United States Patent 1;
`4,964,848
`{11] Patent Number:
`Oct. 23, 1990
`[45] Date of Patent:
`Bicom
`
`[54] TREATMENT OF MULTIPLE SCLEROSIS
`WITH LYMPHOCYTAPHERESIS AND
`CHEMO-IMMUNOSUPPRESSION
`
`Numbers Vary with Clinical Activity?”, Annals of the
`N.Y. Academyof Sciences, vol. 436, pp. 267-270, 1984.
`Kurtzke, “Disability Rating Scales in Multiple Sclero-
`sis”, Annals of the N.Y. Academyof Sciences, Multiple
`Philip M, Bloom, 12508 Briarwood
`Sclerosis, vol. 436, pp.. 347-360, 1984.
`Ter., Minnetonka, Minn. 55343
`Ellison et al., “Therapeutic Trials in Multiple Sclerosis:
`[21] Appl. No.: 212,209
`Azathioprine”, Ann. of the N.Y. Academyof Sci., Mul-
`[22] Filed:
`Jun. 27, 1988
`tiple Sclerosis, vol. 436, pp. 361-365, 1984.
`Khatri et al., ““Plasmopherosis and Combined Immuno-
`[S12]
`Tent. CUS onic ccc eceteeecsseeeneeeesene A61M 37/00
`suppressive Drug Therapy in Chronic Progressive
`FS2] US. Ca eects ceeeeseresassscssvsssnenssenenees 604/6
`
`MS”, Ann. of the N.Y. Acad. of Sci., AZS, vol. 436, pp.
`[58] Field of Searcla ...................::cceecseeeeeeees 604/4-6,
`389-396, 1984.
`604/20; 128/897, 898; 514/903
`Hafstein et al., “Total Lymphoid Irradiation in Chronic
`References Cited
`Progressive Multiple Sclerosis”, Ann. of the N.Y.
`_ U.S. PATENT DOCUMENTS
`Academy of Sci, MS, vol. 436, pp. 397-409, 1984.
`Devereux, Hafstein et al., “Effect of Total Lymphoid
`3,802,432 4/1974 Dijerassi ................::cecereeees 128/214
`Radiation ...”, Neurology 38 (Suppl. 2) Jul., 1988, pg.
`......-.....ccecseseseeesenees 604/6
`3,892,236 F/1975 Dijerassi
`
`5/1982 Winter.......
`- 604/20
`4,331,145
`32, Same, Cook p. 41.
`4,362,155 12/1982 Skerkovich...
`128/214
`Silberberg, “Azathioprine in Multiple Sclerosis ...”,
`
`1/1984 Edelsonn ................sccceceeesseeesteee 604/6
`4,428,744
`Neurology 38 (Suppl. 2), Jul., 1988, pp. 24-26.
`
`6/1985 McMichael...
`4,521,405
`424/92
`British & Dutch MS—Group, “Double—Masked Trial. of
`9/1986 Bemsinger .............:cccssesesenees 604/6
`4,614,513
`
`Azathioprine in MS”, The Lancet, Jul. 23, 1988, pp.
`4,617,319 10/1986 Kerwar...........0
`514/647
`179-183.
`
`6/1987 Popovichetal. ...
`- 604/28
`4,673,385
`Intensive Immunosuppression in Progressive MS, New
`
`4,683,889-8/1987 Edelson............0.. seevee 604/6
`Eng. Jour. Med, vol. 308, No. 4, Jan. 27, 1983.
`
`ween 424/95
`4,695,459
`9/1987 Steinman ...
`Plasma Exchange of Lymphocytapheresis in MS, Int.
`4,708,713 TL/1987 Lentz ........ccccecesecrereeecenerseneees 604/5
`Jour. Artif. Organs, 7 pp. 39-42.
`Long Term Lymphacytapheresis Therapy in MS, Eur.
`Neurol. 25, pp. 225-236.
`Primary Examiner—C. Fred Rosenbaum
`Assistant Examiner—Sharon Rose
`Attorney, Agent, or Firm—James V. Harmon
`
`[76]
`
`Inventor:
`
`[56]
`
`FOREIGN PATENT DOCUMENTS
`
`0184040
`
`............ 514/903
`6/1986 European Pat. Off.
`OTHER PUBLICATIONS
`
`Meneghetti et al., “Lymphocytapheresis and Immuno-
`suppressive Drugs in the Treatment of MS”, 13th
`World Congress of Neurology, Hamburg, West Ger-
`many, Sept. 1-6, 1985, J. Neurol 232 (Suppl.) 1985, p.
`125.
`Ferla et al., “Effect of LCA Plus Cyclophosphamide on
`... MS”, et al. J. Neurol. Sci. 6:283-286, 1985.
`Maida et al., “Long-Term LCA Therapy in MS”, Eur.
`Neurol. 25:225-232 (1986).
`Hauseret al., “LCA in Chronic Progressive MS”, Neu-
`rology, vol. 34, pp. 922-926, Jui., 1984.
`Knight, “The Effect of Intensive Immunosuppression
`on the In Vitro Activity of Lymphocytes from MS
`Patients”, Post Graduate Medical J., 1976, vol. 52,
`Suppl. 5, pp. 131-134.
`Paty et al., “Suppressor T Cells in MS: Do Changes in
`DISABILITY STATUS SCALE
`
`ABSTRACT
`[57]
`Autoimmune diseases, such as multiple sclerosis, are
`treated by conducting lymphocytapheresis in a series of
`treatments until the peripheral blood lymphocyte count
`has been reduced to less than 500 cells/jl and prefera-
`bly to less than 300 cells/pl and thereafter continuing
`such treatments while administering an immunosup-
`pressive compounds such as azathioprine at about 2.5
`mg/Kg per day and prednisone at about 15 mg per day
`sufficient to maintain the PBL count at less than 500
`cells/jl and preferably less than 300 cells/pl.
`
`8 Claims, 1 Drawing Sheet
`(DSS)
`
`RIDDEN
`
`MIN-
`IMAL
`
`MOD-
`ERATE
`
`AMBULATORY:
`NO SUPPORT
`GAIT_ DISTURBANCE
`PARESIS
`|
`
`15% 15%
`
`LY SEVERE
`
`2 A
`
`0-1
`INVENTION
`PRE-ENTRY C—] VS POST-—TREATMENTEEE
`
`POST - 3.3
`
`DISABILITY SCALE:
`ENTRY- 5.7
`
`Hopewell EX1033
`
`Hopewell EX1033
`
`1
`
`

`

`US. Patent
`
`Oct. 23, 1990
`
`«4,964,848
`
`DISABILITY STATUS SCALE
`
`(DSS)
`
`0-1
`NIL
`
`O-1
`
`30
`
`20
`
`10
`
`IMAL
`
`MOD-
`ERATE W SEVERE
`
`AMBULATORY:
`NO SUPPORT
`GAIT DISTURBANCE
`PARESIS
`
`8
`BED-
`RIDDEN
`
`25%
`
`20%
`
`10%
`
`6EZ
`
`es
`
`10%
`
`7
`
`8
`
`INVENTION
`PRE-ENTRY __] VS POST—TREATMENT E22
`
`
`
`-15%
`15%
`5% a 6
`
`
`
`
`DISABILITY SCALE:
`ENTRY- 5.7
`
` POST - 3.3
`
`
`FIG. 1
`
`37 5%
`
`10% 10%
`
`PRIOR ART REFERENCE NO.1
`ENTRY Co vS
`TREATMENT
`
`DISABILITY SCALE :
`ENTRY.
`- 5.9
`POST
`— 5.4
`
`
`
`FIG.
`
`2
`
`

`

`1
`
`TREATMENT OF MULTIPLE SCLEROSIS WITH
`LYMPHOCYTAPHERESIS AND
`CHEMO-IMMUNOSUPPRESSION
`
`FIELD OF THE INVENTION
`The invention relates to treatment of autoimmune
`diseases and particularly multiple sclerosis. More specif-
`ically, the invention is concerned with the combined use
`of lymphocytapheresis (LCP) and chemotherapy.
`BACKGROUND OF THE INVENTION
`
`10
`
`4,964,848
`2
`cytes removed and the numbers of peripheral blood
`lymphocytes were not monitored.
`In reference 3, a long-term therapy was administered
`without an intense induction phase. In this protocol, the
`number of lymphocytes removed was determined but
`the PBL counts were not monitored as the measure of
`effective therapy. Improvement was obtained in 3 of 9
`patients, and a decrease in the relapse rate in 6 of 9
`patients was observed. There were no relapses in 7 of 9
`patients while on LCP. In this treatment lymphocyta-
`pheresis was not combined with any other therapy.
`Two-thirds of the patients remained unchanged but
`suffered exacerbations less often.
`
`Multiple sclerosis is a disease of the central nervous
`system with variable neurologic deficits due to demye-
`lination in the brain and spinal cord. The course of the
`in accordance with the present invention
`Briefly,
`disease is. variable, in some patients multiple sclerosis is
`treatment of MS patients is carried out in two phases.
`chronic and progressive. Although the etiology is not
`First, an intense induction phase in which lymphocyta-
`precisely understood, there is convincing evidence that
`the disease is of an autoimmune nature. Defective and
`pheresis is performed 3 to 5 times per week during
`which lymphocytes are removed continuously from the
`abnormal immune responses have been observed. Cur-
`rent evidence indicates that the defective immune re-
`blood until the peripheral blood lymphocyte (PBL)
`sponse causes destruction of central nervous system
`countis less than 500 cells/j1l as tested on three consec-
`myelin by the autoreactive (cytotoxic:lymphocyte)
`utive days. Second, in a maintenance phase patients are
`cells. The damageis initiated in two stages: In thefirst
`treated with LCP about once every 3 weeks for 6
`25
`stage, [4 (helper-inducer) cells stimulate the T8 CTL
`months and then once every 4 weeks indefinitely, or as.
`cells to proliferate; and in the second stage, the T4 and
`required to reduce the PBL countto less than about 500
`the T8 cells are believed to be a direct cause of primary
`cells/yl and preferably less than 300 cells/ul. After the
`lesions. During this process the T4 cells recruit macro-
`induction phase as soon as the PBL. count is depleted to
`phages which may also cause direct cell damage. It is
`the level of about 500 cells/p1, chemotherapyis started
`thus believed that the T4 cells mediate this autoimmune
`with an immunosuppresive or immunomodulating agent
`process. Finally, there is evidence that a basic defect in
`such as azathioprine, 2.5 mg/Kg. The addition of pred-
`the T4 cell is a failure to induce proliferation of another
`nisone to this combined Ry is preferred. Therapy is
`subset of T8 suppressor cells which would normally
`continued with both lymphocytaphersis and chemo-
`inhibit the above progression. The defective T4 sup-
`immunotherapy to maintain the PBL. countat less than
`pressor-inducer celis thus fail to perform the normal
`about 500 cells/pi and preferably less than 300 cells/l.
`inhibitory function.
`The invention will be better understood by reference
`As. a result of these immunological defects, attempts
`to the following detailed description and figures.
`have been madeto interrupt the course of the disease
`THE FIGURES
`with immunosuppression. See: (1) “Intensive Immuno-
`suppression in Progressive Multiple Sclerosis,” New
`England Journal of Medicine, Vol. 308, No. 4, Jan.
`1983, S. L. Hauser, et al; (2) “Plasma Exchange and
`Lymphocytapheresis in Multipie Sclerosis,” Int J Artif
`Organs, 7:39-42, 1984, P. Hocker, et al; and (3) “Long-
`Term Lymphocytapheresis Therapy in Multiple Sclero-
`sis,’ Eur Neurol, 25:225-236, 1986, E. Maida,etal.
`In reference 1, 58 patients were divided into three
`groups. All patients received ACTH Ryandoneof the
`three groups received only ACTH. The second group
`received high-dose cyclophosphamide and the third
`group was treated with plasma exchange and low-dose
`cyclophosphamide administered orally. It was discov-
`ered that high-dose cyclophosphamide plus ACTH was
`‘the most effective in halting disease progression. How-
`ever, in this study there was no lymphocytapheresis.
`Patients were treated with low-dose (2 mg/Kg/day
`unless the WBC was less than 4000 pl) intravenous
`cyclophosphamide and ACTH for producing hydro-
`cortisone by stimulating the adrenal gland. In the plas-
`mapheresis group, the cyclophosphomide was adminis-
`tered orally.
`In reference 2, treatment with azathioprine and pred-
`nisone was combined with plasmapheresis, performed
`either four times in two weeks or two to three times in
`one week. In patients with persistent disease of overfive
`years duration, there was an improvement in 50% to
`70% of the cases. In this protocol there was no mainte-
`nance lymphocytapheresis, and the number of lympho-
`
`While the pathogenesis of MS is unknown,the patho-
`logic process results in demyelination of the nerve
`axons in the central nervous system accompanied by
`inflammation and gliosis. Recent evidence indicates, as
`pointed out above, that MS is an autoimmune disease
`that appears to involve a defective immune response.
`The exact role of the T8 and T4 cells is unknown, but
`the peripheral blood lymphocytes (PBL) are believed
`by meto bein equilibrium with those in the brain so that
`there is a continuous recruitment of blood lymphocytes
`from the blood into the brain. It is to be noted that the
`MSplaques are most often found adjacent to the peri-
`ventricular blood vessels of the brain.
`The approachof the present invention is to radically
`reduce the peripheral blood lymphocyte mass to a pre-
`determined level as measured by the numbers of lym-
`phocytes removed and especially the numbers of PBL
`remaining, and to maintain this level. After treatment
`the patient then becomessufficiently immunologically
`unresponsive to control the disease.. While the primary
`effect is believed to be the elimination of an inappropri-
`
`15
`
`SUMMARY OF THE INVENTION
`
`FIG. 1 is a bar chart illustrating the clinical results
`achieved with the invention, and
`FIG. 2 is a bar chart similar to FIG. 1 illustrating
`results achieved in a prior art method.
`DETAILED DESCRIPTION OF THE
`INVENTION
`
`30
`
`35
`
`45
`
`50
`
`55
`
`65
`
`3
`
`

`

`4,964,848
`
`3
`ate immune reaction, treatment may also remove lym-
`phocytes activated against the central nervous system.
`Evidenceindicates the existence of circulating lympho-
`cytes which are directed presumably against the myelin
`substance. While in the past there has been evidence
`that autoimmunity is involved in plaque formation,
`previously none of the means for reducing the immune
`reaction have been as effective as the present method in
`maintaining immune suppression and protecting the
`patient from exacerbations. After treatment in accor-
`dance with the present method, the number of PBL are
`lowered to a predetermined level. Thereafter the re-
`cruitment of lymphocytes from the peripheral blood is
`strikingly reduced and there are therefore fewer cells
`available to infiltrate the central nervous system. The
`improved results obtained through the present inven-
`tion are due in large part to achieving control over PBL
`depletion and in finding a way to maintain this control.
`It has now been found that from about 90 to 250x 10°
`lymphocytes must be removed from a human patient for
`the treatmentto be effective.
`
`METHOD OF LYMPHOCYTE DEPLETION
`
`In the process of lymphocytapheresis, lymphocytes
`are removed by any known lymphocytapheresis equip-
`ment. In the present work a Quinton double lumen
`catheter or a Scribner shunt are used during the induc-
`tion phase. In the latter procedure, access is achieved by
`insertion of a U-tube into an artery and a vein of the
`wrist or forearm by a surgeon. The U-tubeis then con-
`nected to the LCP centrifuge... In the maintenance
`phase, the Scribner shunt is converted to an arteriove-
`nous fistula. Lymphocytapheresis is then performed
`using two needies inserted into the fistula. One serves to
`continuously withdraw blood and the other continu-
`ously returns the blood after lymphocytapheresis. To
`the fistula where the artery and vein are connected, two
`needles are attached, one to withdraw and oneto return
`blood continuously to the patient.
`Cell removal
`is accomplished using any suitable
`equipment. One preferred LCP apparatus is knownas a
`CS 3000 by Fenwall Division of Baxter Laboratories,
`Round Lake, Ill. Alternatively, an IBM 2995 or a Ha-
`emoneters Model 30 or a PEX can be used.
`The CS 3000 was operated at a speed of 1600 rpm,
`resulting in removal of 95% of the lymphocytes to-
`gether with a small number of platelets and erythro-
`cytes. The blood flow is set at 60 ml/min. The chamber
`employed is granulocyte A35 with platelet sparing in-
`sert.
`
`INDUCTION PHASE TREATMENT
`
`During the initial or induction phase, an intense lym-
`phocytapheresis program is carried out. During each
`treatment, 5 to 6 liters of plasma are processed pertreat-
`ment and continuously returned to the body. Treatment
`is continued until 5,000 cc of plasma have passed
`through the centrifuge, at which time treatment is ter-
`minated for the day. Treatment can be terminated ear-
`lier if dictated by patient fatigue. Five treatments are
`carried out in the first week; thereafter, three treatments
`are given per week until the following criteria are met:
`the patient has a PBL count of less than 500 lym-
`phocytes/1 on three consecutive days of treatment and
`the number oflymphocytes removed per treatmentis
`about 3 to 4x 109.
`The number of treatments required in the induction
`phase varies from about 15 to 25 depending upon the
`
`4
`size and weight ofthe patient. In any event, the removal
`of a total of about 90 to 250 10° lymphocytes over a
`period of from about five to seven weeks is accom-
`plished, resulting at the end of that timein a PBL count
`of less than about 500 lymphocytes/pl on three consec-
`utive days of treatment. PBL count is done convention-
`ally by microscopic examination or automated differen-
`tial cell counter methods.
`
`10
`
`20
`
`25
`
`30
`
`35
`
`45
`
`50
`
`55
`
`65
`
`MAINTENANCE PHASE TREATMENT
`
`In the maintenance phase, chemotherapyis instituted
`with an immunosuppressive or immunomodulating che-
`motherapeutic compound adapted to reduce the forma-
`tion or activation of lymphocytes. One preferred regi-
`men is azathioprine (AZA) administered at about 2.5
`mg/Kg combined with prednisone at the dosage de-
`scribed below.
`In addition to the chemotherapy, during the mainte-
`nance phase lymphocytapheresis is continued every
`three weeks for six months and then every four weeks
`indefinitely. During each LCP treatment the goal is to
`maintain a removal level per treatment of 1.5 to 2 10°
`lymphocytes andpreferably less than 1.5 x 10° removed
`per treatment..The precise numbers removed will de-
`pend upon the efficiency of the cytapheresis machine
`employed. At the beginning of the induction phasetotal
`lymphocytes removed may be from about10 to 25 x 109
`iymphocytes per treatment. Later in the program, only
`about 1 to 2 10° lymphocytes are typically removed
`per treatment because of the lymphocyte depletion in
`the peripheral blood.
`It is important to note that the chemotherapy is
`started only after the induction phase when the depleted
`state is reached as defined above. Chemotherapy is not
`started earlier becauseit is believed to be undesirable to
`stop the production of white blood cells prior to deple-
`tion. It has been found to be undesirable to start chemo-
`therapy prior to the removal of the unaltered lympho-
`cytes. Treatment dosage with AZA (e.g., Imuran ® by
`Burroughs Wellcome Drug Company)is graduated as
`follows: day 1, 5 mg/Kg; day 2, 4 mg/Kg; day 3, 4
`mg/Kg; day 4 and thereafter, 2.5 mg/Kg per day. The
`AZA appears to function by slowing the production of
`lymphocytes. Prednisone, when used,is started at 60
`mg/day orally and reduced daily by 5 mg/day decre-
`ments at weekly intervals to a maintenance dose of 15
`mg/day. It is recommended that the prednisone be
`further reduced to 15 mg every second day one year
`after induction or after the most recent exacerbation.
`Throughout the maintenance phase, the lymphocyte
`countis held to less than 500 celis/1l and preferably in
`most patients to a level of less than 300 ceils/j1.
`CLINICAL RESULTS
`
`A total of 19 human patients were treated. All of
`these patients exhibited chronic progression of the dis-
`ease prior to treatment as determined by the Kurtzke
`Disability Status Score indicated in FIG. 1. See: Rose,
`Kuzma, Kurtzke, Sibley and Tourtellotte, ‘““Coopera-
`tive Study in the Evaluation of Therapy in Multiple
`Sclerosis: ACTH vs Placebo in Acute Exacerbations.
`Preliminary Report.” Neurology (Minneapolis), 1968, 18
`(6; Part 2).
`The following overall results were achieved. Eighty
`percent were improved, 5% werestabilized and 15%
`progressed. A total of 3 patients ultimately dropped out
`within the first year. Two of them interrupted their
`course of treatment, one after 9 months and the other
`
`4
`
`

`

`4,964,848
`
`5
`after 4 months. Three patients progressed in spite of
`treatment. In all three patients, the treatment was dis-
`continued in their second year because of treatment
`failure. All the patients that responded to the combined
`therapy had chronic progressive disease for 2 to 14
`years. At entry, 6 patients (35%) were working, while
`after treatment 12 (71%) were working. At entry, 11
`were disabled and unable to work. Following treat-
`ment, 7 returned to work but 4 remained disabled.
`The effectiveness of the present method can be seen
`by reference to FIG. 1. Here a comparison can be made
`with the prior art treatment of reference 1 as shown in
`FIG.2. It can be seen in FIG. 1 that prior to treatment
`with the present method there were no patients in Cate-
`gories 1 and 2, but following treatment 45% of the
`patients entered these categories. Moreover,
`in the
`worst two categories (7 and 8) the numbersofpatients
`were reduced from 20% to 5% and from 15% to 10%,
`respectively.
`As shownin FIG.1, the previous treatment described
`in reference 1 does not show the marked shift into the
`first three categories of the disability scale. The num-
`bers of patients in Categories 1 and 2 increased by only
`5%. and there was no decrease in the numbers of pa-
`tients in Categories 7 and 8.
`In the present invention there were exacerbations in
`17 instances. However, in 77% of these instances the
`patients responded to additional treatment.
`Manyvariations are possible. For example, cyclospo-
`rin appears to be an effective adjunctive along with
`other chemotherapy and LCP.It appears that this drug
`may be required by only a few patients whoareactivat-
`ing newly formed lymphocytes. Cyclosporin is prefera-
`bly used only in treatment failures of the present proto-
`col. The immunesuppressor or immunomodulating che-
`motherapeutic compounds make it possible to keep a
`patient in a cell-depleted state. Fewer new lymphocytes
`are being produced because the production of lympho-
`cytes is reduced by the immunosuppressor. Another
`alternative immunosuppressive compound is 6-mercap-
`topurine administered at the dosage of 2.5 mg/Kg/day.
`EXACERBATIONS
`
`The present work indicates exacerbations and re-
`lapses are morelikely to occur if lymphocyte counts are
`not kept at the limits established as outlined above.
`Forty-five percent of all the exacerbations were associ-
`ated with high lymphocyte counts. In 3 patients who
`were unable to use AZA it was necessary to adjust the
`numbers of cytapheresis treatments. The numbers of
`treatments were increased to lower the lymphocyte
`count to the criteria levels established. In the treatment
`of patients having exacerbations, 3 to 9 booster treat-
`ments were used three times per week. If no response
`was obtained through this treatment, cyclosporin .was
`administered to achieve a blood level between 50 to 150
`mg/ml for 4 months or longer. Cyclosporin appears to
`arrest activation of new cells, while AZA slows down
`the proliferation of new lymphocytes so that fewer are
`being formed. Cyclosporin, on the other hand, may
`prevent existing cells from progressing from the resting
`to the activated state.
`Whatis claimedis:
`1. A method of treating demyelinating neuroim-
`munologic diseases in a human, comprising,
`removing blood from the patient,
`conducting lymphocytapheresis by separating and
`removing lymphocytes from the blood and return-
`ing the remaining fraction of the blood to the pa-
`tient,
`
`6
`conducting said lymphocytapheresis in a series of
`separate treatmentsteps, each treatment step com-
`prising at least about 5000 cc of plasma, sufficient
`to reduce the peripheral blood lymphocyte count
`to less than about 500 cells/pl,
`im-
`or
`administering
`an.
`immunosuppressive
`compound
`munomodulating
`chemotherapeutic
`while continuing to administer said lymphocyta-
`pheresis steps at periodic intervals,
`said immunosuppressive or immunomodulating com-
`pound being administered in an amount sufficient
`together with the lymphocytapheresis treatments
`to remove over 90109 lymphocytes and to main-
`tain the peripheral blood lymphocyte countat less
`than about 500 cells/l such that the human subject
`is immunologically unresponsive by an amount
`sufficient to control the disease.
`2. The method of claim 1 wherein the immunosup-
`pressive or immunomodulating chemotherapeutic com-
`pound comprises at least one member selected from the
`group consisting of prednisone, azathioprine, cyclo-
`phosphamide, cyclosporin and 6-mercaptopurine or a
`pharmacologically acceptable salt thereof.
`3. The methed of claim 2 wherein prednisone cr a
`pharmacologically acceptable salt or precursor thereof
`is also administered to a human patient in an amount
`from about 60 mg to about 15 mg per day.
`4. The method of claim 1 wherein the peripheral
`blood lymphocyte count is maintained below a level of
`about. 300 ceils/pl and following initial lymphocyte
`depletion only about 1.5 to 2.0x 10° lymphocytes are
`removed per treatment.
`5. The method of claim 1 wherein the immunosuppre-
`sive compound comprises azathioprine or a pharmaco-
`logically acceptable salt thereof administered in the
`amount of about 5 mg/Kgto about 2.5 mg/Kgper day.
`6. The methed of claim 5 wherein. prednisone or a
`pharmacologically acceptable salt thereof is adminis-
`tered in the amount of from about 15 mg to 60 mg per
`day.
`J. The method of claim 1 wherein the immunosup-
`pressive compound comprises cyclosporin administered
`in an amount adapted to achieve a serum level of be-
`tween about 50 and 150 mg/ml.
`8. A method of treating demyelinating neuroim-
`munologic diseases in a human, comprising,
`removing blood from the patient,
`conducting lymphocytapheresis by separating and
`removing lymphocytes from the blood and return-
`ing the remaining fraction of the blood to the pa-
`tient,
`the removing, separating and returning steps being
`performed substantially continously and simulta-
`neously with one another,
`conducting said lymphocytapheresis in a series of
`separate treatment steps sufficient to reduce the
`peripheral blood lymphocyte count to less than
`about 500 cells/l,
`im-
`or
`immunosuppressive.
`administering
`an
`compound
`chemotherapeutic
`munomodulating
`while continuing to administer said lymphocyta-
`pheresis steps at periodic intervals,
`said immunosuppressive or immunomodulating com-
`pound being administered in an amountsufficient
`together with the lymphocytapheresis treatments
`to remove from about 90-250 109 lymphocytes
`and to maintain the peripheral blood lymphocyte
`countat less than about 500 cells/j4l such that the
`human subject is immunologically unresponsive by
`an amount sufficient to control the disease.
`*
`*
`*x
`*
`=
`
`tar
`
`20
`
`25
`
`30
`
`35
`
`45
`
`50
`
`35
`
`65
`
`5
`
`