Immunomodulating effective as plasma exchange. However, corti-costeroids alone

 Immunomodulating Treatment considered
sufficiently severe to outweigh the advantage of four exchanges. As outlined in
further detail in the following 
sections, plasma exchange is more effective than  treatment alone. IV Ig therapy appears to
cal  as effective as plasma exchange.
However, corti-costeroids alone do not alter the outcome of GBS.

Plasma exchange

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In 1978, Brettleet al first drew attention to the
improved outcome in a patient with Guillain- Barré syndrome following plasma
exchange.(23) In the North American trial, patients were subjected
to a plasma exchange amounting to 200–250 ml/kg body weight over 7–14 days.(24)
The complications of plasma exchangeinclude hypotension, septicaemia, hypocalcaemia,and
abnormal clotting.(25)

 

 

High-Dose Immunoglobulin

 

IVIg was first
introduced for the treatment of idiopathic thrombocytopenic purpura in 1981 (26)
and is now a promising therapy in patients with various autoimmune diseases.

IVIg and plasma
exchange were compared as  regards their
effectiveness in a multicentre study  150
patients with GBS in The Netherlands.(27) IVIg was given at a dosage
of 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 were
not blinded.

Thus, these two
treatments were compared again in  a
large multicentre, randomised trial.(28) Plasma ex-  change (five times over 10–14 days) was
compared. with IVIg 400mg/kg/day for 5 consecutive days’ treatment, and with a
combined treatment of plasma exchange followed by IVIg in 379 patients
with  severe GBS.

 

Corticosteroids

Corticosteroids are widely used to
treat many in autoimmune disorders.In a large, controlled study involving 124
patients with GBS treated with a high-dose corticosteroid (intravenous
methylprednisolone 500mg for 5 days) and 118 patients treated with placebo, no
significant difference was observed in any of the following: mean disability at
4 weeks, proportion of patients. who had improved one clinical grade, or
clinical grade at 12 months.(29) The Cochrane evidencewalking; based
review of 2003, which included six eligible trials, concluded that
corticosteroids 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 a
recent study conducted in 37 patients with GBS who were unable to walk
unassisted, functionalimprovement was assessed at 28 days after randomisation
to CSF infiltration or plasma exchange. It was concluded that CSF filtration
andstandard plasma exchange are equally efficacious.(31) This
treatment needs further confirmation.A therapeutic benefit from interferon-?suggested
because interferon-??inhibits in vitro
lymphocyte 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 inhibit
clinical and histological features of the disease, suggesting that these are
useful as additional therapeutic agents in GBS.(33)

 

 Supportive
Treatment

The advent of
respiratory assistance with improved care has significantly improved the
outcome of patients with GBS. Care for severely affected patients is best
provided in tertiary centres with intensive care facilities and a team of
medical 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 supportive
treatment.(34)

 

Measurement of
maximal expiratory vital capacity suffices for bedside guidance as to the
adequacy of diaphragmatic strength and the likelihood of respiratory failure.
If the vital capacity falls to 15 mL/kg, endotracheal intubation and mechanical
ventilation should be considered. Patients with bulbar palsy may require
intubation even earlier to prevent aspiration, but mechanical ventilation is
not always required at the same time. (34)

Continuous
monitoring of blood pressure and  heart
rate is useful to prevent death from arrhythmia and haemodynamic instability
related to autonomic  involvement.
Hypotension secondary to dysautonomia, which occurs in approximately 10% of
severely  affected patients, is treated
by intravenous volume  and the use of
vasopressor agents for brief periods. Prominent hypertension is managed by  short-acting antihypertensive medication. The
choice of short-acting agent is important because a  drop in blood pressure may rapidly succeed
hypertension.(34)