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

Immediate Treatment for Guillain-Barré Syndrome

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

Initial Assessment and ICU Admission Criteria

When a patient is diagnosed with GBS, immediate evaluation for potential ICU admission is critical. Admit patients to the ICU if they have any of the following:

• Evolving respiratory distress
• Severe autonomic cardiovascular dysfunction (arrhythmias, blood pressure fluctuations)
• Severe swallowing dysfunction or diminished cough reflex
• Rapidly progressive weakness 2

Respiratory Monitoring

Monitor respiratory function using the "20/30/40" rule 1:

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

The Erasmus GBS Respiratory Insufficiency Score (EGRIS) can help identify patients at risk of requiring mechanical ventilation within the first week 2.

Treatment Options

First-Line Treatment

IVIG is the treatment of choice due to:

• Equal efficacy to plasma exchange 2, 1
• Easier administration
• Better completion rates
• Wider availability
• Fewer complications 3, 4

Alternative Treatment

Plasma exchange (200-250 ml plasma/kg body weight in five sessions) is equally effective as IVIG but:

• Requires specialized equipment
• Has higher complication rates
• Is more likely to be discontinued 2, 1

In resource-limited settings, small-volume plasma exchange might be considered, though its efficacy requires further validation 2.

Important Treatment Considerations

• Do not use corticosteroids: Despite their anti-inflammatory properties, corticosteroids have shown no benefit and may even have negative effects in GBS 2, 1
• Do not combine treatments: Plasma exchange followed by IVIG is no more effective than either treatment alone 2, 1
• Treatment timing: Both IVIG and plasma exchange are most effective when started within the first two weeks of symptom onset 5
• Special populations: IVIG is preferred for pregnant patients and children due to better tolerance and safety profile 1

Management of Complications

Pain Management

• Use gabapentinoids, tricyclic antidepressants, or carbamazepine for neuropathic pain 1
• Pregabalin, gabapentin, or duloxetine are recommended non-opioid options 1

Other Supportive Care

• Implement DVT prophylaxis for bed-bound patients
• Address corneal protection in patients with facial palsy
• Monitor for and manage limb contractures
• Provide psychological support for anxiety, depression, and hallucinations 2
• Implement appropriate bowel and bladder management 1

Treatment-Related Fluctuations (TRFs)

About 6-10% of patients experience TRFs, defined as disease progression after initial treatment-induced improvement within 2 months 2. In these cases:

• Consider repeating the full course of IVIG or plasma exchange
• Monitor for development of chronic inflammatory demyelinating polyneuropathy (CIDP), especially if there are three or more TRFs or clinical deterioration ≥8 weeks after disease onset 2

Prognosis

Despite treatment, GBS remains a serious condition:

• Mortality rate: 3-10%
• About 20% of patients have severe disability
• 80% regain independent walking ability by 6 months
• Residual symptoms like fatigue, weakness, and pain are common and may persist for years 2, 1, 5

The modified Erasmus GBS outcome score (mEGOS) can help predict the probability of regaining walking ability 2.