Effectiveness and Safety of Plasmapheresis in MOGAD Attacks: A Systematic Review and Meta-Analysis.

Abstract

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an inflammatory demyelinating disorder characterized by attacks of optic neuritis, myelitis, and brain inflammation. High-dose intravenous methylprednisolone (IVMP) is the most commonly used first-line therapy for acute attacks. However, recovery after IVMP varies, and a substantial proportion of patients require treatment escalation. Thus, we aim to evaluate the effectiveness and safety of plasmapheresis in individuals with acute MOGAD attacks. PubMed, Embase, Web of Science, and the Cochrane Library from inception through October 20, 2025. Eligible studies included ≥5 patients treated with plasmapheresis, IVMP, or intravenous immunoglobulin for acute MOGAD attacks. Outcomes were visual acuity measured by Snellen charts and/or the log of the minimum angle of resolution (logMAR), complete/almost complete (excellent) recovery and clinically significant (good) recovery, and plasmapheresis-related adverse events. Two reviewers independently screened studies and extracted data following the Preferred Reporting Items for Systematic Review and Meta-Analyses reporting guideline. Random-effects meta-analyses were performed, with subgroup analyses to examine whether outcomes varied by treatment approach and clinical presentation. Heterogeneity was investigated by Q test, <i>I</i>² values, leave-one-out, and Baujat analyses. Publication bias was assessed using funnel plots. This study was registered in PROSPERO (CRD420251169201). A total of 10 publications (1,045 patients, 1,368 attacks, mean age 35 ± 17 years, 56.5% female) were included in the systematic review, and data from 8 studies (710 patients, 1,033 attacks, mean age 36 ± 17 years, 59.1% female) were analyzed. In patients with optic neuritis, plasmapheresis was associated with significant improvement in visual acuity assessed by logMAR (mean difference 1.43; 95% CI 0.63-2.24) and an excellent recovery rate (81%; 95% CI 33%-100%). Subgroup analysis of steroid-refractory attacks showed a smaller, yet still clinically meaningful improvement in logMAR. In presentations including myelitis and/or cerebral involvement, the rate of good recovery after plasmapheresis was also high (94%; 95% CI 88%-100%). Plasmapheresis-related adverse effects were rare (3%; 95% CI 1%-14%). Heterogeneity was high, reflecting variability in study design, treatment timing, and attack severity. Plasmapheresis may be associated with good outcomes for MOGAD attacks, particularly in isolated optic neuritis. Future randomized trials are essential to validate these findings with enhanced patient selection and less heterogeneity.