IMMUNOTHERAPY
- Both intravenous immunoglobulin (IVIG) and plasmaphoresis (plasma exchange) have been proven to accelerate the rate of recovery in Guillain-Barre Syndrome [18,19,20.]
- There is no significant difference in therapeutic efficacy between plasma exchange and intravenous immunoglobulin. There are clear practical advantages to using immunoglobulins. A combination of both treatments shows only a trend favouring that approach[21.]
- 10% of early treated patients will relapse in the following 10 days
- Retreatment is recommended in cases of relapse (using half of the original dose of immunoglobulin)
- Late treatment (treatment instituted more than three weeks after the first symptoms) is not of any proven benefit.
Immunoglulin
Intravenous immunoglobulin (IVIG) should be given in the following circumstances:
- Patient is deteriorating at the time the diagnosis is made, irrespective of the functional state of the child or physical findings.
- Patient is non-ambulant at the time of diagnosis.
- Any evidence of bulbar or respiratory dysfunction at diagnosis.
Schedule
- Total dose of 2g/kg, divided into 5 consecutive daily doses of 400mg/kg each or 3 consecutive days of 700mg/kg each.
- or a 2g/kg continuous infusion over 3 days.
- or a single dose (2g/Kg) infusion over 24 hours[22,23]
Advantages
- Simple to use
- Requires peripheral intravenous access only
Side Effects (rare)
- Chemical meningitis
- Anaphylaxis
- Thromboembolic events eg: stroke
- Acute renal failure in patients with underlying renal impairement
- Theoretical risk of blood borne infection, including HIV (no synthetic product available).
Plasmaphoresis
Currently there is no indication for using plasmaphoresis in preference to immunoglobulins. One specific situation for using plasmaphoresis rather than immunoglobulin is for religious reasons (eg; if the child/family are Jehovah's witnesses).
Schedule as follows:
- 50ml/kg over 7 days (using plasma exchange on the 1st,3rd,5th & 7th day)
- Two exchanges will benefit mild cases, four exchanges are preferable for moderate or severe cases.[19]
Advantage
- Unequivocally proven accelerated rate of recovery.[18,19,20.]
- Anecdotally, potentially useful in cases of relapse post IVIG.
Disadvantages
- Difficulty with venous access, placement and maintenance; infection.
- Cardiovascular symptoms, mainly hypotension
- Difficulty in completing treatment course (10-15% failed to complete course vs 5% for IVIG)
Corticosteroids:
- Corticosteroids should not be used in the treatment of GBS.
- If a patient requires steroids for some other reason its use will probably do no harm.
- The effect of intravenous methylprednisolone combined with intravenous immunoglobulin in GBS is being evaluated in a randomised trial.[24]