Evidence-based guideline update: Plasmapheresis in neurologic disorders
JosephSchwartz, M.D. Chair, ASFA Applications Committee for the Members of the Guidelines Subcommittee., Columbia University Medical Center, New York, NYjs2745@columbia.edu
Submitted July 05, 2011
Cortese et al. reviewed the role of plasma exchange in treating neurologic disorders. [1] We were greatly interested as the guideline subcommittee of the American Society for Apheresis (ASFA) which is responsible for developing the ASFA guidelines for the use of therapeutic apheresis in clinical practice. The fifth edition of the ASFA guidelines was recently published in the Journal of Clinical Apheresis. [18]
Although both groups agreed on many indications, each arrived at different conclusions and recommendations for the following diseases: paraproteinemic polyneuropathy due to IgM, MG, PANDAS, and Sydenham's chorea. Specifically, the ASFA guidelines considers these disorders as category I (primary treatment modality) with a strong recommendation for the use of plasma exchange with variable quality of evidence ranging from high (MG) to low (paraproteinemic polyneuropathy due to IgM).
The ASFA categories and the use of GRADE system [19] incorporated evidence from case reports, case series, controlled and randomized trials utilizing recognized tools for evaluation of different levels of evidence. The AAN subcommittee included only controlled clinical trials based on the process established by AAN for level of evidence. [20] Therefore, disparities in recommendations have emerged. While it would be ideal to base decisions solely on controlled trials, these trials are not always available for patients with uncommon disorders. ASFA maintains that all of the available evidence should be considered when promulgating indications for apheresis treatment.
Another consideration is the need for the correct usage of terminology. Apheresis terminology has been inconsistent prompting confusion among those who search for citations involving apheresis related articles (i.e., different MESH search) and those who pay for its use (i.e., insurance companies). Plasmapheresis refers to the method where plasma is removed but not replaced, such as for the collection of donor plasma. Plasma exchange is a therapeutic procedure where a substantial volume of patient plasma is removed and replaced, most commonly with 5% albumin or donor plasma. Cortese et al. reviewed indications for therapeutic plasma exchange for the treatment of neurologic disorders, not plasmapheresis.
The effort by the AAN to create guidelines for the use of therapeutic apheresis in patients with neurological disorders would be significantly enhanced by harmonization of recommendations and the use of systematic review tools that are more widely accepted.
References
18. Szczepiorkowski ZM, Winters JL, Bandarenko N, et al. Guidelines on the use of therapeutic apheresis in clinical practice--evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apher 2010;25:83-177.
19. Atkins D, Best D, Briss PA, et al. Grading quality of the evidence and strength of recommendations. BMJ 2004;328:1490-1497.
20. Gross RA, Johnston KC. Levels of evidence: taking Neurology to the next level. Neurology 2009;72:8-10
Disclosure: Dr. Schwartz consulted for UCB/Celltech.
Cortese et al. reviewed the role of plasma exchange in treating neurologic disorders. [1] We were greatly interested as the guideline subcommittee of the American Society for Apheresis (ASFA) which is responsible for developing the ASFA guidelines for the use of therapeutic apheresis in clinical practice. The fifth edition of the ASFA guidelines was recently published in the Journal of Clinical Apheresis. [18]
Although both groups agreed on many indications, each arrived at different conclusions and recommendations for the following diseases: paraproteinemic polyneuropathy due to IgM, MG, PANDAS, and Sydenham's chorea. Specifically, the ASFA guidelines considers these disorders as category I (primary treatment modality) with a strong recommendation for the use of plasma exchange with variable quality of evidence ranging from high (MG) to low (paraproteinemic polyneuropathy due to IgM).
The ASFA categories and the use of GRADE system [19] incorporated evidence from case reports, case series, controlled and randomized trials utilizing recognized tools for evaluation of different levels of evidence. The AAN subcommittee included only controlled clinical trials based on the process established by AAN for level of evidence. [20] Therefore, disparities in recommendations have emerged. While it would be ideal to base decisions solely on controlled trials, these trials are not always available for patients with uncommon disorders. ASFA maintains that all of the available evidence should be considered when promulgating indications for apheresis treatment.
Another consideration is the need for the correct usage of terminology. Apheresis terminology has been inconsistent prompting confusion among those who search for citations involving apheresis related articles (i.e., different MESH search) and those who pay for its use (i.e., insurance companies). Plasmapheresis refers to the method where plasma is removed but not replaced, such as for the collection of donor plasma. Plasma exchange is a therapeutic procedure where a substantial volume of patient plasma is removed and replaced, most commonly with 5% albumin or donor plasma. Cortese et al. reviewed indications for therapeutic plasma exchange for the treatment of neurologic disorders, not plasmapheresis.
The effort by the AAN to create guidelines for the use of therapeutic apheresis in patients with neurological disorders would be significantly enhanced by harmonization of recommendations and the use of systematic review tools that are more widely accepted.
References
18. Szczepiorkowski ZM, Winters JL, Bandarenko N, et al. Guidelines on the use of therapeutic apheresis in clinical practice--evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apher 2010;25:83-177.
19. Atkins D, Best D, Briss PA, et al. Grading quality of the evidence and strength of recommendations. BMJ 2004;328:1490-1497.
20. Gross RA, Johnston KC. Levels of evidence: taking Neurology to the next level. Neurology 2009;72:8-10
Disclosure: Dr. Schwartz consulted for UCB/Celltech.