What are the medication doses for Guillain-Barré Syndrome, myasthenia gravis, and spinal cord injury?

Medication Dosages for Guillain-Barré Syndrome, Myasthenia Gravis, and Spinal Cord Injury

Guillain-Barré Syndrome (GBS)

For Guillain-Barré Syndrome, the standard treatment is intravenous immunoglobulin (IVIG) 2 g/kg over 5 days OR plasmapheresis for 5 days. 1

Treatment Algorithm:

1. All grades warrant immediate intervention (there is no grade 1 toxicity)
2. Discontinue any immune checkpoint inhibitors if applicable
3. Admit patient with capability for rapid transfer to ICU-level monitoring
4. Administer:
   • IVIG: 0.4 g/kg/day for 5 days (total dose 2 g/kg) OR
   • Plasmapheresis plus concurrent corticosteroids (methylprednisolone 2-4 mg/kg/day)
5. Monitoring:
   • Frequent neurological checks
   • Pulmonary function monitoring
   • Monitor for autonomic dysfunction
6. Additional care:
   • Nonopioid management of neuropathic pain
   • Treatment of constipation/ileus

Myasthenia Gravis

First-line Treatment:

• Pyridostigmine starting at 30 mg PO three times daily, gradually increasing to a maximum of 120 mg orally four times daily as tolerated based on symptoms 1, 2
• Maximum daily dose can be up to 600 mg daily 2
• For extended-release formulation: One to three 180 mg tablets, once or twice daily, with intervals between doses of at least 6 hours 3

For Moderate to Severe Symptoms (Grade 2 or higher):

• Prednisone 1-1.5 mg/kg PO daily, with gradual weaning based on symptom improvement 1, 2
• For severe cases (Grade 3-4):
  • IVIG 2 g/kg over 5 days OR
  • Plasmapheresis for 5 days 1, 2

Steroid-Sparing Agents:

• Methotrexate: 15 mg weekly
• Azathioprine: 2 mg/kg of ideal body weight in divided doses
• Mycophenolate mofetil: 500 mg twice daily increasing to 1000 mg twice daily 2

Spinal Cord Injury

There are no specific medication dosages provided in the evidence for spinal cord injury management. However, the following medications are commonly used in critical care transport and emergency settings, which may be relevant for spinal cord injury:

For Elevated Intracranial Pressure:

• Dexamethasone: IV/IO: 1-2 mg/kg 1

For Pain Management:

• Avoid opioids if possible due to respiratory depression risk
• Consider non-opioid pain management strategies

For Transport Medications:

• Critical care transport should include medications listed in Table 2 of the guidelines for inter- and intrahospital transport of critically ill patients 1

Important Considerations

For Myasthenia Gravis:

• Avoid medications that can worsen myasthenia, such as β-blockers, IV magnesium, fluoroquinolones, aminoglycosides, and macrolides 1, 2
• Contraindicated medications: Methocarbamol and Orphenadrine 2

For Guillain-Barré Syndrome:

• Diagnostic workup should include neurology consultation, MRI of spine, lumbar puncture, serum antiganglioside antibody tests, and electrodiagnostic studies 1
• Monitor for respiratory compromise with negative inspiratory force (NIF) measurements, with values between -20 to -60 cm H2O requiring close monitoring 2

For Both Conditions:

• Early diagnosis and proper treatment yield better prognosis 4, 5
• Regular neurological assessments and monitoring for signs of respiratory compromise are essential 2
• The combination of MG and GBS is rare but has been reported, requiring careful differential diagnosis 4, 5