Pharmacological treatment other than corticosteroids, intravenous immunoglobulin and plasma exchange for Guillain Barré syndrome
Abstract
Background
Plasma exchange and intravenous immunoglobulin, but not corticosteroids, are beneficial in Guillain‐Barré syndrome (GBS). The efficacy of other pharmacological agents is unknown.
Objectives
To review systematically the evidence from randomised controlled trials for pharmacological agents other than plasma exchange, intravenous immunoglobulin and corticosteroids.
Search methods
We searched the Cochrane Neuromuscular Disease Group Specialized Register (5 July 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 2), MEDLINE (January 1966 to June 2010) and EMBASE (January 1980 to June 2010) for treatments for GBS. We considered evidence from non‐randomised studies in the Discussion.
Selection criteria
We included all randomised or quasi‐randomised controlled trials of acute (within four weeks from onset) GBS of all types, ages and degrees of severity. We discarded trials which only tested corticosteroids, intravenous immunoglobulin or plasma exchange. We included other pharmacological treatments or combinations of treatments compared with no treatment, placebo treatment or another treatment.
Data collection and analysis
Change in disability after four weeks was the primary outcome. Two authors checked references and extracted data independently. One author entered and another checked data in Review Manager (RevMan). We assessed risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. We calculated mean differences and risk ratios with their 95% confidence intervals. We assessed strength of evidence with GradePro software.
Main results
Only very low quality evidence was found for four different interventions. One randomised controlled trial with 13 participants showed no significant difference in any outcome between interferon beta‐1a and placebo. Another with 10 participants showed no significant difference in any outcome between brain‐derived neurotrophic factor and placebo. A third with 37 participants showed no significant difference in any outcome between cerebrospinal fluid filtration and plasma exchange. In a fourth with 20 participants, the risk ratio of improving by one or more disability grades after eight weeks was significantly greater with the Chinese herbal medicine tripterygium polyglycoside than with corticosteroids (risk ratio 1.47; 95% confidence interval 1.02 to 2.11).
Authors' conclusions
The quality of the evidence was very low. Three small randomised controlled trials, of interferon beta‐1a, brain‐derived neurotrophic factor and cerebrospinal fluid filtration, showed no significant benefit or harm. A fourth small trial showed that the Chinese herbal medicine tripterygium polyglycoside hastened recovery significantly more than corticosteroids but this result needs confirmation. It was not possible to draw useful conclusions from the few observational studies.
PICOs
Plain language summary
Drug treatment other than corticosteroids, intravenous immunoglobulin and plasma exchange for acute Guillain Barré syndrome
Guillain‐Barré syndrome (GBS) is an acute paralysing disease caused by inflammation of the nerves. Between 3.5% and 12% of people with GBS die of complications during the acute stage. A quarter of patients need artificial ventilation. Recovery takes several weeks or months and is often incomplete. Plasma exchange (washing harmful substances out of the blood) and intravenous immunoglobulin (infusion of human antibodies harvested from blood donations into the blood stream) are beneficial but corticosteroids are not. Since current treatments are insufficient, new methods need to be discovered. We searched for randomised controlled trials of other drugs for GBS. We only found very low quality evidence. One randomised controlled trial with only 13 participants tested interferon beta‐1a, a drug which is beneficial in multiple sclerosis. Another with only 10 participants tested a nerve growth factor which theoretically should be beneficial. A third trial with 37 participants compared cerebrospinal fluid filtration (washing the nerve roots around the spinal cord) and plasma exchange. None of these trials was large enough to confirm or refute benefit or harm in acute GBS. A fourth trial with 20 participants suggested that the Chinese herbal medicine tripterygium polyglycoside improved disability faster than corticosteroids but this result needs confirmation with more research. There was very little evidence other than that from randomised controlled trials. There is a need to develop and test new treatments.
