Use of Therapeutic Plasma Exchange in Autoimmune Neuromuscular Disorders

Therapeutic plasma exchange (TPE) plays a pivotal role in the management of autoimmune neuromuscular disorders by facilitating the removal of pathogenic autoantibodies, immune complexes, and proinflammatory mediators, often resulting in short-term symptomatic improvement. This monograph provides a comprehensive review of the indications, mechanisms, clinical applications, and evidence supporting TPE across a spectrum of autoimmune neuromuscular conditions. TPE is utilized in both acute and maintenance settings, particularly when rapid immunomodulation is required. However, sustained disease control frequently requires combination therapy with immunosuppressive or immunomodulatory agents. Current recommendations are guided by the American Society for Apheresis (ASFA) guidelines, which categorize disorders into four levels (I-IV) based on quality of evidence and clinical utility, with strength of recommendations graded using the GRADE framework. Strong evidence supports the use of TPE in conditions such as Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), and myasthenia gravis (MG). In selected refractory cases-including stiff-person spectrum disorders (SPS), paraneoplastic neurologic syndromes (PNHS), and idiopathic inflammatory myopathies (IIMs)-TPE may be considered based on clinical judgment and guideline recommendations. Emerging strategies, including immunoadsorption and targeted biologic therapies, are being explored as adjunctive or alternative approaches. This review aims to provide clinicians with an evidence-based framework to optimize the use of TPE in autoimmune neuromuscular disorders.