In this interview, senior physician Anna-Katharina Eser explains how immunoadsorption for multiple sclerosis relapses works, when it is used, and what advantages this treatment may offer.
Immunoadsorption is sometimes described in simple terms as a form of “blood washing”. In multiple sclerosis, it can be considered when an acute relapse does not improve sufficiently after high-dose corticosteroid treatment.
I have summarized and shortened Dr. Eser’s answers for better readability.
This interview was originally published in August 2021 on the German MS-Perspektive podcast. This article is a translated and adapted version for an international audience. Please note that availability, clinical use, treatment pathways and reimbursement of immunoadsorption may vary from country to country. The basic procedure itself, however, remains the same.
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More InformationIntroduction: Anna-Katharina Eser
Anna-Katharina Eser: My name is Anna-Katharina Eser. I am a senior physician at the Neurological Centre in Mainkofen, Lower Bavaria, in Germany. I have been working as a senior physician there since 2018. Before that, I also completed my specialist training in Mainkofen.
Mainkofen is located between Deggendorf and Passau, near the Austrian border and about 100 kilometres from Regensburg.
What were the most important steps in your career so far?
Anna-Katharina Eser: I originally did not plan to study medicine. Until I finished school, I actually wanted to study law. After graduation, I spent six months in Brazil, working in a children’s home in the favelas of Recife.
There, I experienced how poor medical care can be in other countries. That changed my perspective. When I returned from Brazil, I decided to study medicine instead. After medical school, I completed my specialist training in Mainkofen and have been a senior physician there since 2018.
What personally motivated you to become a doctor?
Anna-Katharina Eser: The time in Brazil was very formative for me. Seeing how limited medical care was for many people made me want to contribute in a different way. That experience was one of the main reasons why I chose medicine.
When is immunoadsorption used in multiple sclerosis?
Anna-Katharina Eser: In multiple sclerosis, immunoadsorption is a rather specialized treatment. It is used when a person has an acute relapse and high-dose corticosteroid therapy does not lead to sufficient improvement.
This is called a steroid-refractory relapse. “Steroid-refractory” means that the relapse symptoms do not respond adequately to corticosteroids.
Immunoadsorption is sometimes called “blood washing”. What is being removed from the blood and how does the treatment work?
Anna-Katharina Eser: In simple terms, the aim is to clean the blood of disease-causing antibodies.
First, a Shaldon catheter is placed. This is a special catheter inserted into a larger blood vessel, for example in the neck or below the collarbone. It is not the same as a small infusion needle in the hand or arm.
The blood is then guided through a machine. Inside the machine, there is a special filter. The antibodies that are thought to contribute to the disease activity are adsorbed there, meaning they stick to the filter. The cleaned blood is then returned to the patient.
I often explain it with a simple kitchen image: If you make raspberry juice, you press the fruit puree through a sieve so the small seeds stay behind. In immunoadsorption, the filter works a bit like that sieve. The “seeds” are the unwanted antibodies.
How demanding is immunoadsorption for the body and what side effects may occur?
Anna-Katharina Eser: Overall, immunoadsorption is considered a gentle procedure compared with some other forms of blood purification. This is because mainly the antibodies are removed, while the other blood components are returned to the patient.
That is also why immunoadsorption can usually be performed on five consecutive days.
Possible side effects include a drop in blood pressure after the treatment. The treatment is carried out while lying down and can take several hours. So patients should sit up slowly afterwards and give their circulation time to adjust.
Some people also feel cold or shivery during the treatment. This can usually be managed well with extra blankets or warm air.
How long does one treatment session take? Is immunoadsorption carried out as an inpatient or outpatient treatment?
Anna-Katharina Eser: Immunoadsorption is always carried out as an inpatient treatment.
The duration depends on several factors, including height, weight, smoking status and certain blood values. In smokers, treatment may take longer because of the influence on specific blood parameters such as the haematocrit, which describes the proportion of red blood cells in the blood.
As a rough example, a young, slim non-smoking woman may need about four hours of treatment per day over five consecutive days. For a tall, heavier patient who smokes, treatment may take six to seven hours per day and sometimes one additional day.
These are only examples. The exact duration is calculated individually.
What is the difference between immunoadsorption and plasmapheresis, and what is the benefit for patients?
Anna-Katharina Eser: In immunoadsorption, the aim is to remove mainly disease-relevant antibodies. In multiple sclerosis, we still do not know exactly which antibodies are responsible, but they belong to the IgG antibody group.
With plasmapheresis, more blood components are affected. Electrolytes and other parts of the blood may be removed to a greater extent. This can also influence blood clotting more strongly.
That is one of the reasons why plasmapheresis is often not performed on five consecutive days, whereas immunoadsorption can usually be done on consecutive days.
Is immunoadsorption only useful in relapsing-remitting MS?
Anna-Katharina Eser: Yes. In multiple sclerosis, immunoadsorption is approved for relapsing forms of MS when an acute relapse does not improve sufficiently with corticosteroids.
There are exceptions. If a patient has had a severe intolerance to corticosteroids in the past, immunoadsorption may be considered directly. For example, we once had a patient who developed liver failure under corticosteroid treatment. In such a case, you would not simply repeat the same treatment and wait to see whether liver failure happens again.
But in general, corticosteroid treatment remains the first step. Immunoadsorption is used when that treatment fails or cannot be used for serious medical reasons.
Can immunoadsorption be repeated?
Anna-Katharina Eser: Yes. Immunoadsorption can theoretically be repeated whenever the medical indication is present again. That means: if another acute relapse occurs and does not respond adequately to corticosteroids, immunoadsorption can be considered again.
There are also other diseases outside MS where patients may receive immunoadsorption repeatedly, for example every few months.
Why is immunoadsorption not offered immediately to people with MS?
Anna-Katharina Eser: One reason is that immunoadsorption is more expensive than corticosteroid treatment. Another important point is that it is more invasive.
For corticosteroid treatment, a small infusion needle in the hand or arm is usually enough. For immunoadsorption, a larger catheter has to be placed into a larger blood vessel. This carries higher risks, for example inflammation, infection or injury during catheter placement.
That is why the lower-risk treatment with corticosteroids is usually tried first.
When did you introduce this treatment in Mainkofen and what had to be done beforehand?
Anna-Katharina Eser: We started our first immunoadsorption treatment in Mainkofen in autumn 2016. The first patient did not have MS, but another condition.
A lot of preparation was necessary before we could start. The staff had to be trained intensively and further education was needed. During immunoadsorption, one nurse is assigned completely to one patient. That also had to be planned in terms of staffing.
Additional nurses had to be recruited and trained. We also needed special machines for the procedure. Different suppliers and devices had to be compared, including their advantages and disadvantages.
So there were weeks filled with organization and paperwork before we could finally begin. As doctors, we usually prefer working directly with patients, but the preparation was essential.
For which other diseases is immunoadsorption also used?
Anna-Katharina Eser: In neurology, immunoadsorption can also be used for immune-mediated polyneuropathies. Polyneuropathy means damage or inflammation affecting peripheral nerves, meaning nerves outside the brain and spinal cord.
It can also be used in other autoimmune diseases, such as inflammatory diseases of the brain, including limbic encephalitis.
Outside neurology, immunoadsorption is also used in cardiology for certain heart diseases and in nephrology for some kidney diseases.
How often do you perform immunoadsorption and how many of these patients have multiple sclerosis?
Anna-Katharina Eser: In Mainkofen, we treat roughly two to five patients per month with immunoadsorption.
If there are two patients in one month, that already means around ten treatment days. If there are five patients, it can mean about 25 treatment days, including the need for additional nursing staff.
Roughly one third of these patients have multiple sclerosis.
Quickfire Q&A
Please complete the sentence: “For me, multiple sclerosis is…”
Anna-Katharina Eser: “A disease with not only a thousand faces, but a thousand and one faces. And it is also a disease that can be treated very well preventively today. For every patient and every life situation, we can find a suitable medication.”
Which websites about MS can you recommend?
Anna-Katharina Eser: (Note: Answer adjusted for international audience) “MS-Perspektive is a very helpful resource. I also recommend reliable patient information from established MS organizations and medical institutions. It is important to use trustworthy, evidence-based sources and to be cautious with unmoderated internet forums.”
For international readers, helpful starting points include:
- National Multiple Sclerosis Society – patient-friendly information, treatment overviews and support resources for people with MS.
- MS International Federation (MSIF) – global MS information and links to MS organizations around the world.
- Multiple Sclerosis Society UK – accessible information about symptoms, treatment, relapse management and everyday life with MS.
- PubMed – for readers who want to explore scientific publications, including research related to immunoadsorption, plasma exchange and steroid-refractory MS relapses.”
What breakthrough in MS research or treatment would you like to see in the next five years?
Anna-Katharina Eser: “I do not think the one big breakthrough will happen within the next five years. But we have seen many new medications become available in recent years, and more are in the pipeline. I expect that more oral therapies, injectable therapies and infusion therapies will be approved.
In the longer term, stem cell research may bring important progress. And perhaps further in the future, there may even be a vaccine against MS progression.”
Farewell
Is there anything you would like to share with the listeners?
Anna-Katharina Eser: Every person with MS should know that the diagnosis is not a dead end.
I like the spirit of a quote often attributed to Albert Einstein: We all have difficult things to carry, because this is inseparable from life. But one thing helps: to stand together in friendship and help carry one another.
Contact
Anna-Katharina Eser on PubMed: Eser AK – Search Results – PubMed
Many thanks to senior physician Anna-Katharina Eser for this interview and for explaining immunoadsorption in such a clear and encouraging way.
See you soon and try to make the best out of your life,
Nele
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