What is the preferred treatment between Intravenous Immunoglobulin (IVIG) and plasmapheresis (plasma exchange) for Guillain-Barré Syndrome (GBS)?

IVIG vs Plasmapheresis for Guillain-Barré Syndrome

IVIG is the preferred first-line treatment for GBS over plasmapheresis, despite equal efficacy, because it is easier to administer, more widely available, has higher treatment completion rates, and requires less intensive monitoring. 1, 2

Treatment Efficacy: Equally Effective, But IVIG Preferred

Both treatments are equally effective at hastening recovery and reducing long-term morbidity when comparing clinical outcomes 1, 2, 3:

• Standard IVIG dosing: 0.4 g/kg/day for 5 consecutive days (total 2 g/kg) 1, 2, 4
• Standard plasmapheresis: 200-250 ml plasma/kg body weight over 5 sessions 1, 4
• No significant difference in achieving functional recovery (Hughes score improvement) at 4 weeks 5
• No significant difference in length of hospitalization or duration of mechanical ventilation 5
• No significant difference in risk of GBS relapse (6-10% for treatment-related fluctuations within 2 months) 2, 4, 5

Why IVIG is Preferred Over Plasmapheresis

The practical advantages of IVIG make it the treatment of choice 1, 2:

• Significantly lower discontinuation rates: IVIG has 78% lower risk of treatment discontinuation compared to plasmapheresis (RR: 0.22; 95% CI: 0.06-0.88) 5
• Easier administration: No need for specialized equipment or vascular access expertise 1, 4
• Wider availability: Can be administered in most hospital settings without specialized plasmapheresis equipment 1, 2
• Comparable adverse event rates: Despite early studies suggesting plasmapheresis had more complications, recent meta-analysis shows similar overall complication rates between treatments 1, 5

When to Initiate Treatment

Start treatment immediately for patients who cannot walk unaided or have any of the following 2, 3:

• Moderate to severe weakness with rapid progression 2
• Any signs of respiratory compromise 2, 3
• Dysphagia, facial weakness, or bulbar weakness 2
• Treatment should be initiated within 2 weeks of symptom onset for maximum effectiveness 4, 3

Special Populations Where IVIG is Strongly Preferred

Children: IVIG is the clear first-line choice due to better tolerability, fewer complications, and less discomfort compared to plasmapheresis 1, 2, 3, 6

Pregnant women: IVIG is preferred because plasmapheresis requires additional monitoring considerations and precautions, though neither is contraindicated 1, 2, 3

Limited resources: While small-volume plasma exchange may be considered as an economical alternative in resource-limited settings, it cannot be recommended for general use until further evidence establishes efficacy 1

Critical Monitoring Requirements

Approximately 20-25% of GBS patients require mechanical ventilation, necessitating close respiratory monitoring 4, 3:

• Admit to monitored unit with rapid ICU transfer capability 2, 4, 3
• Use the "20/30/40 rule": Patient at risk if vital capacity <20 ml/kg, maximum inspiratory pressure <30 cmH₂O, or maximum expiratory pressure <40 cmH₂O 2, 4, 3
• Calculate EGRIS score (Erasmus GBS Respiratory Insufficiency Score) to predict probability of requiring mechanical ventilation within 1 week 1, 2, 4

Important Treatment Pitfalls to Avoid

Never combine or sequence treatments: Plasmapheresis followed by IVIG is no more effective than either treatment alone and increases adverse events without proven benefit 1

Avoid corticosteroids: Eight randomized controlled trials showed no benefit, and oral corticosteroids may worsen outcomes 1, 2, 4

Avoid medications that worsen neuromuscular function 2, 4, 3:

• β-blockers
• IV magnesium
• Fluoroquinolones
• Aminoglycosides
• Macrolides

Do not routinely give second course of IVIG for poor prognosis: This increases serious adverse events without proven benefit, except for treatment-related fluctuations occurring within 2 months of initial improvement 4

Expected Outcomes and Realistic Expectations

• 40% of patients do not improve in the first 4 weeks following treatment—this does not indicate treatment failure 2, 4
• 80% regain walking ability at 6 months after disease onset 2, 4, 3
• Mortality remains 3-10%, primarily from cardiovascular and respiratory complications 2, 4, 3
• Treatment-related fluctuations occur in 6-10% of patients within 2 months; repeating the full IVIG course is appropriate for these cases 2, 4