New Horizons in Guillain-Barré Treatment

November 1, 2007

The Dutch Guillain-Barré Study Group found that intravenous immunoglobulin and therapeutic plasma exchange were equally effective in the treatment of GBS. The Plasma Exchange/Sandoglobulin Guillain-Barré; Syndrome Trial Group demonstrated that therapeutic plasma exchange alone, intravenous immunoglobulin alone, and therapeutic plasma exchange immediately followed by a course of intravenous immunoglobulin were all equally effective.

 

What are the most effective therapies for Guillain-Barr syndrome (GBS)?

---- Herbert Gersh, MD
Treasure Island, Fla

The Dutch Guillain-Barr Study Group found that intravenous immunoglobulin and therapeutic plasma exchange were equally effective in the treatment of GBS.1 The Plasma Exchange/Sandoglobulin Guillain-Barr Syndrome Trial Group demonstrated that therapeutic plasma exchange alone, intravenous immunoglobulin alone, and therapeutic plasma exchange immediately followed by a course of intravenous immunoglobulin were all equally effective.2 Intravenous immunoglobulin after a course of therapeutic plasma exchange does not confer additional benefit. Anecdotal evidence suggests that relapses may be more frequent with intravenous immunoglobulin than with therapeutic plasma exchange, but this may result from differences in the length of treatment.3 Corticosteroids are not recommended for the treatment of GBS.4

The French Cooperative Group reported that among patients with severe GBS, 6 days of therapeutic plasma exchange was no more effective than 4 days.5 Research is needed to determine whether intravenous immunoglobulin given for longer than 5 days would be associated with fewer relapses.

Researchers are currently investigating treatments that might prove superior to intravenous immunoglobulin and therapeutic plasma exchange:

• Interferon-β may decrease adhesion and transmigration of lymphocytes and thus provide a potential therapeutic benefit to patients with GBS.6,7

• CSF filtration removes soluble inflammatory mediators and antibodies from sites where myelin or nerve damage may occur.8 CSF filtration could be used in combination with therapeutic plasma exchange or intravenous immunoglobulin to remove inflammatory mediators and antibodies from the spinal fluid and the blood.

• Immunoadsorption with a tryptophan-linked polyvinyl alcohol gel has been investigated in small studies.9,10

• Administration of nerve growth factors might enhance axonal regeneration.11

Further research on the pathogenesis of GBS is needed to develop more specific and more effective treatments. In the meantime, ancillary measures such as effective analgesia, proper timing of intubation and tracheostomy, and deep venous thrombosis prophylaxis can improve outcomes in patients with GBS.3

---- Deborah M. Green, MD
Associate Clinical Professor of Medicine
Associate Director, Stroke Center
University of Hawaii School of Medicine
Honolulu

References:

REFERENCES:


1.

van der Meché FG, Schmitz PI. A randomized trial comparing intravenous immune globulin and plasma exchange in Guillain-Barré syndrome. Dutch Guillain-Barré Study Group.

N Engl J Med.

1992;326:1123-1129.

2.

Plasma Exchange/Sandoglobulin Guillain-Barré Syndrome Trial Group. Randomised trial of plasma exchange, intravenous immunoglobulin, and combined treatments in Guillain-Barré syndrome.

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1997;349:225-230.

3.

Green DM, Weakness in the ICU: Guillain-Barré syndrome, myasthenia gravis, and critical illness polyneuropathy/myopathy.

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4.

Hughes RA, Wijdicks EF, Barohn R, et al. Practice parameter: immunotherapy for Guillain-Barré syndrome. Report of the Quality Standards Subcommittee of the American Academy of Neurology.

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5.

French Cooperative Group on Plasma Exchange in Guillain-Barré Syndrome. Appropriate number of plasma exchanges in Guillain-Barré syndrome.

Ann Neurol.

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6.

Creange A, Chazaud B, Plonquet A, et al. IFN-beta decreases adhesion and transmigration capacities of lymphocytes in Guillain-Barré syndrome.

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7.

Pritchard J, Gray IA, Idrissova ZR, et al. A randomized controlled trial of recombinant interferon-beta 1a in Guillain-Barré syndrome.

Neurology.

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Wollinsky KH, Hulser PJ, Brinkmeier H, et al. CSF filtration is an effective treatment of Guillain-Barré syndrome; results of a randomized clinical trial.

Neurology

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9.

Haupt WF, Birkmann C, van der Ven D, et al. Apheresis and selective adsorption plus immunoglobulin treatment in Guillain-Barré syndrome.

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10.

Diener HC, Haupt WF, Kloss TM, et al. A preliminary, randomized, multicenter study comparing intravenous immunoglobulin, plasma exchange, and immune adsorption in Guillain-Barré syndrome.

Eur Neurol.

2001;46:107-109.

11.

Bensa S, Hadden RD, Hahn A, et al. Randomized controlled trial of brain-derived neurotrophic factor in Guillain-Barré syndrome: a pilot study.

Eur J Neurol.

2000;7:423-426.

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