Start Early Plasmapheresis or Immunoglobulins in Guillain-Barré Patients
Jose I. Suarez MD
Guillain-Barré syndrome (GBS) is an acute inflammatory disease of the peripheral nervous system that is usually characterized by ascending paralysis with a paucity of objective sensory findings. The progression and severity of the disease vary. However, many patients will require intensive care within the first few days of presentation and about one-third of them will need mechanical ventilation.
What to Do
There are currently two therapeutic modalities recommended for GBS: plasma exchange and immunoglobulin administration (IVIg). The decision to treat GBS patients depends on the severity of the disease, rate of progression of symptoms, and duration of symptoms to time of presentation. Patients with mild symptoms (e.g., mild sensory complaints and very distal motor involvement) may need to be treated with supportive care alone. Patients who present within 2 weeks of onset of symptoms may require treatment. Patients presenting beyond 2 weeks should probably also be treated, but the evidence is less convincing.
Plasma exchange has been available longer than IVIg for GBS and the only one compared with conventional therapy. Statistically significant differences, favoring the plasma-exchange-treated group, were found in terms of improvement to 4 weeks, time to independent walking, and outcome at 6 months. Plasma exchange is particularly efficacious in those patients presenting within 7 days of symptom onset and in those requiring mechanical ventilation. One of the main disadvantages of plasma exchange is its availability (Table 209.1). Not all centers are well equipped and experienced to perform plasma exchange in all patients with GBS. About 10% of patients may experience recurrent symptoms within 1 to 2 weeks after treatment with plasma exchange. This may be because of a rebound production of antibodies. Further treatments with plasma exchange improve symptoms. The recommended amount of plasma exchange is 200 to 250 mL/kg of body weight every other day for a total of five treatments.