Here is My Question:
Do you have any experience with plasma exchange (plasmapheresis) for progressive MS, and if so, do you believe that it can be helpful for some patients (even if it is difficult to predict which ones)? To be clear, I am NOT asking about using plasma exchange for an acute relapse. I have secondary progressive MS, have tried all of the latest and greatest DMTs (currently on Ocrevus), and my mobility continues to decline at an increasing rate. Thank you.
PLEX isn't accepted as a disease modifying strategy for relapsing or progressive forms of MS. You are correct that is can be beneficial for those with a steroid-refractory relapse. More to your point, there is very little published data on use of PLEX in progressive forms of MS; however, those that are published suggest that if PLEX is helpful, it seems to skew towards younger patients with less MS disease duration. This isn't altogether surprising since approximately 30% of PPMS patients show signs of subclinical inflammatory disease activity (ie, new lesions showing up on a brain MRI). In fact, these patients seem to be the ones that benefit from immunotherapy (such as ocrevus, rituximab, siponimod, etc). Those without signs of inflammation tend not to show a response.
Also, it is important to remember that there appears to be an independent neuro-degenerative ("progressive") phase of MS. In other words, the progressive phase in many respects appears to be independent of inflammation. So, even on a proven therapy such as Ocrevus, the data do not show a cessation of progression, but rather, a slowing of the rate of progression.
At present, Ocrevus is likely a good option to maximize immunotherapy to benefit progressive MS (assuming you are still in the inflammatory phase as well), but given PLEX in addition does run the risk of removing the Ocrevus (monoclonal antibody) from your circulation and rendering it relatively ineffective.
A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente
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