Myasthenia gravis (MG) is usually treated with medications like immunosuppressants, corticosteroids, cholinesterase inhibitors, and newer targeted drug classes such as FcRn inhibitors, complement inhibitors, and B-cell-directed therapies.

However, if medications aren’t working or if your symptoms are worsening, your healthcare provider might recommend treating your blood directly. Plasmapheresis is a broad term for procedures, including therapeutic plasma exchange, that clean parts of your blood to provide short-term symptom relief.

In this article, we’ll explain how this treatment works, its potential side effects, and when it might be used for people with myasthenia gravis.

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Myasthenia Gravis Caused by Antibodies Gone Wrong

Myasthenia gravis is an autoimmune disorder. Normally, the immune system protects you from getting sick. Specialized proteins called antibodies bind to specific targets, like bacteria and viruses, to help the immune system eliminate them. But in autoimmune disorders, abnormal antibodies called autoantibodies attack your own tissues instead of bacteria and viruses.

In myasthenia gravis, the body’s immune system produces antibodies that attack the connection points between nerves and muscles, known as the neuromuscular junction. Normally, muscles contract when they receive signals from the brain. These signals are carried by chemicals called neurotransmitters.

In myasthenia gravis, autoantibodies interfere with these signals, making it harder for muscles to respond. This leads to muscle weakness and fatigue.

One important neurotransmitter is called acetylcholine. It binds to receptor sites located between nerves and muscles. When enough of these acetylcholine receptor sites are damaged by autoantibodies, the muscles are unable to properly receive messages from the brain, causing muscle weakness.

Autoantibodies can also cause myasthenia gravis by attacking other proteins. One is tyrosine kinase, a muscle-specific receptor that helps build receptor sites. Myasthenia gravis can also involve another protein called lipoprotein-related protein 4 (LRP4).

What To Expect During Plasmapheresis

Plasmapheresis is often done in a hospital, either as part of an inpatient stay or as an outpatient procedure.

During plasmapheresis treatment, you’ll sit in a reclining chair or bed. A healthcare provider will insert a needle or IV line into a vein in your arm or into a catheter. The plasmapheresis machine will slowly remove your blood and separate the plasma.

Plasma, once separated from the blood cells, looks like yellow liquid. After removal, the plasma is disposed of in its bag, along with any autoantibodies.

Healthcare providers will then replace the plasma with a fluid solution. This fluid may contain saline, a protein called albumin, or donor plasma. None of the replacement fluid will have autoantibodies.

Plasmapheresis usually takes two to three hours, depending on your height, weight, and blood health.

Recovery

After plasmapheresis, you may feel tired. If possible, bring a friend or family member to help you get home, especially if you need to drive. Rest for 24 hours after finishing plasmapheresis and avoid alcohol or heavy exercise.

Plasmapheresis Schedules

A typical regimen for treatment is five exchanges over one or two weeks. Typically, these sessions are every other day. Although, depending on the case, more frequent treatment may work better.

One study found that people having a myasthenic crisis may spend less time in the hospital if they receive plasmapheresis daily instead of every other day. Additionally, people in another study who were admitted to the hospital for myasthenia gravis recovered faster if they started plasmapheresis within two days of admission.

Side Effects of Plasmapheresis

Plasmapheresis usually doesn’t cause any serious side effects. During the procedure, you may feel cold, dizzy, or nauseous. If you feel unwell, a nurse or technician can adjust your position or pause the procedure briefly. As mentioned above, you may feel tired afterward.

You may also experience a bit of pain when the initial IV is inserted into your arm. While the procedure is happening, you might also feel some numbness or tingling sensations.

Other than the minor side effects listed above, a few rare complications can also occur.

• Low calcium levels — Plasmapheresis can remove too much calcium from the body, causing low calcium levels in the blood. If this happens, your healthcare provider will give you calcium through an IV.
• Low blood pressure — Plasmapheresis can lead to low blood pressure, or hypotension. Your healthcare provider can treat this with transfusions of extra fluids.
• Low body temperature — Your body temperature may drop too low after plasmapheresis. This is treated by pumping warm fluids into your body through an IV.
• Bleeding — Some people bleed more than expected during the procedure.
• Changes in heart rhythm — Rarely, someone may experience changes in heart rhythm during plasmapheresis.
• Muscle cramps — Some people experience muscle cramps during plasmapheresis.
• Reaction to chemicals used in replacement fluid — Occasionally, people have a reaction to citrate, an anticoagulant in the extracorporeal blood circuit.

If you receive repeated plasmapheresis over time, a catheter may need to be inserted at a central venous site. A catheter comes with risks of blood clots and infections.

When Is Plasmapheresis Used To Treat Myasthenia Gravis?

Plasmapheresis may be recommended for people with myasthenia gravis who have rapidly worsening symptoms. It may also be used to treat people experiencing a myasthenic crisis, especially in life-threatening cases of severe respiratory or swallowing problems. It also helps during serious flare-ups of myasthenia gravis when quick relief is needed.

“I did plasmapheresis for a year when I was in severe crisis mode. I say embrace whatever works for you.”

— An MGteam member

Doctors may use plasmapheresis before a thymectomy (surgery to remove the thymus) in high-risk people with myasthenia gravis. It can also be a treatment option while waiting for slower-acting medicines to start working.

Plasmapheresis and intravenous immunoglobulin (IVIG) are both rapid-acting treatments. Your medical team will choose which one is best for you based on the situation.

Plasmapheresis and Myasthenia Gravis Symptoms

While undergoing plasmapheresis, your healthcare provider will likely prescribe steroids and other immunosuppressants. These medications will help prevent your body from producing more autoantibodies.

You’ll usually need to keep taking these drugs for a few months after stopping plasmapheresis.

“Plasmapheresis treatments were very effective temporarily, but not available where I live. My symptoms are now back.”

— An MGteam member

Plasmapheresis can provide quick relief for myasthenia gravis symptoms. You’ll probably feel improvements in muscle weakness in a few days. The effects of plasmapheresis vary from person to person and are short term, usually only lasting for a few weeks to a few months. Plasma exchange provides rapid, temporary improvement and is often used as a bridge while longer-acting treatment takes effect.

Plasmapheresis may be a helpful addition to your myasthenia gravis treatment. Your medical team can answer any specific questions you may have about plasmapheresis and myasthenia gravis.