guillain_barre

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Guillain-Barre Syndrome - IV immunoglobulin as effective as plasma exchange

Clinical Bottom Line:
Plasma exchange and IV immunoglobulin were equally effective in improving disability grade for Guillain-Barre syndrome

Citations:

van der Meche FG, Schmitz PI and the Dutch Guillain Barre study group. A randomised trial comparing intravenous immune globulin and plasma exchange in GBS. N Engl J Med 1992;23:1123-9.
Plasma Exchange/Sandoglobulin GBS Trial Group. Randomised trial of plasma exchange, intravenous immunoglobulin, and combined treatments in Guillain-Barre Syndrome. Lancet 1997;349:225-30.

Clinical question: In a patient with GBS, is IVIg as effective as plasma exchange in improving disability?

Search: "guillain barre" in Best Evidence

Study 1

randomised, controlled, single-blind trial with 4 week follow-up
included pts with GBS who could not walk 10 metres independently and had onset of symptoms within the previous 14 days

Control (N=73): plasma exchange - 200-250 ml of plasma/kg body weight in 5 sessions within 7-14 days-could be repeated if pt deteriorated > 1 week after responding to treatment

Experimental (N=74): IVIg (0.4 g/kg body weight per d for 5 days) - could be repeated if patient deteriorated

The Evidence

OUTCOME	CER	EER	ABI (95% CI)	NNT
improvement of = 1 point in motor function*	0.34	0.53	0.19 (3 to 34)	5
OUTCOME	CER	EER	ARR (95% CI)	NNT
multiple complications	0.22	0.07	0.15	7 (4 to 24)

*7-point (healthy-dead) scale of motor function

Study 2

randomised, controlled, single-blind trial with 48 week follow-up, analysis by intention to treat
included pts with severe GBS (required an aid to walk or worse) and had onset of neuropathic symptoms within the previous 14 days

Group 1: 121 pts received plasma exchange (5 exchanges over 8-13 days)

Group 2: 130 pts IVIg for 5 days

Group 3: 128 pts plasma exchange immediately followed by IVIg

The Evidence

Treatment Group	Difference in Improvement
Group 1 vs Group 2	0.09 grade (-0.23 to 0.42)
Group 3 vs Group 1	0.20 grade (-0.14 to 0.54)
Group 3 vs Group 2	0.29 grade (-0.04 to 0.63)

Comments

study 1 stopped early because the 4 week improvement rate in motor function was significant
median times to improvement and to recovery of independent function were 27 days compared with 41 days and 55 days compared with 69 days for Ig and PE respectively in study 1
in study 2, clinically important effect was assumed to be at least 0.5 disability grade improvement
cost-effectiveness data would be important to help with decision making

Appraised by: Straus; Nov 1997, Expiry Date: March 1998

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