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Double-Filtration Plasmapheresis Versus Efgartigimod for Generalized Myasthenia Gravis: Severity-Stratified Benefits
Kan Wang1,2, Hanyu Xin2, Mengze Zhang1
1Department of Neurology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
Introduction:
Double-Filtration plasmapheresis (DFPP) and efgartigimod (EFG) are both effective acute exacerbation therapies for generalized myasthenia gravis (gMG), yet real-world comparative evidence remains limited. This study aims to systematically compare their clinical efficacy and safety to guide individualized treatment strategies.
Methods:
This prospective multicenter study (Aug 2019-Mar 2025) evaluated gMG patients treated with a cycle of DFPP (3-5 sessions) or EFG (4 weekly infusions). Primary endpoints included changes in Quantitative Myasthenia Gravis (QMG) and Myasthenia Gravis Activities of Daily Living (MG-ADL) scores from baseline (T0) to post-treatment (T1) and 1 month after T1 (T2). Secondary endpoints covered clinical meaningful improvement (CMI), deep improvement rates (defined as ≥ 5-point reduction in MG-ADL or ≥ 9-point in QMG), immunological changes, and safety.
Results:
Among 66 MG patients (EFG = 41, DFPP = 25), both DFPP and EFG significantly reduced QMG and MG-ADL scores at T1 and T2. In moderate-to-severe gMG (MGFA ≥ IIb), 3/5-session DFPP was superior to 4-infusion EFG at T2 (p < 0.05), while efficacy was comparable in mild cases (MGFA ≤ IIa). Sustained CMI rates (through T2) increased with higher treatment intensity; the 5-session DFPP rate was significantly higher than the 3-session DFPP (85% vs. 45%, p = 0.049) and numerically higher than the 4-infusion EFG (85% vs. 70%, p = 0.413). The proportion of patients achieving deep improvement in 5-session DFPP was higher than 4-infusion EFG. DFPP broadly reduced immunoglobulins/complement versus EFG's selective immunoglobulin G (IgG) reduction. Adverse events occurred in 28.0% of the DFPP group (mainly catheter-related thrombosis) and 39.0% of the EFG group (predominantly headache; p = 0.431), with no serious events reported.
Conclusion:
Both DFPP and EFG effectively treat gMG, though DFPP offers greater benefit in moderate-to-severe cases, underscoring the need for individualized therapy.
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