IVIG, Plasmapheresis Comparable in Long-Term Efficacy for Treatment of Myasthenic Crisis

According to a systematic review and comparative analysis of several clinical trials and observational studies that examined the effectiveness of intravenous immunoglobulin (IVIG) and plasmapheresis (PLEX) therapies for myasthenic crisis, each treatment demonstrated comparable long-term efficacy, and no sufficient data were available to establish the superiority of either regimen.¹

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Myasthenic crisis is a complication of myasthenia gravis (MG), a progressive autoimmune disorder caused by autoantibodies, which leads to a disruption in neuromuscular transmission. In myasthenic crisis, a patient’s respiratory and bulbar muscle weakness rapidly worsens and requires non-invasive ventilation or intubation. Given the serious nature of the complication, prompt identification of proper treatment and the early management of symptoms is essential.^1,2

Both PLEX and IVIG are used as treatments for MG. However, in recent years there has been a rise in the use of IVIG in MG management. The reasons for this upward trend are multifaceted; IVIG provides the convenience of easier administration compared to plasma exchange, while also providing positive long-term effects in patients without significant comorbid medical conditions.^1,3

In this review, the investigators sought to examine previously conducted trials to determine if one treatment for myasthenic crisis could be deemed superior to the other. In general, experts have viewed both IVIG and PLEX as equally effective treatments. But the decision to undertake one treatment over the other hinges on myriad factors, including treatment accessibility, institutional experience, established practices, and individual patient characteristics and desires.^1,4

A randomized control trial in 1997 analyzed the tolerability and efficacy of PLEX or IVIG in patients with exacerbated MG. There were no significant differences in efficacy, but interestingly, more side effects were observed in those receiving PLEX than IVIG. Thus, better tolerability was observed in the IVIG group.¹

Other trials indicated more favorable outcomes with PLEX. In 2022, Wang et al conducted a study of 40 patients with myasthenic crisis, finding that PLEX was associated with a shorter intensive care unit (ICU) stay and faster clinical improvement—though 1-month efficacy was found to be similar across both therapies. Additionally, a report from Stricker et al in 1993 documented 4 patients that were unresponsive to IVIG but improved their condition on PLEX, though it cannot be relied on to determine the superiority of one treatment over the other.¹

Overall, many trials pulled for the systematic review found comparable efficacy between the treatments. Trials and reviews from Barth et al, Murray et al, and Pavlekovics et al featuring a variety of patients found that the 2 treatments were equivalent in efficacy with no major differences between them regarding side effects. Though some investigators observed a quicker beneficial effect of PLEX treatment compared with IVIG, they shared similar efficacy rates at longer-term follow-ups.¹

The decision to undertake either treatment is often ultimately based on a patient’s clinical picture and other factors, such as cost. One itemized comparative cost-minimization analysis, conducted by Heatwole et al in 2011, found that IVIG could be a short-term cost-minimizing therapy compared with PLEX, though from Furlan et al another came to the same conclusion regarding PLEX in patients with a specific body mass index.¹

Aside from patient preference, each treatment comes with their own positives and negatives. IVIG may not be regionally accessible, but it does not require extensive venous access and its administration is simpler. On the other hand, PLEX requires extensive venous access and has comparatively high cost and higher risk of adverse reactions.¹

“In general, PLEX is associated with a rapid improvement of clinical outcomes; however, the efficacy of both treatment options over the long term is comparable, and there is no sufficient data to establish the superiority of one option over the other,” the investigators concluded.¹

REFERENCES

1. Zain A, Akram M, Ashfaq F, et al. Comparative analysis of intravenous immunoglobulin (IVIG) vs plasmapheresis (PLEX) in the management of myasthenic crisis. Cureus. 2024;16(9):e68895. doi:10.7759/cureus.68895

2. Sanders DB, Wolfe GI, Benatar M, et al. International consensus guidance for management of myasthenia gravis. Neurology. 2016;87(4):419-425. doi:10.1212/WNL.0000000000002790

3. Jani-Acsadi A, Lisak RP. Myasthenic crisis: Guidelines for prevention and treatment. Journ Neuro Sciences. 2007;261(1):127-133. doi:10.1016/j.jns.2007.04.045

4. Gilhus NE. Myasthenia gravis. N Engl J Med. 2016;375(26):2570-2581. doi:10.1056/NEJMra1602678