Role of Plasma Exchange in Guillain-Barré Syndrome
Plasma exchange is an equally effective first-line treatment for Guillain-Barré Syndrome (GBS) compared to intravenous immunoglobulin (IVIg), with the recommended regimen being 200-250 ml plasma/kg body weight administered in five sessions. 1
Efficacy and Indications
Plasma exchange has been proven effective in treating GBS through multiple clinical trials and is considered a standard treatment option. The specific protocol should be tailored based on disease severity:
- Mild GBS (can walk with or without aid but not run, or can stand unaided): 2 plasma exchanges
- Moderate GBS (cannot stand unaided): 4 plasma exchanges
- Severe GBS (mechanically ventilated): 4 plasma exchanges (6 exchanges provide no additional benefit) 1, 2
Plasma exchange works by removing antibodies and inflammatory mediators from the circulation, thereby reducing immune-mediated nerve damage in GBS.
Comparison with IVIg
Both plasma exchange and IVIg (0.4 g/kg daily for 5 days) demonstrate comparable efficacy in GBS treatment. The choice between these treatments is often based on:
- Availability: IVIg is generally more widely available
- Ease of administration: IVIg is easier to administer
- Completion rates: Early studies showed plasma exchange was more likely to be discontinued than IVIg
- Patient factors: Cardiovascular stability, venous access, comorbidities 1
Special Considerations
GBS Variants
- Miller Fisher Syndrome (MFS): Treatment generally not recommended due to mild course and good spontaneous recovery, but close monitoring is essential
- Bickerstaff Brainstem Encephalitis (BBE): Plasma exchange or IVIg recommended due to severity 1
Special Populations
- Pregnant women: Both plasma exchange and IVIg are safe, but IVIg may be preferred due to simpler monitoring requirements
- Children: IVIg is typically preferred as plasma exchange is associated with greater discomfort and higher complication rates in pediatric patients 1
Axonal Variants
Patients with axonal forms of GBS (AMAN, AMSAN) may particularly benefit from plasma exchange, with some evidence suggesting it could be more effective than IVIg in these variants 3
Treatment Protocol
The standard plasma exchange protocol for GBS includes:
- 200-250 ml plasma/kg body weight
- Divided into five sessions
- Usually performed every other day or daily depending on patient stability
- Central venous access typically required 1
Treatment Failures and Fluctuations
- Treatment-related fluctuations (TRFs): Occur in 6-10% of patients within 2 months after initial improvement
- Insufficient response: About 40% of patients do not improve within 4 weeks of treatment
- Management: Repeating the treatment course may be considered, though evidence for this approach is limited 1, 4
Resource-Limited Settings
In settings with limited resources, small-volume plasma exchange (SVPE) might be a feasible alternative:
- Involves blood cell sedimentation and removal of supernatant plasma
- Requires less specialized equipment
- Early studies suggest it may be safe and feasible 5
Monitoring and Complications
During plasma exchange, patients should be monitored for:
- Hypotension
- Electrolyte imbalances
- Coagulation abnormalities
- Catheter-related complications (infection, thrombosis)
- Allergic reactions to replacement fluids 1
Practical Considerations
- Early initiation of treatment is crucial for better outcomes
- Treatment should begin as soon as the diagnosis is reasonably certain
- Plasma exchange should be performed in centers with appropriate expertise
- Close monitoring of respiratory function is essential during treatment 1
Plasma exchange remains a valuable treatment option for GBS, particularly in patients who have contraindications to IVIg or in settings where IVIg is unavailable or prohibitively expensive.