Abstract
BACKGROUND: Therapeutic plasma exchange (TPE) and intravenous immunoglobulin (IVIG) are high-cost treatments used for relapsed or refractory autoimmune neurological disorders. OBJECTIVE: To compare the effectiveness, safety and economic outcomes of therapeutic plasma exchange (TPE) compared with intravenous immunoglobulin (IVIG) for treating autoimmune neurological disorders. METHODS: MEDLINE, Embase, PubMed, The Cochrane Library, Transfusion Evidence Library, ClinicalTrials.gov and WHO ICTRP were searched from inception to 30th April 2025. Only randomised controlled trials (RCTs) involving people diagnosed with any autoimmune neurological disorders and comparing TPE with IVIG were included. Quality of the included studies was assessed via Cochrane risk of bias tool (ROB2). Meta-analysis was performed when feasible. Additionally, a rapid review was conducted on model-based economic evaluations for treating MG, GBS, and CIDP to identify and highlight existing gaps and limitations in included clinical trials for developing an economic model. A review protocol was pre-registered at PROSPERO 2024 CRD42024552257. RESULTS: Fifteen RCTs were eligible for inclusion: five for myasthenia gravis (MG) (N = 247), eight for Guillain-Barré Syndrome (GBS) (N = 887) and two for chronic immune-mediated polyradiculoneuropathy (CIDP) (N = 32). No trials were found for any other disorders. The trials were at low to high risk of bias. For MG there was no difference between TPE and IVIG at three weeks on the functional improvement scale (SMD 0.31, 95% confidence interval − 0.01 to 0.64, low-certainty evidence). No significant differences were found with regard to the frequency of serious adverse events (SAEs), any adverse events (AEs), length of hospital stay or quality of life on the MG-QoL60 and MG-QoL15 scales. The mean overall direct medical cost was approximately 1.4 times higher in the IVIG group compared to the TPE group. For GBS, there was no significant difference at three to six weeks on functional improvement scale (SMD = -0.65 95% CI -1.40 to 0.11, low-certainty evidence). Two studies comparing mean and median direct cost between IVIG and TPE for GBS patients showed that IVIG group impose approximately 1.5 times higher costs than TPE. Data on other outcomes were limited and economic evaluation for indirect costs, disutilities due to AEs and carer disutilities were absent. For CIDP, limited data showed a lower level of deficit at 6 weeks with no significant difference between TPE and IVIG (MD 15.00, 95% CI -16.37, 46.37) and no difference regarding SAEs or any other AEs. No trials estimated costing. CONCLUSION: The effectiveness and safety of TPE were comparable to IVIG for treating autoimmune neurological disorders, although data are limited. TPE conveys lower overall healthcare costs than IVIG. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12883-026-04780-1.