What is the preferred treatment for Guillain-Barré Syndrome (GBS), Intravenous Immunoglobulin (IVIG) or plasmapheresis?

Treatment of Guillain-Barré Syndrome: IVIG vs. Plasmapheresis

Intravenous immunoglobulin (IVIG) is the preferred first-line treatment for Guillain-Barré Syndrome due to its effectiveness, safety profile, and ease of administration compared to plasma exchange. 1

Treatment Algorithm

1. First-line treatment: IVIG 0.4 g/kg daily for 5 days (total dose 2 g/kg)

   • Equal efficacy to plasma exchange
   • Easier to administer
   • Higher completion rates
   • Fewer adverse effects 2, 1

2. Alternative treatment: Plasma exchange (when IVIG is unavailable, contraindicated, or cost is a significant factor)

   • Standard protocol: 200-250 ml plasma/kg in five sessions over 1-2 weeks
   • Requires specialized equipment and expertise
   • Higher discontinuation rates than IVIG 2, 1

Evidence Supporting IVIG as First Choice

• Both IVIG and plasma exchange have been proven equally effective in treating GBS in multiple randomized controlled trials 2, 3
• IVIG is significantly more likely to be completed than plasma exchange 3
• IVIG offers practical advantages:
  • Easier administration without specialized equipment
  • More widely available
  • Better tolerated in many patients 4
  • Lower frequency of complications 4

Special Patient Populations

Pregnant Women

• Both IVIG and plasma exchange are safe during pregnancy
• IVIG is generally preferred due to simpler monitoring requirements 2, 1

Children

• IVIG is recommended over plasma exchange due to:
  • Less discomfort
  • Lower complication rates
  • Greater availability 2, 1
• Standard 5-day regimen is preferred over accelerated 2-day regimen due to fewer treatment-related fluctuations 1

GBS Variants

• Miller Fisher Syndrome: Treatment generally not required due to good spontaneous recovery, but close monitoring recommended 2
• Bickerstaff Brainstem Encephalitis: IVIG or plasma exchange recommended due to disease severity 1

Important Caveats and Pitfalls

• Avoid corticosteroids: They show no benefit and may have negative effects in GBS 2, 1
• Avoid combination therapy: Plasma exchange followed by IVIG is no more effective than either treatment alone 2
• Timing matters: Treatment should be initiated within 2 weeks of symptom onset for maximum efficacy 3
• Resource-limited settings: Small-volume plasma exchange may be considered as a more economical alternative, though further research is needed to establish efficacy 2

Monitoring During Treatment

• Use the "20/30/40 rule" to assess respiratory function:
  • Vital capacity <20 ml/kg
  • Maximum inspiratory pressure <30 cmH₂O
  • Maximum expiratory pressure <40 cmH₂O 2, 1
• Regularly assess muscle strength using the Medical Research Council grading scale
• Monitor functional disability using the GBS disability scale
• Consider using the Erasmus GBS Respiratory Insufficiency Score (EGRIS) to predict need for ventilation 2, 1

IVIG has become the treatment of choice for GBS in most clinical settings due to its comparable efficacy to plasma exchange, better safety profile, and practical advantages in administration.