Therapeutic Plasma Exchange in Neuromyelitis Optica Spectrum Disorder: Real‐World Clinical Outcomes and Safety From a Tertiary Care Center in Northwest India

BACKGROUND AND OBJECTIVES: Neuromyelitis Optica Spectrum Disorder (NMOSD) is a severe autoimmune demyelinating disorder of the central nervous system characterized by relapsing attacks that can result in permanent neurological disability. Therapeutic Plasma Exchange (TPE) is recommended for steroid-refractory acute exacerbations. This study evaluated the efficacy and safety of TPE in patients with acute NMOSD attacks. MATERIALS AND METHODS: A prospective observational study was conducted over 18 months at SMS Jaipur, India. Forty adult patients fulfilling the 2015 International Panel for NMO Diagnosis criteria and presenting with steroid-refractory acute attacks were enrolled. TPE was performed using continuous-flow centrifugation, exchanging 1.0-1.4 estimated plasma volumes per session for 3-7 alternate-day procedures. Clinical outcomes were assessed using the EDSS, Snellen visual acuity, and MRC muscle strength grading. RESULTS: The cohort had a female predominance (65.0%) with a mean age of 36.5 years. Acute first presentations accounted for 77.5% of cases, while 22.5% were relapses. Anti-aquaporin-4 antibody positivity was detected in 45.0% of patients. Among 37 patients with motor deficits, 94.6% showed clinical improvement following TPE, including marked (35.1%), moderate (43.2%), and mild (16.2%) responses. Mean EDSS improved significantly from 7.4 to 4.1 (95% CI and p < 0.001). Visual improvement was observed in 84.4% of patients with baseline visual impairment. Adverse events occurred in 25.0% of patients, predominantly transient hypotension and mild citrate-related hypocalcemia, with no procedure-related treatment discontinuation. CONCLUSION: TPE is a safe and effective rescue therapy for steroid-refractory NMOSD exacerbations, producing substantial neurological and visual recovery with a favorable safety profile.