eMedicine Specialties > Physical Medicine and Rehabilitation > Peripheral Neuropathy

Guillain-Barre Syndrome: Treatment & Medication

Author: Heather Rachel Davids, MD, Physician, Department of Anesthesiology, Interventional Pain Medicine, University of Colorado Health Sciences Center
Coauthor(s): Joyce L Oleszek, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver Health Sciences Center, The Children's Hospital of Denver; Angela Cha-Kim, MD, Director of Spinal Cord Injury, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Contributor Information and Disclosures

Updated: Sep 15, 2009

Treatment

Rehabilitation Program

Physical Therapy

Estimates suggest that approximately 40% of patients who are hospitalized with GBS require inpatient rehabilitation. Unfortunately, no long-term rehabilitation outcome studies have been conducted, and treatment is often based on experiences with other neurologic conditions. The goals of the therapy programs are to reduce functional deficits and to target impairments and disabilities resulting from GBS.

Early in the acute phase of the disease course, patients may not be able to fully participate in an active therapy program. At that stage, patients benefit from daily range of motion (ROM) exercises and proper positioning to prevent muscle shortening and joint contractures. Addressing upright tolerance and endurance also may be a significant issue during the early part of rehabilitation. Active muscle strengthening can then be slowly introduced and may include isometric, isotonic, isokinetic, or progressive resistive exercises. Mobility skills, such as bed mobility, transfers, and ambulation, are targeted functions. Patients should be monitored for hemodynamic instability and cardiac arrhythmias, especially upon initiation of the rehabilitation program. The intensity of the exercise program also should be monitored, because overworking the muscles may, paradoxically, lead to increased weakness.

Occupational Therapy

Occupational therapy professionals should be involved early in the rehabilitation program to promote upper body strengthening, ROM, and activities that aid functional self-care. Both restorative and compensatory strategies can be used to promote functional improvements. Energy conservation techniques and work simplification also may be helpful, especially if the patient demonstrates poor strength and endurance.

Speech Therapy

Speech therapy is aimed at promoting speech and safe swallowing skills for patients who have significant oropharyngeal weakness with resultant dysphagia and dysarthria. In ventilator-dependent patients, alternative communication strategies also may need to be implemented. Once weaned from the ventilator, patients with tracheostomies can learn voicing strategies and can eventually be weaned from the tracheostomy tube. Cognitive screening also can be performed conjointly with neuropsychology to assess for deficits, since cognitive problems have been reported in some patients with GBS, especially after they have had an extended stay in the intensive care unit (ICU).

Recreational Therapy

Participation in recreational therapy assists in the patient's adjustment to disability and improves integration into the community. Recreational activities, either new or adapted, can be used to promote the growth, development, and independence of a long-term hospital patient.

Medical Issues/Complications

Good supportive care is critical in the treatment of patients with GBS.23 Because most deaths related to GBS are associated with complications of ventilatory failure and autonomic dysfunction, many patients with GBS need to be monitored closely in ICUs by physicians experienced in acute neuromuscular paralysis and its accompanying complications. Competent intensive care includes the following features:

  • Respiratory therapy
  • Cardiac monitoring
  • Safe nutritional supplementation
  • Monitoring for infectious complications, such as pneumonia, urinary tract infections, and septicemia

Approximately one third of patients with GBS require ventilatory support. Monitoring for respiratory failure, bulbar weakness, and difficulties with swallowing help to anticipate complications. Proper positioning of the patient to optimize lung expansion and secretion management for airway clearance is required to minimize respiratory complications. Serial assessment of ventilatory status is needed, including measurements of vital capacity and pulse oximetric monitoring. Respiratory assistance should be considered when the expiratory vital capacity decreases to less than 18 mL/kg or when a decrease in oxygen saturation is noted (arterial PO2 <70 mm Hg).

Close monitoring of heart rate, blood pressure, and cardiac arrhythmias allows early detection of life-threatening situations. Critically ill patients require continuous telemetry and close medical supervision in an ICU setting. Antihypertensives and vaso-active drugs should be used with caution in patients with autonomic instability.

Enteral or parenteral feedings are required for patients on mechanical ventilation to ensure that adequate caloric needs are met when the metabolic demand is high. Even patients who are off the ventilator may require nutritional support if dysphagia is severe. Precautions against dysphagia and dietary manipulations should be used to prevent aspiration and subsequent pneumonias in patients at risk.

The prevention of secondary complications of immobility, such as deep venous thrombosis (DVT), pressure sores, and contractures, also is required. This preventative action entails careful positioning, frequent postural changes, and daily ROM to prevent the latter 2 complications. Subcutaneous heparin and thromboguards are often used in the treatment of immobile patients to prevent lower extremity DVTs and secondary pulmonary embolisms (PE). Pain management with analgesics and adjunct medications also may be needed. Modalities such as transcutaneous electrical nerve stimulation (TENS) and heat may prove beneficial in the management of myalgia. Desensitization techniques can be used to improve the patient's tolerance for activities.

Although bowel and bladder dysfunction is generally transitory, management of these functions is needed to prevent other complications. Initial management should be directed toward safe evacuation and the prevention of overdistension. Monitoring for secondary infections, such as a urinary tract infection, also is an area of concern.

Hospitalized patients with GBS may experience mental status changes, including hallucinations, delusions, vivid dreams, and sleep abnormalities. These occurrences are thought to be associated with autonomic dysfunction and are more frequent in patients with severe symptoms. Such problems resolve as the patient recovers.

Surgical Intervention

Tracheotomy may be required in a patient with prolonged respiratory failure, especially if mechanical ventilation is required for more than 2 weeks. Percutaneous feeding tubes also may be needed, in order to meet the nutritional needs of patients with prolonged, severe dysphagia. A central venous line needs to be placed for patients undergoing plasmapheresis.

Consultations

  • Consultation with a neurologist can be helpful in the initial diagnosis, workup, and treatment of patients admitted to the medical floor with GBS.
  • Critical care specialists may be required for patients in the ICU to help manage respiratory failure and multiple medical complications.
  • Consultation with a pulmonologist may be needed to perform workup and to manage respiratory issues, such as acute respiratory distress syndrome (ARDS), pneumonia, and respiratory failure.
  • Consultation with a cardiologist may be required if significant cardiovascular complications, such as labile blood pressure and cardiac arrhythmias, arise from the associated autonomic dysfunction.
  • Consultation with a surgeon may be required for the placement of tracheostomies, enteral feeding tubes, and central lines.
  • Physical medicine and rehabilitation specialists should evaluate patients for impairments and disabilities arising from the disease and should help to determine the most appropriate setting for and intensity of rehabilitation care.

Medication

Immunomodulatory therapy, such as plasmapheresis or the administration of IVIGs, is frequently used in GBS patients.24 The efficacy of plasmapheresis and IVIGs appears to be about equal in shortening the average duration of disease.25,26,27,28 Combined treatment has not been shown to produce a further, statistically significant reduction in disability. The decision to use immunomodulatory therapy is based on the disease's severity and rate of progression, as well as on the length of time between the condition's first symptom and its presentation. Risks, such as thrombotic events associated with IVIGs, should be taken into consideration.29,30 Patients with severe, rapidly progressive disease are most likely to benefit from treatment, with improvements occurring in the rate of functional recovery.31

Immunomodulatory agents

These medications are used to improve the clinical and immunologic aspects of GBS. They may decrease auto-antibody production and increase the solubilization and removal of immune complexes.


Intravenous immunoglobulin (Carimune, Gammagard S/D, Gammar-P, Gamunex, Polygam S/D)

IVIG is derived from fractionated, purified human plasma collected from a large pool of multiple donors. The product is treated with solvents and detergents to inactivate any blood-borne virus.
IVIG may work via several mechanisms, including the blockage of macrophage receptors, the inhibition of antibody production, the inhibition of complement binding, and the neutralization pathologic antibodies.

Adult

2 g/kg IV, generally divided over 5 d
Some centers administer IVIG over 2 d at 1 g/kg/d, especially in younger patients with normal renal and cardiovascular function

Pediatric

Administer as in adults

Prior anaphylactic reaction with IVIG; anaphylactic reactions may occur in patients with IgA deficiency with anti-IgA antibodies; when present, IVIG treatments can be performed with low-level IgA preparations; renal complications can be minimized by diluting the IVIG preparation, slowing the rate of infusion, and ensuring adequate hydration of patients; in severe congestive heart failure, complications can be reduced by using slower rates of infusion to minimize the risk of rapid fluid overload

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adverse reactions to IVIG are usually minor (eg, headache, fever, chills, malaise, myalgia); less common adverse effects may include migraines, aseptic meningitis, pulmonary edema, skin reactions (eg, urticaria, pruritus, petechia), and renal complications; serum viscosity increases with IVIG therapy, which can result in thrombotic events, such as stroke, PE, and myocardial infarction


Plasma exchange, or plasmapheresis

The mechanism of plasmapheresis is the removal of immunoglobulins and antibodies from the serum by removing the blood from the body, separating cells from the plasma, and replacing the cells in fresh frozen plasma, albumin, or saline.

Adult

3-5 exchanges of 50 mL/kg of plasma IV over 1-2 wk via central venous catheter suggested

Pediatric

Administer as in adults

Septicemia, active bleeding, and severe cardiovascular instability

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Plasma exchange requires skilled personnel and specialized equipment that may not be available in all hospitals; in theory, plasma exchange may increase the risk of infection and hemorrhage as a result of the removal of immunoglobulins and clotting factors; complications and side effects from plasma exchange include hypotension, septicemia, pneumonia, cardiac arrhythmias, malaise, hypoprothrombinemia with bleeding/abnormal clotting, and hypocalcemia

More on Guillain-Barre Syndrome

Overview: Guillain-Barre Syndrome
Differential Diagnoses & Workup: Guillain-Barre Syndrome
Treatment & Medication: Guillain-Barre Syndrome
Follow-up: Guillain-Barre Syndrome
References
Further Reading
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Keywords

Guillain-Barré syndrome, Guillain-Barre syndrome, Guillain-Barre, demyelination, Campylobacter jejuni, demyelinating neuropathy, polyradiculoneuropathy, GBS, C jejuni, acute inflammatory demyelinating polyradiculoneuropathy, Landry-Guillain-Barre syndrome, Landry-Guillain-Barre-Strohl syndrome, acute demyelinating neuropathy, infectious polyneuritis, acute polyradiculoneuritis, axonal Guillain-Barre syndrome, acute motor axonal neuropathy, acute motor-sensory axonal neuropathy, Miller-Fisher syndrome, pharyngeal-cervical-brachial GBS

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Contributor Information and Disclosures

Author

Heather Rachel Davids, MD, Physician, Department of Anesthesiology, Interventional Pain Medicine, University of Colorado Health Sciences Center
Heather Rachel Davids, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Coauthor(s)

Joyce L Oleszek, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver Health Sciences Center, The Children's Hospital of Denver
Joyce L Oleszek, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Angela Cha-Kim, MD, Director of Spinal Cord Injury, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Angela Cha-Kim, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Paraplegia Society
Disclosure: Nothing to disclose.

Medical Editor

Daniel D Scott, MD, MA, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver and Health Sciences Center
Daniel D Scott, MD, MA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, National Multiple Sclerosis Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD, Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital
Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

 
 
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