DR ANAND MUDKANNA D.M NEUROLOGYSPARSH NEUROCARE CENTRESOLAPUR

The first RCT on the use of IVIg in GBS was published in 1992,and demonstrated that it is as effective as PE.

A randomised trial comparing IVIG and PE in GBS.Dutch Guillain-Barre Study Group Van der Meche FG,Scmitz PI N Engl J Med.1992 Apr 23;326(17)

The combination of IVIg after PE wasnot significantly better than PE or IVIG alone Randomised trial of PE ,IVIg and combined treatment in GBS.Plasma exchange / Sandoglobulin GBS trial group

Lancet.1997 Jan 25;349(9047

By definition maximum is reached in 4 weeks, but most patients reach it in 2-3 weeks

Despite standard treatment with IVIG / PE, about 20% severely affected patients donot respond

Failure to respond to standard dose of IVIG, could be due to

1. greater axonal damage secondary to more severe & prolonged autoimmune attack.

2. variable IVIG clearance depending on disease severity & individuals.

Reinfusion is a reasonable approach for such patients

Recent study by KUITWAARD et al suggested a positive correlation between low globulin level increment & poor outcome

Rise in serum IgG ( delta IgG ) Two weeks after IVIG varies between patients

Patients with low delta IgG recovered more slowly & incompletely

K. Kuitwaard et al Ann Neural 2009 Nov ; 66 (5) : 597-603

174 GBS patients who had previously participated in 2 randomized clinical trails at entry, all patients were unable to walk unaided & received a standard dose of IVIG.Total IgG levels in serum samples obtained immediately before & 2 week after of IVIG administration were determined by turbidmentry & related to clinical outcome at 6 months

The increase in serum IgG 2 weeks after IVIG treatment varied considerably between patients ( mean 7.8g/l : standard deviation , 5.6 g/l ) patients with a low AigG significantly more slowly & fewer reached the ability to walk unaided at 6 month ( log rank p<0.001 ) in multivariate analysis adjusted for other known prognostic factors, a low IgG was independently associated with poor outcome ( p = 0.022 )

After a standard dose of IVIg treatment, GBS patients show a large variation in pharmacokinetics which is related to clinical outcome. This may indicate that patients with a small increase in serum IgG level may benefit from a higher dosage or second of IVIg

Ann Neurol 2009:66:597-603

P Farcas demonstrated hat even in patients showing early axonal degeneration & inexitable nerves at 15 days responded favorably to 2nd dose of IVIG given between days 14 & 21

( Farcas et al Lancet vol 351, no 9104 march 1998 )

5 -10 % GBS patients deteriorate after initial improvement or stabilization after IVIg.

Prolonged immune response causing persistent nerve damage these patients alos respond to 2nd dose of IVIg

1) Improvement in GBS disability scale of atleast one grade after IVIg followed by worsening of GBS disability scale of altleast one grade within first 2 months of disease onset.

2) Stabilization for more than 1 week after IVIg followed by worsening of GBS disability scale of more than one grade within first 2 months of disease onset.

1) when treatment is applied early in the disease cause, when disease process is still very active.

2) when there is on going immune reactivation

LH visser, PA van Doorn & The Dutch GBS group JNNP 1998

Age of the patient Presence of preceding diarrhea Severity on GBS disability scale at 1-2

weeks after admission (EGOS)

In addition factor to be included now is the magnitude of rise in the IgG titer of 2 weeks of IVIg.

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