Plasma exchange for Guillain-Barre syndrome

Background Guillain-Barre syndrome is an acute paralysing disease caused by peripheral nerve inflammation. This is an update of a review first published in 2001 and last updated in 2008. Objectives To assess the effects of plasma exchange for treating Guillain-Barre syndrome. Search methods We searched the Cochrane Neuromuscular Disease Group Specialized Register (14 June 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (2011, Issue 2), MEDLINE (January 1966 to June 2011) and EMBASE (January 1980 to June 2011). Selection criteria Randomised and quasi-randomised trials of plasma exchange versus sham exchange or supportive treatment. Data collection and analysis Two review authors agreed the selection of eligible studies and independently assessed the risk of bias in included studies. Data were extracted by one review author and checked by a second review author. Likewise data for adverse events were extracted by one review author and checked by a second review author. Main results In the first version of this review there were six eligible trials concerning 649 participants comparing plasma exchange with supportive treatment. No new eligible trials have been identified in subsequent updates. Overall the included trials had a low risk of bias. Primary outcomes In one trial with 220 severely affected participants, the median time to recover walking with aid was significantly faster; with plasma exchange (30 days) than without (44 days). In another trial with 91 mildly affected participants, the median time to onset of motor recovery was significantly shorter with plasma exchange (six days) than without (10 days). After four weeks, combined data from three trials accounting for a total of 349 patients showed that plasma exchanged significantly increased the proportion of patients who recovered the ability to walk with assistance (risk ratio (RR) 1.60, 95% confidence interval (CI) 1.19 to 2.15). Secondary outcomes In five trials with 623 participants in total, the RR of being improved by one or more grades after four weeks was 1.64 (95% CI 1.37 to 1.96) in favour of plasma exchange. Participants treated with plasma exchange also fared significantly better in time to recover walking without aid (three trials with 349 participants, RR 1.72 (95% CI 1.06 to 2.79)) and requirement for artificial ventilation (five trials with 623 participants, RR 0.53 (95% CI 0.39 to 0.74)). There were significantly more participants with relapses by the end of follow-up in the plasma exchange than the control group (6 trials with 649 participants, RR 2.89 (95% CI 1.05 to 7.93)). Despite this, at one year the likelihood of full muscle strength recovery was significantly greater with plasma exchange than without (five trials with 404 participants, RR 1.24 (95% CI 1.07 to 1.45)) and the likelihood of severe motor sequelae was significantly less (six trials with 649 patients, RR 0.65 (95% CI 0.44 to 0.96)). There was no significant difference in deaths (six trials with 649 participants, RR 0.86 (95% CI 0.45 to 1.65)) or participants with adverse events (three trials with 556 participants), except fewer arrhythmias in plasma exchange treated participants (RR 0.75 (95% CI 0.56 to 1.00)). Authors' conclusions Moderate-quality evidence shows significantly more improvement with plasma exchange than supportive care alone in adults with Guillain-Barre syndrome without a significant increase in serious adverse events. There was a small but significant increase in the risk of relapse during the first six to 12 months after onset in people treated with plasma exchange compared with those that were not treated. Despite this, after one year, full recovery was significantly more likely and severe residual weakness less likely with plasma exchange.