Indications for Plasmapheresis in Guillain-Barré Syndrome
Plasmapheresis (plasma exchange) is indicated for GBS patients who cannot walk unaided (GBS disability score ≥3) and should be initiated as early as possible, preferably within 2 weeks of symptom onset, though it remains beneficial up to 30 days after disease onset. 1, 2, 3
Primary Indications by Disease Severity
Mild GBS
- Patients who cannot walk unaided but do not require ventilation should receive 2 sessions of plasma exchange (200-250 ml plasma/kg body weight total, divided over sessions) 3
- Treatment is most effective when started within 7 days of symptom onset 3, 4
Moderate GBS
- Patients with significant disability requiring assistance for most activities should receive 4 sessions of plasma exchange 3
- Four sessions are significantly superior to two sessions in this population 3
Severe GBS Requiring Mechanical Ventilation
- Patients requiring mechanical ventilation should receive 4 sessions of plasma exchange 3
- Six sessions are not superior to four sessions in ventilated patients, so the standard remains 4 sessions 3
- Plasma exchange is particularly effective when initiated in patients who require mechanical ventilation after study entry 5
Critical Clinical Indicators for Treatment
Respiratory compromise indicators that warrant immediate plasma exchange consideration include: 1, 2
- Vital capacity <20 ml/kg
- Maximum inspiratory pressure <30 cmH₂O
- Maximum expiratory pressure <40 cmH₂O
- Approximately 20% of GBS patients will require mechanical ventilation 1, 6
Additional high-risk features warranting plasma exchange: 2
- Rapid progression of weakness
- Dysphagia or bulbar weakness
- Facial weakness
- Presence of facial and/or bulbar weakness at hospital admission (increases EGRIS score) 7
Timing Considerations
Optimal treatment window: 3, 4
- Most beneficial when started within 7 days of disease onset
- Still beneficial when started between 7-30 days after onset, though benefit is less apparent after 7 days
- Early plasmapheresis (within 7 days) results in 2-3 grade power improvement in 82.14% of patients versus only 50% when started late 4
Special Populations
Children
- IVIg is strongly preferred over plasma exchange in pediatric patients due to better tolerability and fewer complications 1, 2, 6
- Plasma exchange is only recommended in children when IVIg is unavailable or contraindicated, and should only be performed at centers experienced with its use 7
Pregnant Women
- Neither plasma exchange nor IVIg is contraindicated during pregnancy 7, 2
- However, IVIg is generally preferred because plasma exchange requires additional monitoring considerations and precautions 7, 1
GBS Variants
- Miller-Fisher Syndrome (MFS): Treatment generally not recommended as most patients recover completely within 6 months without intervention, though close monitoring is essential 7, 2
- Bickerstaff Brainstem Encephalitis (BBE): Severity justifies treatment with plasma exchange or IVIg, though evidence is limited 7
- Other clinical variants: No specific evidence available, but many experts administer plasma exchange or IVIg 7
When Plasma Exchange is Preferred Over IVIg
While IVIg and plasma exchange are equally effective, plasma exchange may be preferred in: 7, 6
- Resource-limited settings where cost is a major factor (plasma exchange costs ~$4,500-5,000 versus IVIg at $12,000-16,000)
- Patients who fail to respond to IVIg (immunoadsorption plasmapheresis may be considered as second-line therapy) 8
Important Caveats
Combination therapy is NOT recommended: 7
- Plasma exchange followed by IVIg is no more effective than either treatment alone
- Sequential therapy should be avoided
Treatment-related fluctuations (TRFs): 2, 6
- Occur in 6-10% of patients within 2 months of initial improvement
- Repeating the full course of plasma exchange is common practice for TRFs
Non-response does not indicate treatment failure: 6
- 40% of patients do not improve in the first 4 weeks following treatment
- Recovery can continue for more than 5 years after disease onset