Guillain Barr syndrome

Plasma exchange (PE) was the first treatment to be shown to be effective in GBS.73 Subsequent trials confirmed its efficacy so that it became accepted as the gold standard74 before being superseded by intravenous immunoglobulin (IVIg). A Dutch trial showed that the rate of recovery was similar or possibly slightly faster in patients treated with IVIg 0 4 g/kg daily for five days compared with those treated with PE.75 A large international trial compared PE alone with IVIg alone and PE followed by IVIg.76 A Cochrane review including these and other smaller trials concluded that there is no significant difference in outcome between the treatments.77 Although IVIg is expensive, it is not much more expensive than PE and it is more widely available and simpler to give. Although there was a trend towards more rapid recovery in the patients who received combined treatment with PE followed by IVIg, this was not significant, and not sufficient to justify the extra inconvenience, risk, and cost.76 The usual regimen is 0 4 g/kg of intravenous immunoglobulin by intravenous infusion daily for five consecutive days. There is a small risk of anaphylaxis which is greatest during the first 20 minutes of each infusion. There is also a concern about exacerbating pre-existing renal failure. Side effects include headache, myalgia, flushing, hypotensive reactions, and skin rashes including eczema on the hands.

Although steroids might have been expected to be beneficial in GBS, neither a small trial of oral prednisolone nor a large double-blind trial of intravenous methylprednisolone 500 mg daily for five days demonstrated any benefit. A Cochrane systematic review concluded that corticosteroids should not be used in GBS.78 This conclusion may need to be revised when the results of another large trial comparing combined IVIg and intravenous methylprednisolone 500 mg daily for five days with IVIg and placebo is published. The abstract reports slightly faster recovery with the combined treatment but no difference in the long term outcome.79 It is unlikely that the meta-analysis of all the high quality evidence will show benefit from steroids. Physicians will have to decide whether to draw conclusions from the overall analysis or only from the most recent trial, which might be considered more relevant since the patients all received IVIg which is now almost universally used as the first-line treatment.

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