What is the immediate treatment for 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 days, or alternatively, plasma exchange (PE) consisting of 200-250 ml plasma/kg body weight in five sessions over 2 weeks. 1, 2

Initial Assessment and Management

• Immediate neurological consultation should be obtained for any patient with suspected GBS 3, 1
• Diagnostic workup should include:
  • MRI of spine with and without contrast to rule out compressive lesions 3
  • Lumbar puncture (CSF typically shows elevated protein) 3
  • Serum antiganglioside antibody tests 3
  • Electrodiagnostic studies to evaluate polyneuropathy 3

First-Line Treatment Options

• IVIg (0.4 g/kg body weight daily for 5 days) is the preferred first-line therapy due to:

  • Equal efficacy to plasma exchange 2, 4
  • Better tolerability and fewer complications 1, 2
  • Higher completion rates and easier administration 2, 5
  • Should be initiated within 2 weeks of symptom onset for maximum effectiveness 2, 6

• Plasma exchange (200-250 ml plasma/kg in five sessions over 2 weeks) is an effective alternative when:

  • IVIg is contraindicated 1, 7
  • IVIg is not available 1, 7
  • Should be initiated within 4 weeks of symptom onset if patient is unable to walk unaided 6, 7

• Corticosteroids alone are NOT recommended for GBS treatment as they:

  • Show no significant benefit in randomized controlled trials 2, 6
  • May have negative effects on outcomes 2

Monitoring and Respiratory Support

• Close monitoring for respiratory failure is essential using:

  • Vital capacity (risk if <20 ml/kg) 1, 2
  • Maximum inspiratory pressure (risk if <30 cmH₂O) 1, 2
  • Maximum expiratory pressure (risk if <40 cmH₂O) 1, 2
  • Assessment of swallowing and coughing difficulties to prevent aspiration 1

• Admission to inpatient unit with capability for rapid transfer to intensive care unit-level monitoring is recommended for all grades of GBS 3

• Frequent neurological checks and pulmonary function monitoring should be performed 3

Management of Complications

• Monitor for autonomic dysfunction, including cardiovascular complications 3
• Implement preventive measures for pressure ulcers, hospital-acquired infections, and deep vein thrombosis 3, 1
• Manage pain with non-opioid treatments for neuropathic pain 3, 1
• Provide psychological support for anxiety, depression, and hallucinations which are frequent in GBS patients 1

Management of Disease Progression

• About 40% of patients do not show improvement in the first 4 weeks following treatment, which doesn't necessarily indicate treatment ineffectiveness 3, 2
• Treatment-related fluctuations (TRFs) occur in 6-10% of patients within 2 months of initial improvement 3, 2
• For patients with TRFs, repeating the full course of IVIg or switching to plasma exchange is common practice, although evidence supporting this approach is limited 3, 2

Special Considerations

• In children, IVIg is preferred over plasma exchange due to better tolerability and fewer complications 1, 2
• Combined treatment with PE followed by IVIg has not shown significant additional benefit over PE alone 4
• Avoid medications that can worsen neuromuscular function, such as β-blockers, IV magnesium, fluoroquinolones, aminoglycosides, and macrolides 3

Prognosis

• About 80% of patients regain walking ability at 6 months after disease onset 3, 2
• Mortality occurs in 3-10% of cases, most commonly due to cardiovascular and respiratory complications 3, 2
• Long-term residual complaints can include neuropathic pain, weakness, and fatigue, but recovery may still occur >5 years after disease onset 3, 1