Plasmapheresis vs total lymphoid irradiation in the treatment of severe rheumatoid arthritis

In an ongoing study patients with severe rheumatoid arthritis (RA) who had previously failed conventional therapy including gold salts and penicillamine were randomly assigned on an open basis to a plasma exchange or fractionated total lymphoid irradiation protocol. Nine patients (eight female, one male) with erosive RA of long duration exchanged 40 ml/kg of plasma over a period of two to four weeks. Nine patients (eight female, one male) with similar characteristics, received 2,000 rads to lymphoid tissues in fractionated doses (200 rads each) over 4 to 5 weeks. Treatment was completed in all patients and follow-up ranged from two to twelve months for plasma exchange and eight to sixteen months for radiation. Results of the study showed subjective and objective improvement including morning stiffness, joint score, and pertinent laboratory evaluation in six patients admitted to plasmapheresis with duration of remission lasting as long as seven weeks. Three patients failed to show any improvement in the activity of the disease. Eight patients on the radiation protocol showed a marked decrease in disease activity which has been maintained until the present time. Side effects for the plasma exchange group included mild febrile reactions during the exchange and one non-A non-B Hepatitis. In the radiation group occipital alopecia, loss of appetite and nausea was seen in all patients and severe leucopenia in one (WBC 500/mm3). The present results suggest that both procedures can reduce disease activity in severe RA. Plasma exchange efficacy appears to be short-lived when compared to total lymphoid radiation. The latter was poorly tolerated by all patients submitted to the program.