Plasmapheresis or IVIG for GBS

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Plasmapheresis or IVIG for GBS www.rrnmf.com Richard J. Barohn, MD Chair, Department of Neurology Gertrude and Dewey Ziegler Professor of Neurology University Distinguished Professor Vice Chancellor for Research University of Kansas Medical Center Kansas City, KS

GBS 245 pts/21 centers Randomized/Not Blinded Time to Walk Unaided Plasmapheresis North American Study (Neurology 1985; 35:1096) 245 pts/21 centers Randomized/Not Blinded Time to Walk Unaided Pheresis pts dec. time by: 32 days (all) 72 days (respirator) Average Time on Vent. Dec. by 12 Days

GBS: Dutch IVIG vs. Plasmapheresis Studies Compared to the North American Plasmapheresis Study IVIG PE Control Total patients 74 73 108 120 Improved 1 grade (4 wk) 53% 34% 59% 39% Median days to 1 grade ^ 27 41 19 40 Days grade 2 55 69 # multiple complications 5 6 -- Ventilator by week 2 27% 42% Dutch Guillain-Barré Study Group. N Engl J Med 1992;326, 1123-1129

PE, IVIG, and PE + IVIG for GBS Mean change in disability .9 .8 1.1 Number of patients ventilated 28 29 21 Days to stopping ventilation 26 18 Days to unaided walking 49 51 40 Days to hospital discharge 63 53 Days to returning to work 290 371 281 Unable to walk after 48 days 19 17 Deaths 5 6 8 Hughes et al. Lancet.1997;349:225-230.

AAN Practice Parameters: Immunotherapy for GBS (Quality Standards Subcommittee AAN) Treatment with plasma exchange (PE) or IVIG hastens recovery from GBS PE is recommended in non-ambulant adult pts within 4 weeks of onset symps IVIG is recommended for non-ambulant adult pts within 2 or possibly 4 weeks of onset of symps PE and IVIG are treatment options for children with severe GBS Corticosteroids are not recommended for the management of GBS Hughes et al. Neurology.2003;61(6):736-740

Level of Evidence – Class 1 Neurology 2011; 76:294-300 Pheresis for GBS Level of Evidence – Class 1 Recommendation: Level A for severe GBS Level B for mild GBS

Level of evidence - Class 1 Recommendation: Neurology 2012; 78: 1009 - 1015 IVIG for GBS Level of evidence - Class 1 Recommendation: Level A, established effective because it is comparable to pheresis

GBS Treatment Caveats After PE or IVIG, Be Patient, Don’t Expect Dramatic Results No Reason to Use Both PLEX and IVIG No Reason to Use Steroids