Plasma exchange and immunoadsorption for autoimmune neurologic diseases - current guidelines and future perspectives

There is increasing interest from neurologists to use therapeutic apheresis in autoimmune neurologic diseases due to growing knowledge of pathogenic relevance of autoantibodies. Developments in that field have been summarized in this review focusing on German guidelines and recent results from clinical research. Therapeutic apheresis can offer a therapeutic armamentarium with rapid response for severe acute neurologic symptoms, and a drug-free option for clinical courses being refractory to drug based strategies or complicated by drug side effects. Plasma exchange (PE) as the classical method has become part of current guidelines within basic and escalating immunomodulatory treatments of autoimmune neurologic diseases, and in daily practice gets increasingly replaced by selective immunoadsorption (IA) due to its equivalent efficacy in combination with a superior safety profile. Therapeutic effects of PE and IA in autoantibody mediated diseases can be attributed to 3 major mechanisms: immediate intravascular reduction of (auto-)antibody concentration, pulsed induction of antibody redistribution, and subsequent immunomodulatory changes. 5 treatments over a period of 8-10 days seem to be an appropriate regimen to restore neurologic function in acute flares or relapses of autoimmune neuropathies, e.g. myasthenic crisis, Guillain-Barré-syndrome, and steroid refractory relapse of multiple sclerosis. Especially in MS a better understanding is needed, who are the best candidates for IA.