Do Not Start Steroids After IVIg in Guillain-Barré Syndrome
Corticosteroids should not be administered after IVIg in GBS, as they have been proven ineffective and may even worsen outcomes. 1
Evidence Against Steroid Use in GBS
The evidence is unequivocal and consistent across multiple high-quality guidelines:
Eight randomized controlled trials demonstrated no significant benefit from corticosteroids in GBS, and oral corticosteroids were actually shown to have a negative effect on outcome 1
Steroids alone are completely ineffective in GBS treatment 2, which is surprising given their efficacy in other autoimmune conditions but reflects the unique pathophysiology of this disease
Plasma exchange followed by IVIg is no more effective than either treatment alone, and there is insufficient evidence supporting add-on treatment with intravenous methylprednisolone in IVIg-treated patients 1
Standard Treatment Approach
The established treatment protocol for GBS is straightforward:
IVIg monotherapy (0.4 g/kg/day for 5 days) is the first-line treatment and is preferred over plasma exchange due to ease of administration, wider availability, and higher completion rates 1, 3, 4
Plasma exchange (200-250 ml/kg over 5 sessions) is equally effective to IVIg but more difficult to administer 1
No other drugs or procedures beyond IVIg or plasma exchange have proven effective in treating GBS 1
Special Circumstances Where Steroids Are Sometimes Considered
While the guideline evidence is clear against routine steroid use, there are limited contexts where steroids have been tried:
In immune checkpoint inhibitor-related GBS (a distinct entity from classic GBS), methylprednisolone 2-4 mg/kg/day may be considered as a trial alongside IVIG or plasmapheresis, though this represents a different disease mechanism 1
For steroid-refractory immune-related adverse events in cancer immunotherapy patients, corticosteroids are part of the management algorithm, but this applies to the broader context of immune-related toxicities, not specifically to classic GBS 1
What to Do Instead After IVIg
If a patient fails to improve after standard IVIg treatment:
About 40% of patients do not show improvement in the first 4 weeks following treatment, which does not necessarily indicate treatment failure 3, 5
For treatment-related fluctuations (occurring in 6-10% of patients), repeat the full course of IVIg or plasma exchange rather than adding steroids 3, 5
Focus on multidisciplinary supportive care including respiratory monitoring (using the 20/30/40 rule for vital capacity, inspiratory and expiratory pressures), pain management, prevention of complications, and rehabilitation 3
Consider whether the patient has progressed to acute-onset CIDP (defined as three or more treatment-related fluctuations and/or clinical deterioration ≥8 weeks after onset), which requires different management 5
Critical Monitoring Parameters
Rather than adding steroids, focus on these essential monitoring elements:
Respiratory function assessment is paramount, as approximately 20-22% of GBS patients require mechanical ventilation 1, 3
Single breath count ≤19 predicts need for mechanical ventilation 3
Autonomic dysfunction monitoring via ECG, blood pressure, and bowel/bladder function 3
Avoid medications that worsen neuromuscular function including β-blockers, IV magnesium, fluoroquinolones, aminoglycosides, and macrolides 3
Common Pitfall to Avoid
The most important pitfall is assuming that lack of improvement after IVIg means additional immunosuppression with steroids is needed. The evidence clearly shows steroids do not help and may harm. Instead, ensure adequate supportive care, monitor for complications, and consider repeating IVIg or plasma exchange only if true treatment-related fluctuations occur, not simply slow recovery 1, 3, 5.