Immunomodulating Treatment consideredsufficiently severe to outweigh the advantage of four exchanges. As outlined infurther detail in the following sections, plasma exchange is more effective than treatment alone.
IV Ig therapy appears tocal as effective as plasma exchange.However, corti-costeroids alone do not alter the outcome of GBS.Plasma exchangeIn 1978, Brettleet al first drew attention to theimproved outcome in a patient with Guillain- Barré syndrome following plasmaexchange.(23) In the North American trial, patients were subjectedto a plasma exchange amounting to 200–250 ml/kg body weight over 7–14 days.(24)The complications of plasma exchangeinclude hypotension, septicaemia, hypocalcaemia,andabnormal clotting.(25) High-Dose Immunoglobulin IVIg was firstintroduced for the treatment of idiopathic thrombocytopenic purpura in 1981 (26)and is now a promising therapy in patients with various autoimmune diseases.IVIg and plasmaexchange were compared as regards theireffectiveness in a multicentre study 150patients with GBS in The Netherlands.
(27) IVIg was given at a dosageof 400 mg/kg for 5 days consecutively,and the authors concluded that IVIg and plasma exchange were equally effective.However, the two patient groups were not equally matched and the assessors werenot blinded. Thus, these twotreatments were compared again in alarge multicentre, randomised trial.
(28) Plasma ex- change (five times over 10–14 days) wascompared. with IVIg 400mg/kg/day for 5 consecutive days’ treatment, and with acombined treatment of plasma exchange followed by IVIg in 379 patientswith severe GBS. CorticosteroidsCorticosteroids are widely used totreat many in autoimmune disorders.
In a large, controlled study involving 124patients with GBS treated with a high-dose corticosteroid (intravenousmethylprednisolone 500mg for 5 days) and 118 patients treated with placebo, nosignificant difference was observed in any of the following: mean disability at4 weeks, proportion of patients. who had improved one clinical grade, orclinical grade at 12 months.(29) The Cochrane evidencewalking; basedreview of 2003, which included six eligible trials, concluded thatcorticosteroids alone shouldnot be used in the treatment of GBS.
(30) Potentially Interesting Future Treatments Cerebrospinal fluid (CSF)filtration is a new,potentially effective treatment for patients with GBS. In arecent study conducted in 37 patients with GBS who were unable to walkunassisted, functionalimprovement was assessed at 28 days after randomisationto CSF infiltration or plasma exchange. It was concluded that CSF filtrationandstandard plasma exchange are equally efficacious.(31) Thistreatment needs further confirmation.A therapeutic benefit from interferon-?suggestedbecause interferon-??inhibits in vitrolymphocyte adhesion to recombinant vascular adhesion molecule-1.(32)In experimental allergic neuritis(a model of GBS), two new cyclo-oxygenase-2 inhibitors were found to inhibitclinical and histological features of the disease, suggesting that these areuseful as additional therapeutic agents in GBS.(33) SupportiveTreatmentThe advent ofrespiratory assistance with improved care has significantly improved theoutcome of patients with GBS. Care for severely affected patients is bestprovided in tertiary centres with intensive care facilities and a team ofmedical professionals familiar with the special needs of patients with GBS.
Intubation and mechanical ventilation are required for 25–33% of these patients,and therefore respiratory support is the most important form of supportivetreatment.(34) Measurement ofmaximal expiratory vital capacity suffices for bedside guidance as to theadequacy of diaphragmatic strength and the likelihood of respiratory failure.If the vital capacity falls to 15 mL/kg, endotracheal intubation and mechanicalventilation should be considered. Patients with bulbar palsy may requireintubation even earlier to prevent aspiration, but mechanical ventilation isnot always required at the same time.
(34)Continuousmonitoring of blood pressure and heartrate is useful to prevent death from arrhythmia and haemodynamic instabilityrelated to autonomic involvement.Hypotension secondary to dysautonomia, which occurs in approximately 10% ofseverely affected patients, is treatedby intravenous volume and the use ofvasopressor agents for brief periods. Prominent hypertension is managed by short-acting antihypertensive medication. Thechoice of short-acting agent is important because a drop in blood pressure may rapidly succeedhypertension.(34)