second IVIG in GBS

Q: For patients with refractory Guillain-Barré syndrome (GBS) who do not respond to the first round of Intravenous immunoglobulin (IVIG), the second course of infusion can be given as "nothing to lose"? 

A) Yes 

B) No

Answer: B

Giving a second course of IVIG to patients who stayed in refractory GBS may harm the patient. It increases thromboembolic complications. There is no added benefit. A recent study published by the Dutch GBS study group showed no benefit, rather harm. 

It was a randomized, double-blind, placebo-controlled trial. Patients were randomly assigned after eligibility for poor prognosis through modified Erasmus Guillain-Barré syndrome Outcome Score. The primary outcome measure was the Guillain-Barré syndrome disability score after 4 weeks. The study spanned over 8 years (Feb 2010 - June 2018). Out of total 337 patients, 93 patients with poor prognosis were included in the modified intention-to-treat analysis: 49 received second course of IVIG, and 44 received placebo. Patients in the treatment group had more serious adverse events (35% vs 16% in the first 30 days), including thromboembolic events. Four patients died in the intervention group (13-24 weeks after randomization).

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Reference:

Walgaard C, Jacobs BC, Lingsma HF, et al. Second intravenous immunoglobulin dose in patients with Guillain-Barré syndrome with poor prognosis (SID-GBS): a double-blind, randomised, placebo-controlled trial. Lancet Neurol. 2021;20(4):275-283. doi:10.1016/S1474-4422(20)30494-4