What is the immediate treatment for a patient diagnosed with Guillain-Barré Syndrome (GBS)?

Immediate Treatment for Guillain-Barré Syndrome (GBS)

The immediate treatment for Guillain-Barré Syndrome is intravenous immunoglobulin (IVIG) at a dose of 0.4 g/kg body weight daily for 5 consecutive days (total dose of 2 g/kg), which should be initiated within 2 weeks of symptom onset. 1

First-Line Treatment Options

IVIG Therapy

• IVIG is recommended as the first-line treatment by the American College of Physicians with high-strength evidence 1
• Standard dosing: 0.4 g/kg/day for 5 days (total 2 g/kg)
• Should be initiated as soon as diagnosis is suspected, even before confirmation 2
• Advantages: easier administration, fewer complications, and better tolerability compared to plasma exchange 1, 3

Plasma Exchange (Alternative First-Line)

• Equally effective as IVIG in improving clinical outcomes 1, 3
• Typically 4-6 exchanges over 1-2 weeks
• Should continue until anti-GBM antibodies are no longer detectable 2
• Requires specialized equipment and has higher complication rates 1, 4
• Continuous flow plasma exchange may be superior to intermittent flow 5

Treatment Algorithm

1. Immediate intervention: Start treatment without delay if GBS is suspected, even before diagnosis confirmation 2

2. First-line treatment decision:

   • IVIG (preferred): 0.4 g/kg/day for 5 days
   • Plasma exchange (if IVIG unavailable/contraindicated): 4 sessions for moderate GBS, 2 for mild GBS 5

3. Do NOT use:

   • Corticosteroids (not beneficial and may have negative effects) 1
   • Antiviral medications (not effective and may cause adverse effects) 1
   • Combination therapy (IVIG + plasma exchange not superior to either alone) 1

Supportive Care and Monitoring

• Respiratory monitoring: Use the "20/30/40" rule 1:

  • Vital Capacity < 20 ml/kg
  • Maximum Inspiratory Pressure < 30 cmH₂O
  • Maximum Expiratory Pressure < 40 cmH₂O

• ICU admission criteria: Consider for patients with 1:

  • Evolving respiratory difficulty
  • Severe autonomic dysfunction
  • Swallowing difficulties
  • Rapidly progressive weakness

• Pain management: Use gabapentinoids, tricyclic antidepressants, or carbamazepine for neuropathic pain 1

Managing Complications

• Treatment-Related Fluctuations (TRFs): Occur in 6-10% of patients within 2 months following initial improvement 2

  • Consider repeating full course of IVIG or plasma exchange, although evidence is limited 2

• Progression to CIDP: About 5% of GBS patients develop acute-onset Chronic Inflammatory Demyelinating Polyneuropathy 2

  • Characterized by ≥3 TRFs and/or clinical deterioration ≥8 weeks after onset

• Common complications requiring management 2:

  • Deep vein thrombosis prophylaxis
  • Swallowing assessment for bulbar palsy
  • Eye care for facial palsy
  • Prevention of limb contractures
  • Management of pain, hallucinations, anxiety, and depression

Prognosis

• Despite treatment, GBS remains serious with 3-10% mortality 2, 1
• About 80% of patients regain walking ability within 6 months 2
• Long-term residual complaints are common (pain, weakness, fatigue) 2, 1
• Recovery may continue for >5 years after disease onset 1

Important Caveats

• Treatment should begin immediately upon suspicion of GBS, as early intervention improves outcomes 2
• Patients with mild GBS (still able to walk) may benefit from treatment, but evidence is limited 6
• Regular monitoring of respiratory function is crucial as respiratory failure can develop rapidly 1
• Pain management should be proactive as pain is often underrecognized but significantly impacts quality of life 2