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

Immediate Treatment for Guillain-Barré Syndrome

Initiate intravenous immunoglobulin (IVIg) at 0.4 g/kg body weight daily for 5 consecutive days as first-line therapy for any patient with GBS who cannot walk independently (GBS disability score ≥3), starting treatment as early as possible and ideally within 2 weeks of symptom onset. 1, 2, 3

First-Line Immunotherapy Selection

IVIg is strongly preferred over plasma exchange (PE) as initial treatment despite equal efficacy, because it offers:

• Easier administration and wider availability 1, 2
• Higher treatment completion rates 1, 3
• Better tolerability with fewer complications 2, 3
• Particularly preferred in children due to better tolerability 1, 2

However, PE remains an effective alternative (200-250 mL/kg total plasma volume divided into 5 sessions over 2 weeks) when IVIg is contraindicated or unavailable, and may be considered in resource-limited settings due to significantly lower cost (~$4,500-5,000 vs $12,000-16,000 for IVIg). 2, 4

Do NOT use corticosteroids alone—they are ineffective and oral corticosteroids may worsen outcomes. 1, 2

Do NOT routinely combine PE followed immediately by IVIg—this provides no additional benefit over either treatment alone. 3, 4

Critical Immediate Monitoring Requirements

Respiratory Assessment (The "20/30/40 Rule")

Admit ALL patients to an inpatient unit with rapid ICU transfer capability. 1, 3 Approximately 20% will require mechanical ventilation. 2

Patient is at high risk for respiratory failure requiring intubation if: 5, 1, 2

• Vital capacity <20 mL/kg, OR
• Maximum inspiratory pressure <30 cmH₂O, OR
• Maximum expiratory pressure <40 cmH₂O

Neurological Monitoring

• Assess muscle strength using Medical Research Council grading scale in neck, arms, and legs 5
• Document functional disability on GBS disability scale 5
• Monitor for swallowing and coughing difficulties (bulbar involvement) 5

Autonomic Dysfunction Surveillance

• Continuous electrocardiographic monitoring for arrhythmias 5
• Frequent blood pressure monitoring for hypertension/hypotension 5
• Monitor bowel and bladder function 5

Stay vigilant during the recovery phase—up to two-thirds of GBS deaths occur during recovery, primarily from cardiovascular and respiratory complications. 5 This is especially critical for patients recently transferred from ICU or those with cardiovascular risk factors. 5

Medications to AVOID

Immediately discontinue or avoid these medications that worsen neuromuscular function: 1, 2

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

Essential Supportive Care Measures

Prevent Common Complications

• DVT prophylaxis due to immobility 2
• Pressure ulcer prevention through regular repositioning 5, 2
• Prevention of hospital-acquired infections (pneumonia, UTIs) 5, 2
• Constipation/ileus management 1

Symptom Management

• Aggressive pain control with neuropathic pain medications (gabapentinoids, tricyclic antidepressants, or carbamazepine)—severe pain occurs in at least one-third of patients 5, 2, 4
• Psychological support—actively screen for anxiety, depression, and hallucinations, particularly in ICU patients with limited communication 5
• Maintain patient dignity—remember that even completely paralyzed patients typically have intact consciousness, vision, and hearing; explain all procedures and be mindful of bedside conversations 5

Specialized Care for Specific Deficits

• Facial palsy: prevent corneal ulceration 5
• Bulbar palsy: assess swallowing safety, consider speech therapy and dietitian consultation 5
• Limb weakness: prevent contractures, ossification, and pressure palsies through physiotherapy 5

Management of Treatment Non-Response

Approximately 40% of patients do not improve in the first 4 weeks following treatment—this does NOT indicate treatment failure, as progression might have been worse without therapy. 5, 2, 3 Currently, no evidence supports repeating treatment or switching therapies in this scenario. 5

Treatment-Related Fluctuations (TRFs)

If clinical deterioration occurs within 2 months after initial improvement or stabilization (occurs in 6-10% of patients), repeat the full course of IVIg or PE. 5, 2, 3 This indicates the treatment effect has worn off while inflammation continues. 5

Chronic Disease Evolution

If three or more TRFs occur, or clinical deterioration continues ≥8 weeks after onset (~5% of cases), change diagnosis to acute-onset CIDP and adjust treatment accordingly. 5, 3, 4

Prognosis Counseling

• 80% of patients regain independent walking ability at 6 months 5, 2, 3
• Mortality is 3-10%, primarily from cardiovascular and respiratory complications 5, 2, 3
• Risk factors for mortality: advanced age and severe disease at onset 5, 2
• Recovery can continue for >5 years after disease onset 5, 2
• Use the modified Erasmus GBS Outcome Score (mEGOS) to calculate individual probability of walking recovery 5, 4