Plasmapheresis for Lupus
A. G. Moore 10/1/2013
By Mr. Vacchi
On Wikimedia Commons Share-Alike License
Plasmapheresis. The word is a mouthful but the treatment can be a life saver–in the right circumstances. The first time this therapy was used was to treat a child. A California doctor, Michael Rubinstein, was confronted with the problem of treating a boy who was suffering from TTP, a potentially fatal clotting disorder. The boy had not responded to other therapy and prospects for survival were not good. So the doctor tried something radical, something that had at least a long shot at success. The doctor’s gamble paid off and the boy lived. With this auspicious event, the record of treatment with plasmapheresis was begun and a search was underway for the most effective way to use this acute intervention.
The term plasmapheresis is often loosely used to describe a procedure in which plasma is removed from the blood and treated extracorporeally (outside the body). If the plasma is discarded and donor blood is sent back to the patient, that process is called plasma exchange. If the patient’s own, treated plasma, is returned, then the process is called plasmapheresis.
There are essentially two kinds of plasmapheresis (in which the patient’s own, treated blood is returned). One kind is double filtration and the second is immunoadsorption. While both methods are employed by doctors who treat lupus, it seems that immunoadsorption is increasingly chosen over double filtration.
Plasmapheresis was first tried as a treatment for lupus in 1976 (see: Evidence for a Therapeutic Effect of Plasmapheresis in Patients with Systemic Lupus Erythematosus in the Oxford Journal). Reports of this procedure’s effectiveness over the years have varied; in some instances no success was seen–in others, there was evidence of dramatic improvement. Experience gradually guided practice. One important fact that emerged was that the sickest patients responded best to plasmapheresis. Those with mild or moderate lupus did not seem to benefit from the procedure . Also, it became evident that in order to minimize adverse events, certain precautions had to be taken.
Risks from the procedure include infection, blood clots and anaphylaxis. But, as a Brown University article explains, in the proper environment, with established protocols, serious adverse events may occur at a rate of only about 1%.
Many clinicians consider plasmapheresis to be a valuable tool, especially when used as an acute intervention. A case described in the JAMA journal Ophthomology illustrates its efficacy in this kind of situation. The journal describes the case of a 30-year-old woman who suffered from lupus-associated retinal vasculitis, a condition that can lead to severe vision loss. Not only is blindness a possibility, but retinal vasculitis often indicates that systemic disease is active and may be life-threatening. The young woman in this case had been treated previously with hydroxychloroquine, intravenous methylprednisolone and oral prednisone. Still, her vision worsened. Doctors decided that it was worth trying plasmapheresis.
The woman underwent several rounds of this procedure, and was also put on a regimen of methotrexate and prednisone. She was monitored carefully and medication was adjusted to address her progress or setbacks over the next several months. At the end of ten months she was assessed. Her vision had stabilized; she demonstrated visual acuity of 20/30 in one eye and 20/125 in the other. The authors of the article conclude that plasmapheresis may be effective as an acute intervention in “a severely ill patient in whom cyclophosphamide is not effective or is undesirable.” They caution, however, that by itself plasmapheresis will not be of long-term benefit. It needs to be used in conjunction with “an immunosuppressive agent to retard the re-accumulation of immune complexes”.
The author’s summation echoes what most clinicians believe about the optimal use of plasmapheresis for lupus: it can be an effective acute intervention, but is only useful, in the long-term, if combined with immunosuppressive therapy.
The discussion about plasmapheresis in this blog has so far been about the use of plasmapheresis in the treatment of lupus. However, the procedure has proven to be a useful remedy for a number of other conditions. To get an idea of how varied these are, check out the the Aetna Insurance Company’s list of conditions for which plasmapheresis is approved.
As I bring this discussion to a close, I’m aware that some people who read it may simply be curious about plasmapheresis. But others who read this may do so because they, or their doctors, are considering plasmapheresis as a treatment option. I’d like to say to these people, plasmapheresis has been around for a long time. Excellent physicians with a successful history of performing this procedure many times are most likely to insure that everything goes smoothly. These doctors, practicing in top-notch facilities that handle a large volume of lupus patients, not only can minimize risk but also are more likely to insure that the procedure yields the kind of improvement in health that you hope fo