From the Guidelines
The North American Guillain-Barré Syndrome (GBS) Trial, published in 1985, definitively proved that plasma exchange (plasmapheresis) improves outcomes in GBS patients. This landmark multicenter, randomized controlled trial demonstrated that patients who received plasma exchange had significantly faster recovery of motor function, shorter time to independent walking, reduced need for mechanical ventilation, and shorter overall hospital stays compared to those receiving supportive care alone. The typical plasma exchange regimen established in this trial consisted of 5 exchanges over 1-2 weeks, with each exchange removing approximately 50 mL/kg of plasma. However, more recent studies such as the one published in Nature Reviews Neurology in 2021 1 suggest that intravenous immunoglobulin (0.4 g/kg for 5 days) and plasma exchange (usually five sessions at 200–250 ml/kg) are proven and equally effective treatments for GBS. Key points to consider when deciding on a treatment for GBS include:
- The efficacy of plasma exchange and intravenous immunoglobulin might differ in low-income and middle-income countries (LMIC) where different subtypes of GBS are prevalent and patients usually present to hospital in the later stages of disease.
- Plasma exchange is less costly than intravenous immunoglobulin and could theoretically be a preferred treatment option for GBS in LMIC.
- Small volume plasma exchange (SVPE) is a novel, relatively low-cost (~$500), simple technique for selective removal of plasma, and has been shown to be a safe and feasible treatment for GBS in resource-limited settings such as India and Bangladesh, as mentioned in the study published in Nature Reviews Neurology in 2021 1. The study published in 2021 1 highlights the need for low-cost and effective treatment strategies for GBS in LMIC, and suggests that SVPE could be a viable option, although large-scale studies are required before this technique can be implemented in routine clinical practice.
From the Research
Clinical Trials for Plasma Exchange in GBS
The clinical trials that proved better outcomes for plasma exchange in Guillain-Barré syndrome (GBS) are as follows:
- The study published in 2001 2 found that plasma exchange was beneficial in patients with mild, moderate, and severe GBS, and that it was more beneficial when started within seven days after disease onset.
- The study published in 2017 3 found that plasma exchange significantly increased the proportion of patients who recovered the ability to walk with assistance, and that it reduced the requirement for artificial ventilation and the likelihood of severe motor sequelae.
- The study published in 2002 4 found that plasma exchange was superior to supportive treatment alone in GBS, and that it was beneficial in patients with a disease duration of seven or less days and also in those with disease lasting more than seven days.
Comparison with Other Treatments
- The study published in 2015 5 compared the therapeutic effect of plasma exchange and intravenous immunoglobulin (IVIg) for GBS, and found that plasma exchange had a more significantly curative effect.
- The study published in 1997 6 compared plasma exchange with IVIg, and found that the outcome was similar in each of the three groups (plasma exchange, IVIg, and plasma exchange followed by IVIg) after 4 weeks and 48 weeks of follow-up.
Key Findings
- Plasma exchange is beneficial in patients with mild, moderate, and severe GBS 2, 3, 4.
- Plasma exchange is more beneficial when started within seven days after disease onset 2, 3.
- Plasma exchange reduces the requirement for artificial ventilation and the likelihood of severe motor sequelae 3.
- Plasma exchange has a more significantly curative effect compared to IVIg 5.