4. 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
5. 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
6. 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
7. 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
8. 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
9. 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 )
10. 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
11. 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 )
12.
13.
14. 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
15. 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.
16. 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
17.
18. 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.
