What is the immediate treatment for Guillain-Barré Syndrome (GBS)?

Immediate Treatment for Guillain-Barré Syndrome (GBS)

Immediate treatment for Guillain-Barré Syndrome should begin without delay with intravenous immunoglobulin (IVIg) at 0.4 g/kg/day for 5 days or plasma exchange (PE) if the patient is unable to walk unaided and is within 4 weeks of symptom onset. 1, 2, 3

Initial Assessment and Monitoring

• Hospital admission: Patients should be admitted to a hospital with capability for rapid transfer to ICU-level monitoring 1
• Neurological monitoring: Perform frequent neurological assessments to track progression 4, 1
• Respiratory function: Monitor vital capacity, negative inspiratory force, and oxygen saturation 4
• Autonomic function: Monitor heart rate, blood pressure, and bowel/bladder function 4
• Swallowing assessment: Evaluate for bulbar dysfunction and aspiration risk 4

Immunotherapy Options

First-Line Treatment Options

1. Intravenous Immunoglobulin (IVIg):

   • Dosage: 0.4 g/kg/day for 5 consecutive days (total 2 g/kg) 1, 2
   • Timing: Most effective when started within 2 weeks of symptom onset, but can be given up to 4 weeks 2, 3
   • Precaution: Check serum IgA levels before administration to minimize risk of adverse reactions 1

2. Plasma Exchange (PE):

   • Dosage: 200-250 ml plasma/kg divided over 4-5 exchange sessions over 1-2 weeks 1, 2
   • Timing: Effective when started within 4 weeks of symptom onset 2, 3
   • Consider as alternative if IVIg is contraindicated or unavailable 1

Important Treatment Considerations

• Equal efficacy: IVIg and PE have equivalent therapeutic effects 2, 3
• Practical choice: IVIg is often preferred due to greater availability and fewer complications 5
• Avoid combination: Sequential treatment with PE followed by IVIg is not recommended 2, 3
• Avoid steroids alone: Corticosteroids as monotherapy are not beneficial for GBS 2, 3
• Treatment-related fluctuations: About 10% of patients experience secondary deterioration within 8 weeks after initial treatment; consider repeating IVIg in these cases 4, 6

Managing Complications

• Pain management: Consider pregabalin, gabapentin, or duloxetine for neuropathic pain 1, 2
• Respiratory support: Monitor for respiratory failure (occurs in up to 30% of patients) and be prepared for mechanical ventilation 7
• Autonomic dysfunction: Monitor and manage cardiac arrhythmias and blood pressure fluctuations 4
• Thromboprophylaxis: Implement preventive measures for deep vein thrombosis 4
• Pressure ulcer prevention: Regular repositioning and appropriate support surfaces 4

Prognostic Assessment

• Use the modified Erasmus GBS outcome score (mEGOS) to predict walking ability at 1,3, or 6 months 6, 2
• Use the modified Erasmus GBS Respiratory Insufficiency Score (mEGRIS) to assess risk of requiring mechanical ventilation 2
• About 80% of patients regain independent walking ability by 6 months 4
• Mortality rate is 3-10%, most commonly due to cardiovascular and respiratory complications 4, 7

Pitfalls and Caveats

• Don't delay treatment: Treatment should start as soon as GBS is suspected, even before confirmation of diagnosis 2
• Watch for CIDP: About 5% of patients initially diagnosed with GBS develop chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) with acute onset, requiring different long-term management 4, 6, 2
• Monitor after ICU discharge: Up to two-thirds of deaths occur during recovery phase, so continued monitoring is essential 4
• Recognize atypical presentations: Pain can precede weakness, potentially confusing the diagnosis 6
• Avoid overexertion: During rehabilitation, monitor exercise intensity to prevent fatigue 4