Cochrane Review: Intravenous immunoglobulin for Guillain‐Barré syndrome

Abstract

AbstractBackgroundGuillain‐Barré syndrome is an acute, paralysing, inflammatory peripheral nerve disease. Intravenous immunoglobulin is beneficial in other autoimmune diseases.ObjectivesWe aimed to determine the efficacy of intravenous immunoglobulin for Guillain‐Barré syndrome.Search strategyWe updated the searches of the Cochrane Neuromuscular Disease Group Trials Specialized Register, MEDLINE and EMBASE in June 2009 using the terms 'Guillain‐Barré syndrome' and 'acute polyradiculoneuritis' combined with 'intravenous immunoglobulin'.Selection criteriaWe included randomised and quasi‐randomised trials.Data collection and analysisTwo authors independently selected papers, extracted data and assessed quality.Main resultsAnother Cochrane systematic review has shown that plasma exchange significantly hastens recovery. In this review, five trials compared intravenous immunoglobulin with plasma exchange in 536 severely affected, mostly adult participants. The mean difference of change in a seven‐grade disability scale after four weeks was not significantly different between the two treatments: 0.02 (95% CI 0.25 to ‐0.20) of a grade more improvement in the intravenous immunoglobulin than the plasma exchange group. There were also no statistically significant differences in the other measures considered. Three studies including a total of 75 children suggested that intravenous immunoglobulin significantly hastens recovery compared with supportive care.In one trial involving 249 participants comparing plasma exchange followed by intravenous immunoglobulin with plasma exchange alone, the mean grade improvement was 0.2 (95% CI ‐0.14 to 0.54) more in the combined treatment group than in the plasma exchange alone group, not significantly different but not excluding the possibility of significant extra benefit. Another trial with 37 participants comparing immunoabsorption followed by intravenous immunoglobulin with immunoabsorption alone did not reveal significant extra benefit from the combined treatment.Small trials in children showed a trend towards more improvement with high‐dose compared with low‐dose intravenous immunoglobulin and no significant difference when the standard dose was given over two days rather than five days.Authors' conclusionsA previous Cochrane review has shown that plasma exchange hastens recovery compared with supportive treatment alone. There are no adequate comparisons of intravenous immunoglobulin with placebo in adults but this review provides moderate quality evidence that, in severe disease, intravenous immunoglobulin started within two weeks from onset hastens recovery as much as plasma exchange. Adverse events were not significantly more frequent with either treatment but intravenous immunoglobulin is significantly much more likely to be completed than plasma exchange. Also according to moderate quality evidence, giving intravenous immunoglobulin after plasma exchange did not confer significant extra benefit. In children, according to low quality evidence, intravenous immunoglobulin probably hastens recovery compared with supportive care alone. More research is needed in mild disease and in patients whose treatment starts more than two weeks after onset. Dose‐ranging studies are also needed.Plain Language SummaryIntravenous immunoglobulin for Guillain‐Barré syndromeGuillain‐Barré syndrome is an uncommon disease of the peripheral nerves. It causes weakness, numbness and breathing difficulty. Another Cochrane review has shown that plasma exchange (taking blood from one vein, separating the plasma from the blood cells and then returning the blood cells with a plasma substitute into another vein) is more effective than supportive care alone. In adults, moderate quality evidence shows that receiving intravenous immunoglobulin (antibodies that have been purified from donated blood) speeds recovery from severe Guillain‐Barré syndrome as much as plasma exchange. Intravenous immunoglobulin is slightly safer and much easier to give than plasma exchange. According to moderate quality evidence, intravenous immunoglobulin added to plasma exchange is not significantly more effective than either alone. A small amount of evidence suggests that intravenous immunoglobulin is also beneficial in children. More research is needed to determine the best dose in adults and children.