Rituximab and IVIG added to plasma exchange improves the outcome of severe CNS demyelinating attacks: a retrospective study
Year: 2026
Type: article
Study design: Observational Study
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.
Authors: Juan Luis Chico-Garcia, Moisés Morales de la Prida, Almudena Boix Lago, José Manuel García-Domínguez, María Sepúlveda, Eugenia Martínez-Hernández, Mar Guasp, Elianet Fonseca, Alberto Calvi, María Teresa Alba-Isasi, Blanca Albertí, Joan Cid, Miquel Lozano, Paola Charry, Fernando Rodríguez-Jorge, Raquel Sainz-Amo, Susana Sainz de la Maza, Enric Monreal, Luisa Maria Villar, Jaime Masjuan, Gabriel Valero-López, Jorge Millán-Pascual, Juan Pablo Cuello, Michael Palacios, Ariadna Gifreu Fraixinó, María Luisa Martínez-Gins, Gary Álvarez Bravo, José E. Meca-Lallana, Lucienne Costa-Frossard, Yolanda Blanco, Jose Maria Cabrera-Maqueda, Albert Saiz, Sara Llufriu
Institutions: Hospital Universitario Ramón y Cajal, Bellvitge University Hospital, Institut d'Investigació Biomédica de Bellvitge, Instituto Murciano de Investigación Biosanitaria, Hospital Universitario Virgen de la Arrixaca, Universidad Católica de Murcia, Hospital Universitari de Girona Doctor Josep Trueta, Hospital General Universitario Gregorio Marañón, Hospital Clínic de Barcelona, Consorci Institut D'Investigacions Biomediques August Pi I Sunyer, Universitat de Barcelona
Language: English
Subfield: Pathology and Forensic Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,650
OpenAlex ID: W7160535569