From the Guidelines
Inpatient management of Guillain-Barré Syndrome (GBS) should prioritize prompt initiation of immunotherapy with either intravenous immunoglobulin (IVIG) at 0.4 g/kg/day for 5 consecutive days or plasma exchange (PLEX) with 5 exchanges over 2 weeks (50 mL/kg per exchange), as these treatments are equally effective in modulating the immune response that causes nerve damage 1.
Key Considerations
- Supportive care is crucial and includes:
- Respiratory monitoring with frequent vital capacity measurements
- Deep vein thrombosis prophylaxis
- Pressure ulcer prevention
- Pain management with gabapentin or carbamazepine for neuropathic pain
- Physical therapy to prevent contractures
- Autonomic instability requires careful cardiovascular monitoring and treatment of blood pressure fluctuations, arrhythmias, and urinary retention 1.
- Patients should be monitored in units capable of providing ventilatory support and intensive care, as approximately 25% of GBS patients require mechanical ventilation.
- Early rehabilitation consultation is essential to optimize functional recovery, which may continue for up to 2 years after the acute illness.
Monitoring and Complications
- Regular assessment is required to monitor disease progression and the occurrence of complications, including respiratory function, muscle strength, and autonomic dysfunction 1.
- Recognition and adequate treatment of psychological symptoms and pain at an early stage is important because these symptoms can have a major impact on the wellbeing of patients 1.
- Treatment-related fluctuations (TRFs) should be distinguished from clinical progression without any initial response to treatment, and patients with GBS who display TRFs might benefit from further treatment 1.
Treatment Approach
- IVIG and plasma exchange are the primary treatment options, with no other procedures or drugs proven effective in the treatment of GBS 1.
- Corticosteroids are not recommended for idiopathic GBS, but may be considered in ICPi-related forms 1.
- Plasma exchange followed by IVIG is no more effective than either treatment alone, and insufficient evidence is available for the efficacy of add-on treatment with intravenous methylprednisolone in IVIG-treated patients 1.
From the Research
Inpatient Management of Guillain-Barré Syndrome (GBS)
Overview of Treatment Options
The inpatient management of Guillain-Barré Syndrome (GBS) primarily involves the use of intravenous immunoglobulin (IVIg) and plasma exchange (PE) as immunomodulatory treatments to hasten recovery and reduce morbidity 2, 3, 4.
Efficacy of IVIg and PE
- Studies have shown that IVIg is beneficial in treating GBS, with efficacy comparable to PE in severe cases 2, 3.
- A systematic review and meta-analysis found no significant difference in the curative effect between IVIg and PE for patients with severe symptoms, suggesting both treatments are equally effective 3.
- IVIg has been found to be safer and have a lower frequency of complications compared to PE, making it a preferred option for many patients 3, 4.
Dosage and Duration of IVIg Treatment
- The standard dose of IVIg is 2 g/kg over 5 days, but the optimal duration and dose have not been fully established 2, 5.
- A study suggested that in patients with contraindications for plasma exchange, IVIg may be more beneficial when given for 6 days rather than 3 days, especially in ventilated patients 5.
- However, a trial investigating the efficacy of a second IVIg dose in patients with poor prognosis found no significant benefit and an increased risk of serious adverse events 6.
Considerations for Treatment Choice
- The decision between IVIg and PE should consider the patient's specific condition, including the presence of contraindications for PE and the severity of symptoms 5, 4.
- IVIg is considered easier to use and may be preferred for treating GBS due to its similar curative effects and lower risk of discontinuation compared to PE 3.
Future Research Directions
- More research is needed to determine the optimal dose and duration of IVIg treatment, especially in patients with mild disease or those whose treatment starts more than two weeks after onset 2.
- Trials with other immune modulators are also necessary for patients severely affected by GBS, given the limitations and potential risks associated with current treatments 6.