IVIG Treatment Protocol for Guillain-Barré Syndrome
Administer intravenous immunoglobulin (IVIG) at 0.4 g/kg body weight daily for 5 consecutive days (total dose 2 g/kg) as first-line treatment for Guillain-Barré syndrome. 1
Standard Dosing Protocol
- The 5-day regimen (0.4 g/kg/day × 5 days) is mandatory rather than accelerated 2-day protocols, as treatment-related fluctuations occur significantly more frequently with abbreviated courses 1
- Total cumulative dose equals 2 g/kg (for a 50 kg patient, this is 100 g total) 1
- Initiate treatment within 2 weeks of symptom onset for patients unable to walk unaided 2
- Treatment should begin as early as possible in the disease course to maximize effectiveness 1
Why IVIG Over Plasma Exchange
IVIG is preferred over plasma exchange despite equal efficacy because it offers easier administration, wider availability, and significantly higher completion rates 1, 2. Both treatments are equally effective for moderate to severe GBS, but the practical advantages of IVIG make it the first choice 3, 4.
Critical Pre-Treatment Assessment
- Verify serum IgA levels before the first infusion because IgA deficiency increases anaphylaxis risk; use IgA-reduced preparations if deficiency is confirmed 1
- Admit patients to a monitored unit with rapid ICU transfer capability, as approximately 25% develop respiratory failure 2, 5
- Apply the "20/30/40 rule" for respiratory monitoring: patient is at risk if vital capacity <20 mL/kg, maximum inspiratory pressure <30 cmH₂O, or maximum expiratory pressure <40 cmH₂O 1, 2
Medications to Avoid During Treatment
Absolutely avoid these medications as they worsen neuromuscular function: 1, 2, 5
- β-blockers
- IV magnesium
- Fluoroquinolones
- Aminoglycosides
- Macrolides
Monitoring During Infusion
- Monitor rigorously during and after each infusion for neurological function including motor strength, reflexes, and bulbar symptoms 1
- Watch for adverse infusion reactions 1
- Perform frequent respiratory function assessments using vital capacity and maximum inspiratory/expiratory pressures 2, 5
- Calculate the Erasmus GBS Respiratory Insufficiency Score (EGRIS) to predict probability of requiring mechanical ventilation 1, 2
Expected Response and Treatment Failures
- Approximately 40% of patients do not improve in the first 4 weeks following treatment, which does NOT indicate treatment failure 1, 2, 5
- About 80% of patients regain walking ability at 6 months 1, 2
- Treatment-related fluctuations (TRFs) occur in 6-10% of patients within 2 months of initial improvement 1, 5
When to Repeat IVIG
Repeat the full 5-day IVIG course ONLY for treatment-related fluctuations occurring within 2 months of initial improvement 1, 5. Do NOT routinely give a second course to patients with poor prognosis outside this window, as it increases serious adverse events without proven benefit 2, 5.
Special Populations
- Children: Use the same 5-day regimen (0.4 g/kg/day × 5 days); IVIG is preferred over plasma exchange due to better tolerability and fewer complications 1
- Pregnant women: IVIG is preferred over plasma exchange because it requires fewer monitoring considerations, though neither is contraindicated 1
- Miller-Fisher Syndrome: Treatment generally not recommended as most recover completely within 6 months without intervention, though close monitoring is essential 1
Common Pitfalls to Avoid
- Never use corticosteroids alone as they are ineffective and may worsen outcomes 1, 2, 5
- Do not use abbreviated 2-day IVIG protocols 1
- Do not routinely repeat IVIG in non-responders beyond the 2-month window for TRFs 2, 5
- Early recognition and treatment is critical—mortality remains 3-10%, primarily from cardiovascular and respiratory complications 1, 2, 5