Rituximab and IVIG added to plasma exchange improves the outcome of severe CNS demyelinating attacks: a retrospective study

Background: Plasma exchange (PE) is a therapeutic option for CNS demyelinating attacks unresponsive to corticosteroids, but the potential benefit of adding rituximab and IV immunoglobulins to PE (RTX-IVIG-PE), which has shown its efficacy and safety in other immune-mediated conditions, has not been investigated. Objective: We aimed to determine the overall effectiveness of PE in severe demyelinating attacks, identify predictors of response, and compare outcomes between standard PE and RTX-IVIG-PE protocols. Design: Retrospective analysis of patients with CNS demyelinating attacks treated with PE between 2012 and 2023 across five Spanish hospitals. Methods: Clinical response was measured as an improvement or a complete recovery at discharge and 6 months. Uni- and multivariable logistic regression models were developed to identify predictors of PE response. A logistic regression analysis, after inverse probability of treatment weighting (IPTW), was performed to compare the outcome of attacks treated with standard PE and RTX-IVIG-PE. Results: A total of 162 attacks in 150 patients (81 multiple sclerosis; 37 others acquired demyelinating syndromes; 27 neuromyelitis optica spectrum disorder; 5 myelin oligodendrocyte glycoprotein antibody-associated disease; 73% female; median age 43 years (interquartile range 33–52.75)) were analyzed. At discharge, 60% of all attacks showed clinical improvement, and 15% achieved complete recovery. At 6 months, these rates increased to 77% and 31%, respectively. Younger age, lower preattack Expanded Disability Status Scale, and treatment with RTX-IVIG-PE were independent predictors of complete recovery at 6 months. IPTW analysis showed that attacks treated with RTX-IVIG-PE (33) were associated with improvement (adjusted odds ratio (aOR) 5.4, p < 0.001) and complete recovery (aOR 4.55, p < 0.001) at 6 months compared to those treated with standard PE (129), without significant differences in the adverse event profile between the two protocols. Conclusion: PE improves the outcome of steroid-refractory CNS demyelinating attacks, and the addition of rituximab and IVIG to PE may increase the likelihood of long-term recovery.

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Journal
Therapeutic Advances in Neurological Disorders
Published
2026-05-01
DOI
https://doi.org/10.1177/17562864261440665
Primary Topic
Multiple Sclerosis Research Studies
Type
article
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article

Rituximab and IVIG added to plasma exchange improves the outcome of severe CNS demyelinating attacks: a retrospective study

Eugenia Martínez‐Hernández, Moisés Morales de la Prida, Sara Llufriú, Joan Cid et al.
Therapeutic Advances in Neurological Disorders
Multiple Sclerosis Research Studies
article

Rituximab and IVIG added to plasma exchange improves the outcome of severe CNS demyelinating attacks: a retrospective study

Eugenia Martínez‐Hernández, Moisés Morales de la Prida, Sara Llufriú, Joan Cid, Juan Pablo Cuello, Susana Sainz de la Maza, Gary Álvarez Bravo, Ariadna Gifreu Fraixinó, Jorge Millán‐Pascual, Fernando Rodríguez‐Jorge, Alberto Calvi, Lucienne Costa‐Frossard, José María Cabrera‐Maqueda, Michael Palacios, Juan Luis Chico-García, Miquel Lozano, Elianet Fonseca, Paola Charry, Raquel Sainz-Amo, Albert Saiz, Enric Monreal, Yolanda Blanco, Jaime Masjuan, José E. Meca-Lallana, María Luisa Martínez-Gins, Luisa Maria Villar, María Sepúlveda, Blanca Albertí, José Manuel García-Domínguez, Almudena Boix Lago, Gabriel Valero-López, María Teresa Alba-Isasi, Mar Guasp
article en

Abstract

Background: Plasma exchange (PE) is a therapeutic option for CNS demyelinating attacks unresponsive to corticosteroids, but the potential benefit of adding rituximab and IV immunoglobulins to PE (RTX-IVIG-PE), which has shown its efficacy and safety in other immune-mediated conditions, has not been investigated. Objective: We aimed to determine the overall effectiveness of PE in severe demyelinating attacks, identify predictors of response, and compare outcomes between standard PE and RTX-IVIG-PE protocols. Design: Retrospective analysis of patients with CNS demyelinating attacks treated with PE between 2012 and 2023 across five Spanish hospitals. Methods: Clinical response was measured as an improvement or a complete recovery at discharge and 6 months. Uni- and multivariable logistic regression models were developed to identify predictors of PE response. A logistic regression analysis, after inverse probability of treatment weighting (IPTW), was performed to compare the outcome of attacks treated with standard PE and RTX-IVIG-PE. Results: A total of 162 attacks in 150 patients (81 multiple sclerosis; 37 others acquired demyelinating syndromes; 27 neuromyelitis optica spectrum disorder; 5 myelin oligodendrocyte glycoprotein antibody-associated disease; 73% female; median age 43 years (interquartile range 33–52.75)) were analyzed. At discharge, 60% of all attacks showed clinical improvement, and 15% achieved complete recovery. At 6 months, these rates increased to 77% and 31%, respectively. Younger age, lower preattack Expanded Disability Status Scale, and treatment with RTX-IVIG-PE were independent predictors of complete recovery at 6 months. IPTW analysis showed that attacks treated with RTX-IVIG-PE (33) were associated with improvement (adjusted odds ratio (aOR) 5.4, p < 0.001) and complete recovery (aOR 4.55, p < 0.001) at 6 months compared to those treated with standard PE (129), without significant differences in the adverse event profile between the two protocols. Conclusion: PE improves the outcome of steroid-refractory CNS demyelinating attacks, and the addition of rituximab and IVIG to PE may increase the likelihood of long-term recovery.

Therapeutic Advances in Neurological DisordersVol. 19
Instituto Cajal (ES), Bellvitge University Hospital (ES), Hospital General Universitario Gregorio Marañón (ES), Institut d'Investigació Biomédica de Bellvitge (ES), Institut d'Investigació Biomèdica de Girona (ES), Hospital Clínic de Barcelona (ES), Hospital Universitario Virgen de la Arrixaca (ES), Hospital Universitari de Girona Doctor Josep Trueta (ES), Hospital Universitario Ramón y Cajal (ES), Universidad Católica de Murcia (ES), Universitat de Barcelona (ES)
Agència de Gestió d'Ajuts Universitaris i de Recerca, Spanish National Plan for Scientific and Technical Research and Innovation
Good health and well-being
Openalex Percentile: Top 8%
Multiple Sclerosis Research Studies
DOIOpen Access PDFOpenAlex
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