What is the difference between plasmapheresis and intravenous immunoglobulin (IVIG) for treating Guillain-Barré Syndrome (GBS)?

GBS Treatment: Plasmapheresis vs IVIG

IVIG and plasmapheresis are equally effective for treating Guillain-Barré Syndrome, but IVIG is the preferred first-line treatment due to easier administration, wider availability, and higher completion rates. 1

Treatment Efficacy: No Significant Difference

Both treatments produce equivalent clinical outcomes when comparing disability improvement:

• Meta-analysis of 7 trials (623 severely affected patients) showed no statistically significant difference in disability grade improvement at 4 weeks between IVIG and plasmapheresis (mean difference: 0.02 grade, 95% CI -0.20 to 0.25) 2
• Both treatments are equally effective at hastening recovery and reducing long-term morbidity when initiated within 2 weeks of symptom onset 1
• Neither treatment shows superiority in terms of final functional outcomes or mortality reduction 2

Why IVIG is Preferred First-Line

Despite equal efficacy, IVIG has become the treatment of choice for several practical reasons:

• Higher completion rates: IVIG is significantly more likely to be completed than plasmapheresis 2
• Easier administration: No need for specialized equipment or vascular access beyond standard IV 1
• More widely available: Can be administered in most hospitals without specialized apheresis units 1
• Fewer discontinuations: Early studies showed plasmapheresis was more likely to be discontinued due to complications 1

Standard IVIG Protocol

• Dose: 0.4 g/kg body weight daily for 5 consecutive days (total 2 g/kg) 1, 3
• Timing: Most effective when started within 2 weeks of symptom onset 3, 4
• Indication: GBS disability score ≥3 (unable to walk unaided) 3, 4

Standard Plasmapheresis Protocol

• Volume: 200-250 ml plasma/kg body weight over 5 sessions 1
• Duration: Typically completed over 2 weeks 4
• Cost advantage: Significantly less expensive (~$4,500-5,000 vs $12,000-16,000 for IVIG), which may be relevant in resource-limited settings 4

Adverse Events: Comparable Safety Profiles

• No significant difference in overall adverse event rates between IVIG and plasmapheresis 2
• Both treatments carry comparable risks of complications 1
• However, plasmapheresis requires additional monitoring considerations (hemodynamic stability, vascular access complications, coagulopathy) 1

Special Populations

Children

IVIG is strongly preferred over plasmapheresis in pediatric GBS:

• Plasmapheresis produces greater discomfort and higher complication rates in children 1
• IVIG shows better tolerability and fewer complications 3, 4
• Standard adult dosing applies: 0.4 g/kg/day × 5 days 1, 4
• Caution: Administering the full dose over 2 days (instead of 5) resulted in higher treatment-related fluctuation rates (22% vs 0%) 1

Pregnant Women

• Neither treatment is contraindicated during pregnancy 1
• IVIG is generally preferred due to fewer monitoring requirements and considerations compared to plasmapheresis 1, 5

Sequential or Combination Therapy: Not Recommended

Combining plasmapheresis followed by IVIG provides no additional benefit:

• One trial (249 participants) showed no clinically significant extra improvement with combined treatment (mean difference 0.2 grade, 95% CI -0.14 to 0.54) 1, 2
• Sequential therapy is no more effective than either treatment alone 1
• This approach cannot be recommended for routine use 1

Treatment-Related Fluctuations (TRFs)

• Occur in 6-10% of patients within 2 months of initial improvement 3, 4
• When TRFs occur, repeating the full course of either IVIG or plasmapheresis is common practice 3
• Important: 40% of patients do not improve in the first 4 weeks following treatment—this does NOT indicate treatment failure 3, 4

When to Consider Plasmapheresis Over IVIG

Plasmapheresis may be preferred in specific circumstances:

• Resource-limited settings where cost is a major barrier (plasmapheresis costs approximately one-third the price of IVIG) 4
• Centers with established apheresis expertise and infrastructure 1
• Patients with contraindications to IVIG (IgA deficiency with anti-IgA antibodies, severe thrombotic risk factors) 1

Critical Monitoring Regardless of Treatment Choice

The "20/30/40 Rule" for respiratory failure risk 3, 4:

• Vital capacity <20 ml/kg
• Maximum inspiratory pressure <30 cmH₂O
• Maximum expiratory pressure <40 cmH₂O

Approximately 20% of GBS patients require mechanical ventilation, making respiratory monitoring essential regardless of immunotherapy choice 4, 5

Medications to Avoid During Treatment

These medications worsen neuromuscular function and must be avoided 3, 4, 5:

• β-blockers
• Aminoglycosides
• IV magnesium
• Fluoroquinolones
• Macrolides

Expected Outcomes

• 80% of patients regain walking ability at 6 months after disease onset 3, 4
• Mortality: 3-10%, primarily from cardiovascular and respiratory complications 3, 4
• Recovery can continue for more than 5 years after disease onset 4