Can we administer Intravenous Immunoglobulin (IVIG) to a patient with Guillain-Barré Syndrome (GBS) who worsened after initial improvement with plasmapheresis and developed a Deep Vein Thrombosis (DVT)?

Management of GBS Patient with Post-Plasmapheresis Relapse and DVT

Yes, you can and should administer IVIG to this patient who has worsened after initial plasmapheresis response, as IVIG is indicated for GBS patients showing no improvement or worsening after initial treatment. 1

Immediate Management Priorities

Address the DVT First

• Anticoagulation for the DVT must be initiated immediately as DVT is a recognized complication in GBS patients (occurring in up to 15-30% of severe cases requiring immobilization). 1
• IVIG can be safely administered while on anticoagulation therapy—there is no absolute contraindication. 2
• However, monitor closely for bleeding complications given the combination of anticoagulation and IVIG, which can rarely cause thrombotic events paradoxically. 3

Recognize This as a Treatment-Related Fluctuation (TRF)

• This clinical scenario represents a Treatment-Related Fluctuation (TRF), which occurs in 6-10% of GBS patients and is defined as disease progression within 2 months following initial treatment-induced improvement or stabilization. 4
• The worsening 5 days post-discharge after initial improvement with plasmapheresis fits this definition precisely. 4

IVIG Administration Strategy

Why IVIG is Appropriate Now

• For GBS patients showing no improvement or worsening after initial treatment, either plasmapheresis or IVIG is indicated. 1
• Since this patient already received plasmapheresis (3 sessions) and is now worsening, switching to IVIG is the logical next step rather than repeating plasmapheresis. 1
• Do NOT perform plasmapheresis immediately after IVIG, as plasmapheresis will remove the administered immunoglobulin, making the treatment counterproductive. 4

IVIG Dosing

• Standard IVIG dose: 0.4 g/kg/day for 5 days (total 2 g/kg). 5, 6
• This should be initiated promptly given the clinical deterioration. 1

Critical Monitoring During IVIG

• Monitor renal function closely (creatinine, BUN) before, during, and after IVIG infusion, as acute kidney injury is an uncommon but serious complication, particularly with sucrose-containing IVIG preparations. 2
• Risk factors for IVIG-related AKI include older age, pre-existing renal disease, diabetes, hypovolemia, and rapid infusion rates. 2
• Ensure adequate hydration before and during IVIG to minimize AKI risk. 2
• Monitor for thromboembolic complications given the existing DVT and the fact that IVIG itself carries a small thrombotic risk. 3

What NOT to Do

Avoid Repeat Plasmapheresis After IVIG

• If you give IVIG now, do not follow it with plasmapheresis, as this will negate the IVIG effect. 4

Evidence Against Second IVIG Dose

• Do NOT plan a routine second course of IVIG if the patient doesn't respond to the first course, as recent high-quality evidence shows no benefit and potentially increased mortality and thromboembolism risk. 3, 7
• A 2024 systematic review found that second IVIG doses in poorly responsive GBS patients showed no significant improvement (Adjusted OR: 1.4,95% CI: 0.6-3.3, p=0.45) and noted 4 deaths in the intervention group. 3
• A 2025 systematic review concluded with low certainty that there is no beneficial effect of further IVIG in unresponsive GBS. 7

Additional Management Considerations

Respiratory and Autonomic Monitoring

• Admit to a unit with ventilatory support capability, as 15-30% of GBS patients require mechanical ventilation. 1
• Perform daily vital capacity measurements and monitor for bulbar weakness. 1
• Monitor for autonomic dysfunction via continuous ECG, blood pressure monitoring, and assessment of bowel/bladder function. 4

Corticosteroid Consideration

• Steroids are NOT routinely recommended for idiopathic GBS; however, in the context of immune checkpoint inhibitor-related GBS (if applicable), methylprednisolone 2-4 mg/kg/day may be reasonable. 1
• For typical idiopathic GBS, avoid steroids as they have not shown benefit. 1

Multidisciplinary Support

• Initiate physiotherapy, occupational therapy, and speech therapy immediately to prevent complications and optimize recovery. 4
• DVT prophylaxis (now therapeutic anticoagulation given the established DVT) is essential, as immobility significantly increases thrombotic risk. 2

Prognosis and Follow-up

• Most GBS patients show extensive recovery, with approximately 80% regaining walking ability at 6 months. 4
• Continue frequent neurological assessments to track disease progression and watch specifically for further TRFs over the next 2 months. 4
• Recovery may continue for >5 years after disease onset, emphasizing the importance of long-term rehabilitation. 4