. There was a significant reduction in acute MG exacerbations; 7.8 +/- 1.1 mean exacerbations/patient (12-month pre-TPE) to 2 +/- 1.1 mean exacerbations/patient (12-month post-TPE). Conclusion Over a period of 12 months, maintenance TPE therapy improved MG-ADL, and MGC with decreased immunosuppressant requirement, while being well-tolerated.