Should This Improving GBS Patient Receive Plasmapheresis After IVIG?
No, this patient should not receive plasmapheresis at this time because they are demonstrating clear clinical improvement after IVIG treatment. Adding plasmapheresis to a patient already responding to IVIG is not supported by evidence and would not provide additional benefit.
Clinical Reasoning
Current Clinical Status Indicates Treatment Response
- Your patient shows multiple signs of improvement: phonating with PMV valve, regaining arm movement, and overall clinical progression from quadriparesis 1
- Approximately 40% of GBS patients do not improve in the first 4 weeks following treatment, but ongoing progression does not mean treatment is ineffective—progression might have been worse without therapy 1
- The key distinction is that your patient IS improving, not progressing or plateauing 1
Evidence Against Adding Plasmapheresis After IVIG
The highest quality evidence shows no benefit from sequential therapy:
- A trial with 249 participants comparing plasma exchange followed by IVIG versus plasma exchange alone showed the combined treatment provided only 0.2 grade improvement (95% CI -0.14 to 0.54)—not clinically significant 2
- Another trial with 34 participants comparing immunoabsorption followed by IVIG versus immunoabsorption alone revealed no significant extra benefit from combined treatment 2
- Critically, plasmapheresis immediately after IVIG will remove the immunoglobulin you just administered, making the sequence counterproductive 1
When to Consider Additional Treatment
Treatment-Related Fluctuations (TRFs):
- TRFs occur in 6-10% of GBS patients and are defined as disease progression within 2 months following initial treatment-induced improvement or stabilization 1
- If your patient experiences a TRF (worsening after initial improvement), repeating the full course of IVIG or plasma exchange is common practice, though evidence is lacking 1
- Your patient does not meet TRF criteria—they are improving, not fluctuating 1
Insufficient Response to Treatment:
- Consider repeating treatment or changing to alternative therapy only if there is no improvement after 4 weeks, though no evidence exists that this approach improves outcomes 1
- A clinical trial investigating the effect of administering a second IVIG dose is ongoing 1
Comparative Efficacy of IVIG vs Plasmapheresis
- Seven trials with 623 severely affected participants showed no significant difference between IVIG and plasma exchange: mean difference of 0.02 grade improvement (95% CI 0.25 to -0.20) 2
- IVIG is significantly more likely to be completed than plasma exchange, with fewer discontinuations 2, 3
- IVIG showed slight advantage in reducing need for mechanical ventilation and hospital stay duration 3
Expected Recovery Timeline
- Most GBS patients show extensive recovery, especially in the first year after disease onset 1
- Approximately 80% of patients regain walking ability at 6 months 1, 4
- Recovery may still occur >5 years after disease onset 1
Critical Pitfall to Avoid
Do not administer plasmapheresis shortly after IVIG—this will remove the therapeutic immunoglobulins you administered, negating the treatment benefit 1. If plasmapheresis were ever indicated, it should be given first, not after IVIG.
Monitoring Recommendations
- Continue frequent neurological assessments to track disease progression 4
- Monitor for autonomic dysfunction via electrocardiography, heart rate, blood pressure, and bowel/bladder function 4
- Watch specifically for TRFs (worsening after initial improvement) over the next 2 months 1
- Ensure multidisciplinary rehabilitation involvement including physiotherapy, occupational therapy, and speech therapy 1