Comparison of efficacy of plasma exchange versus intravenous immunoglobulin as an add-on therapy in acute attacks of neuromyelitis optica spectrum disorder

J Clin Apher. 2024 Jun;39(3):e22129. doi: 10.1002/jca.22129.


Introduction: Plasma exchange (PE) is considered a Category II option for the treatment of acute attacks and relapse cases of neuromyelitis optica spectrum disorder (NMOSD). However, neurologists are also considering intravenous immunoglobulins (IVIg) as an add-on therapy for this disorder.

Aims: The aim of this study is to evaluate the efficacy of PE in acute attacks of NMOSD when compared with IVIg, in terms of improvement in the Expanded disability status scale (EDSS) and activities of daily living (ADL) scale score and levels of anti-Aquaporin P4 (AQP4) antibody in seropositive patients.

Methods: We enrolled 43 NMOSD patients in two groups: Group 1 (n = 29) received steroids and PE, and Group 2 (n = 14) received steroids with IVIg. The baseline EDSS and ADL scores were recorded and compared with scores at the end of therapy, 4 weeks, and 3 months after. Also, anti-AQP4 antibody was measured at baseline and post-therapy in seropositive patients of both groups.

Results: We observed a significant difference in EDSS (p = 0.00) and ADL score (p = 0.00) at day 10 and 3 months in both groups. However, no significant difference in EDSS, as well as ADL score from baseline (p = 0.83; p = 0.25) to 3 months (p = 0.85; p = 0.19), was observed when delta change of score at 3 months was compared across the two groups (p = 0.39; p = 0.52). We observed improved visual acuity in both groups with mild improvement in findings of magnetic resonance imaging at 3 months. We observed a significant decline in AQP4 antibody concentration (at day 10) in group 1 seropositive patients (p = 0.013) with improved EDSS (p = 0.027) and ADL scores (p = 0.026) of these patients.

Conclusions: PE should be considered as a choice of an add-on therapy in anti-AQP4 antibody-positive NMOSD patients compared with IVIg as it is more effective in reducing antibody concentrations.

Keywords: activities of daily living scale; anti‐AQP4; comparison; expanded disability status scale; intravenous immunoglobins; neuromyelitis optica spectrum disorder; plasma exchange.

Publication types

  • Comparative Study

MeSH terms

  • Activities of Daily Living
  • Adult
  • Aquaporin 4* / immunology
  • Autoantibodies / blood
  • Female
  • Humans
  • Immunoglobulins, Intravenous* / administration & dosage
  • Immunoglobulins, Intravenous* / therapeutic use
  • Male
  • Middle Aged
  • Neuromyelitis Optica* / therapy
  • Plasma Exchange* / methods
  • Treatment Outcome


  • Immunoglobulins, Intravenous
  • Aquaporin 4
  • AQP4 protein, human
  • Autoantibodies