Brain & Nervous System Multiple Sclerosis Treatment What Is Therapeutic Plasma Exchange (TPE)? What to expect when undergoing this procedure By Julie Stachowiak, PhD facebook Julie Stachowiak, PhD, is the author of the Multiple Sclerosis Manifesto, the winner of the 2009 ForeWord Book of the Year Award, Health Category. Learn about our editorial process Julie Stachowiak, PhD Medically reviewed by Medically reviewed by Nicholas R. Metrus, MD on June 18, 2021 linkedin Nicholas R. Metrus, MD, is board-certified in neurology and neuro-oncology. He currently works at the Glasser Brain Tumor Center with Atlantic Health System in Summit, New Jersey. Learn about our Medical Review Board Nicholas R. Metrus, MD on June 18, 2021 Print Table of Contents View All Table of Contents Indications How It Works What the Research Says During the Procedure Side Effects and Risks Cost Therapeutic plasma exchange (TPE), also known as plasmapheresis and apheresis, is a procedure in which the plasma in your blood is removed and replaced with another fluid, similar to what happens in kidney dialysis. It's sometimes used as a therapy in several types of neurological diseases, including multiple sclerosis (MS). TPE is a fairly painless procedure and serious side effects are rare. Verywell / Emily Roberts Indications Therapeutic plasma exchange is recommended by the American Society for Apheresis (ASFA) as a second-line treatment for MS when you're having an acute relapse that's not responding to the go-to therapy of corticosteroids (like Solu-Medrol). It's also sometimes used for people who are unable to receive high doses of corticosteroids. TPE is not currently recommended by the ASFA to treat primary or secondary progressive multiple sclerosis, as there isn't enough evidence that it's effective for this purpose. However, the organization's guidelines do acknowledge that more research may show it to be a beneficial long-term therapy for chronic progressive MS. Contraindications TPE may not be appropriate for some people with certain conditions or allergies, including: People who are unable to have a central line placed People with an allergy to albumin or fresh frozen plasma People who have active sepsis or are otherwise hemodynamically unstable People with hypocalcemia, a low level of calcium in the blood Types of MS TPE For Coronavirus (COVID-19) On March 24, the FDA announced an investigational treatment for COVID-19 using therapeutic plasma exchange. Working under the assumption that people who have recovered from COVID-19 now have antibodies to the SARS-Cov-2 virus in their blood, researchers are interested in using those antibodies as a treatment for those who are sick. In clinical trials, antibody-rich plasma will be collected from blood samples of recovered COVID-19 patients and transferred to critically ill COVID-19 patients. Mount Sinai Health System in New York City will be the first in the U.S. to experiment with therapeutic plasma exchange for this purpose. It is one of dozens of hospitals now a part of the National COVID-19 Convalescent Plasma Project. The FDA is allowing any healthcare provider treating serious cases of COVID-19 to use single-patient emergency Investigational New Drug Applications (eINDs) to request plasma for their patients. How It Works During TPE, a machine removes your blood and then separates the plasma, the liquid portion of blood, from your red and white blood cells. The plasma is then discarded and replaced with a different type of fluid, usually donor plasma and/or albumin solution, before being returned along with the cells back to your body. The goal of TPE is to remove harmful substances that are circulating in your plasma. In the case of MS, this is thought to be antibodies against the protein that makes up myelin. Scientists believe that removing these antibodies during a relapse could limit the duration of the relapse and the damage caused by inflammation. However, once these antibodies are sequestered or deposited in the lesions that occur with MS, plasma exchange can no longer remove them and it will probably not have any treatment benefit. This is why early treatment results in better outcomes. How to Tell If You're Having an MS Relapse What the Research Says The treatment guidelines from the ASFA, which include extensive literature reviews, report that five to seven TPE treatments benefit approximately 50 percent of patients with an MS relapse that doesn't respond to steroid treatment. The researchers also found that the earlier patients were treated, ideally within 14 to 20 days of their symptoms first appearing, the better their outcome was. One 2017 study looked at 37 patients who were treated with TPE because their MS relapses had been unresponsive to corticosteroids. The researchers wanted to see if the TPE treatment helped these patients again become responsive to corticosteroids, so during the first relapse the patients had post-TPE, they were all treated with steroids once again. With the steroid treatment, 10 of the patients showed marked improvement, 24 showed moderate improvement, and there was no effect in three. The researchers concluded that corticosteroids might still be the first-line therapy in subsequent relapses after TPE. Another 2016 study looked at TPE for 36 patients with either secondary progressive or active primary progressive MS that hadn't responded well or at all to steroid treatment for relapse. They were all treated with five courses of TPE within a span of two weeks, followed by one TPE treatment per month for the next year. Half of the patients (18) had a significant improvement in their Expanded Disability Status Scale (EDSS) a year after TPE, while 16 remained stable, and two deteriorated further. Prior to TPE, 16 patients with active primary progressive MS had reported a total of 16 relapses the year before. A year after TPE, the total number of relapses decreased to two. The study also found that the improvement rate was greater in patients with active primary progressive MS (71 percent) than in those with secondary progressive MS (43 percent). These results indicate that TPE may indeed be a beneficial second-line option for some patients with progressive MS who don't respond to steroids. What Is the Expanded Disability Status Scale (EDSS) for MS? During the Procedure During TPE, needles are placed in both of your arms, or sometimes into another location, like your neck, if the veins in your arm can't be accessed. Blood is then drawn out of your body through the needle in one arm, where it goes through a tube into a blood cell separator, a centrifuge that isolates the plasma from the red and white blood cells. The cellular components are combined with the donor plasma and/or albumin solution and a short-acting anticoagulant, usually citrate, is added to prevent clotting. The replacement fluid is then delivered to you through the needle in your other arm. All of these steps happen automatically and continuously through IV-type needles/catheters. In some cases, this is done through one needle and the separation and remixing are done in small batches. Regardless, the whole procedure takes between two and four hours to complete. Although there isn't a specific recommended number of TPE procedures, most people receive somewhere between three and seven treatments, depending on individual needs. How Multiple Sclerosis Is Treated Side Effects and Risks Side effects and complications depend on a number of factors such as your general health, the number of TPE procedures you have, and the type of replacement fluid that's used. The possible side effects include: A drop in blood pressure, which can cause faintness, dizziness, blurred vision, feeling cold, and cramps Mild allergic reactions Muscle cramping Bruising or swelling Fatigue Side effects of TPE are more common when donor plasma is used as the replacement fluid. Serious complications from TPE are not very common. The most dramatic of these is anaphylaxis, which is usually caused by a severe allergic reaction to the plasma replacement fluid. This is one of the reasons why plasma exchange is done within a monitored setting. Infections from TPE are a potential risk, but also rare, thanks to new technology and sterile replacement fluid. Blood clots are another rare serious complication, so your doctor may prescribe a blood thinner called an anticoagulant before your procedure to reduce this risk. Examples include Coumadin (warfarin), Pradaxa (dabigatran), Xarelto (rivaroxaban), Eliquis (apixaban), and Savaysa (edoxaban). Other potential risks of TPE include: Bleeding Irregular heart rhythm Shortness of breath Abdominal cramps Tingling in the limbs Seizures Very rarely, TPE can lead to death, but this occurs in only 0.03 percent to 0.05 percent of cases. The majority of deaths result from respiratory or cardiac complications. Cost Prices vary for TPE depending on where you live, where you have it done, and whether or not your insurance covers the procedure, but are somewhere in the ballpark of $1200 per procedure when albumin is the replacement fluid that's used. If your doctor deems it necessary for you to have TPE, your insurance will likely cover it, though you may need pre-approval or a letter from your doctor. Contact your insurance provider for more information. A Word From Verywell TPE is generally a safe and well-tolerated procedure, so it may be a good approach if you're having a relapse that's not responding to corticosteroids. More research needs to be done on the effects of TPE on progressive MS and as a long-term treatment for MS. Be sure to talk to your doctor about any concerns or questions you may have regarding all of your treatment options and whether TPE might be an appropriate choice for you. You can use our Doctor Discussion Guide below to help you start that conversation. Multiple Sclerosis Doctor Discussion Guide Get our printable guide for your next doctor's appointment to help you ask the right questions. Download PDF Email the Guide Send to yourself or a loved one. Sign Up This Doctor Discussion Guide has been sent to {{form.email}}. There was an error. Please try again. Was this page helpful? Thanks for your feedback! Get tips and advice on how you can live a full and happy life with MS. Sign Up You're in! Thank you, {{form.email}}, for signing up. There was an error. Please try again. What are your concerns? Other Inaccurate Hard to Understand Submit Article Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Bobati SS, Naik KR. Therapeutic Plasma Exchange - An Emerging Treatment Modality in Patients with Neurologic and Non-Neurologic Diseases. J Clin Diagn Res. 2017;11(8):EC35-EC37. doi:10.7860/JCDR/2017/27073.10480 ASFA. Cleveland Clinic. Plasmaphoresis in MS. Ehler J, Koball S, Sauer M, et al. Response to therapeutic plasma exchange as a rescue treatment in clinically isolated syndromes and acute worsening of multiple sclerosis: A retrospective analysis of 90 Patients. PLoS ONE. 2015;10(8):e0134583. doi:10.1371/journal.pone.0134583 Schwartz J, Padmanabhan A, Aqui N, et al. Guidelines on the use of therapeutic apheresis in clinical practice-evidence-based approach from the writing committee of the American Society for Apheresis: The seventh special issue. Journal of Clinical Apheresis. 2016;31(3):149-338. doi:10.1002/jca.21470 USFDA. Coronavirus (COVID-19) update: Daily roundup, March 24, 2020. Updated March 24, 2020. Mount Sinai. Mount Sinai to begin the transfer of COVID-19 antibodies into critically ill patients. Updated March 24, 2020. Michigan State University. National COVID-19 Convalescent Plasma Project. USFDA. Recommendations for investigational COVID-19 convalescent plasma. Updated April 13, 2020. Szczepiorkowski ZM, Winters JL, Bandarenko N, et al. Guidelines on the use of therapeutic apheresis in clinical practice—Evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. Journal of Clinical Apheresis. 2010;25:83-177. doi:10.1002/jca.20240 Ehler J, Blechinger S, Rommer PS, et al. Treatment of the first acute relapse following therapeutic plasma exchange in formerly glucocorticosteroid-unresponsive Multiple Sclerosis patients-A nulticenter study to evaluate glucocorticosteroid responsiveness. Int J Mol Sci. 2017;18(8). doi:10.3390/ijms18081749 Bobati SS, Naik KR. Therapeutic plasma exchange - An emerging treatment modality in patients with neurologic and non-neurologic diseases. J Clin Diagn Res. 2017;11(8):EC35-EC37. doi:10.7860/JCDR/2017/27073.10480 UT Southwestern Medical Center. Therapeutic plasma exchange. Shemin D, Briggs D, Greenan M. Complications of therapeutic plasma exchange: a prospective study of 1,727 procedures. J Clin Apher. 2007;22(5):270-6. doi:10.1002/jca.20143 Lu J, Zhang L, Xia C, Tao Y. Complications of therapeutic plasma exchange: A retrospective study of 1201 procedures in 435 children. Medicine (Baltimore). 2019;98(50):e18308. doi:10.1097/MD.0000000000018308 Saint Luke's. Understanding therapeutic plasma exchange (TPE). Beth Israel Lahey Health Winchester Hospital. Plasmapheresis. Updated August 21, 2018. Szczeklik W, Wawrzycka K, Włudarczyk A, et al. Complications in patients treated with plasmapheresis in the intensive care unit. Anaesthesiol Intensive Ther. 2013;45(1):7-13. doi:10.5603/AIT.2013.0002 Kaplan AA, Fridey JL. Therapeutic apheresis (plasma exchange or cytapheresis): Complications. UpToDate. March 2020. Harris ES, Meiselman HJ, Moriarty PM, Metzger A, Malkovsky M. Therapeutic plasma exchange for the treatment of systemic sclerosis: A comprehensive review and analysis. Journal of Scleroderma and Related Disorders. 2018;3(2):132-152. doi:10.1177/2397198318758606 Additional Reading Ehler J, Blechinger S, Rommer PS, et al. Treatment of the First Acute Relapse Following Therapeutic Plasma Exchange in Formerly Glucocorticosteroid-Unresponsive Multiple Sclerosis Patients-A Multicenter Study to Evaluate Glucocorticosteroid Responsiveness. International Journal of Molecular Sciences. 2017;18(8):1749. Published 2017 Aug 11. doi:10.3390/ijms18081749. Harris ES, Meiselman HJ, Moriarty PM, Metzger A, Malkovsky M. Therapeutic Plasma Exchange for the Treatment of Systemic Sclerosis: A Comprehensive Review and Analysis. Journal of Scleroderma and Related Disorders. 2018;3(2):132–152. doi:10.1177/2397198318758606. Kaplan AA, Fridey JL. Therapeutic Apheresis (Plasma Exchange or Cytapheresis): Complications. UpToDate. Updated August 2, 2018. https://www.uptodate.com/contents/therapeutic-apheresis-plasma-exchange-or-cytapheresis-complications. Olek MJ, Howard J. Treatment of Acute Exacerbations of Multiple Sclerosis in Adults. UpToDate. Updated October 9, 2018. https://www.uptodate.com/contents/treatment-of-acute-exacerbations-of-multiple-sclerosis-in-adults. Panayiota P, Ben-Hur T, Adi Vaknin D, Oded A, Dimitrios K. Clinical Efficacy of Plasma-Exchange in Patients With Progressive Forms of Multiple Sclerosis and NMO-Spectrum Disease. Journal of Multiple Sclerosis. 2016;3:181. doi:10.4172/2376-0389.1000181. Schwartz J, Padmanabhan A, Aqui N, et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. Journal of Clinical Apheresis. 2016;31(3):149–62. doi:10.1002/jca.21470.