Are corticosteroids (such as prednisone or methylprednisolone) effective for treating Guillain-Barré Syndrome (GBS)?

Corticosteroids Are Not Effective for Guillain-Barré Syndrome

Corticosteroids alone should not be used to treat Guillain-Barré Syndrome (GBS), as they have been proven ineffective and may worsen outcomes, particularly in mechanically ventilated patients. 1, 2, 3

First-Line Treatment: IVIg or Plasma Exchange

The standard of care for GBS involves immunotherapy, not corticosteroids:

• Intravenous immunoglobulin (IVIg) at 0.4 g/kg/day for 5 consecutive days (total 2 g/kg) is the first-line treatment for patients who cannot walk unaided or show signs of respiratory compromise, dysphagia, facial weakness, or bulbar weakness 1, 2

• Plasma exchange (PE) is equally effective to IVIg, but IVIg is generally preferred due to easier administration, wider availability, higher completion rates, and fewer adverse effects 1, 2, 3

• Treatment should be initiated as early as possible in the disease course to maximize effectiveness 1

Evidence Against Corticosteroids

Multiple high-quality studies demonstrate that corticosteroids are ineffective or harmful:

• Randomized controlled trials show no significant benefit from corticosteroids alone, and oral corticosteroids may have negative effects on outcomes 1, 3

• In mechanically ventilated patients, adding corticosteroids to IVIg worsens short-term prognosis: only 72.4% showed improvement with combination therapy versus 97% with IVIg alone (P < 0.05) 4

• Network meta-analysis of 2,474 patients from 28 trials confirmed that methylprednisolone and prednisolone showed no improvement compared with placebo, while PE and IVIg were significantly more effective 5

• Corticosteroids are ineffective for GBS but can be considered only when acute-onset chronic inflammatory demyelinating polyneuropathy (A-CIDP) is suspected due to prolonged disease course 6

Treatment Algorithm Based on Disease Severity

For patients unable to walk independently (Hughes Functional Grading Scale >3):

• Initiate IVIg 0.4 g/kg/day for 5 days immediately 1, 2
• Admit to unit with rapid ICU transfer capability 2
• Monitor respiratory function using the "20/30/40 rule" (vital capacity <20 ml/kg, maximum inspiratory pressure <30 cmH₂O, maximum expiratory pressure <40 cmH₂O indicates high risk of respiratory failure) 2

For patients able to walk with help (Hughes grade 3):

• Supportive treatment may be sufficient 4
• Consider IVIg if progression occurs 1

For mildly affected patients (Hughes grade <3):

• Supportive treatment is typically adequate 4

Special Populations

In children:

• IVIg is preferred over plasma exchange due to better tolerability and fewer complications 1
• The same 5-day regimen (0.4 g/kg/day for 5 days) should be used rather than accelerated 2-day protocols 1

In pregnant women:

• IVIg is preferred over plasma exchange due to fewer monitoring requirements, though neither is contraindicated 1

Combination Therapy Evidence

Adding corticosteroids to IVIg or PE provides no additional benefit and may cause harm:

• PE followed by IVIg showed no clinically significant difference compared to PE alone (mean grade improvement 0.2,95% CI -0.14 to 0.54) 3
• Immunoabsorption followed by IVIg did not reveal significant extra benefit from combined treatment 3
• In bedridden patients without mechanical ventilation, combination therapy showed no improvement over IVIg alone 4

Critical Medications to Avoid

The following medications worsen neuromuscular function and must be avoided in GBS patients:

• β-blockers 7, 2
• IV magnesium 7, 2
• Fluoroquinolones 7, 2
• Aminoglycosides 7, 2
• Macrolides 7, 2

Prognosis and Recovery

• Approximately 80% of patients regain walking ability at 6 months after disease onset 1, 2
• Mortality occurs in 3-10% of cases, most commonly from cardiovascular and respiratory complications 1, 2
• About 20% of GBS patients require mechanical ventilation 2
• Recovery can continue for more than 5 years after disease onset 2