GUILLAIN-BARRE-SYNDROME - RESPECTIVE INDICATIONS OF PLASMA-EXCHANGE AND IMMUNOGLOBULINS

The effect of plasma exchange (PE) in the Guillain-Barre syndrome (GBS) has been evaluated in 4 randomized clinical trials. A positive effect could be excluded in only one study conducted in Great Britain which included 29 patients. The more powerful studies conducted in Sweden (39 patients), in North America (245 patients) and in France (220 patients) demonstrated that early use of four PEs in patients with a GBS severe enough to require assistance in walking was followed by decreased duration and severity of the acute phase. These conclusions were ratified at a North American consensus conference. More recently, PE has been demonstrated to increase the number of patients who recover normal muscular power after a 1-year follow-up. The French trial also demonstrated that diluted albumin should be prefered over fresh frozen plasma. The number of plasma exchanges and the role of PE in initially benign forms is of great importance and is now under study by a cooperative group in France. The effect of immunoglobulins (IgG) was recently investigated in a randomized trial including 150 patients. In this study, high doses (0.4 g/kg/day for 5 days) were compared with 5 PE administered between days 7 and 14 in children and adults who, at inclusion, were unable to walk. The main result was that the outcome at one month was as good with IgG as with PE. Treatment is easier with IgG, and morbidity is lower. Direct costs are similar. If IgG are shown to be as effective as PE, IgG should be given for GBS. In the present state of our knowledge, PE is the gold standard treatment for GBS. PE should be performed as early as possible in patients who are unable to walk. The effectiveness of IgG must be confirmed by further trials. Indeed, one series is an insufficient basis for proof of effectiveness. It would, however, be logical to prescribe IgG in cases of immediate or secondary contraindications for PE, which, in our experience, occurs in 10 to 12 % of the patients. Optimal doses of IgG is yet to be determined.