Raphael,Cochrane,2004

Web site designed and maintained by Chris Cairns © SICS EBM Group 2004

GBS: Plasma exchange improves recovery in Guillain-Barre syndrome.

Plasma exchange is superior to supportive treatment alone in patients with Guillain Barre syndrome: improvement in disability score ³ 1 at 1 month.

In severe Guillain Barre syndrome six sessions of plasma exchange are not superior to 4 sessions for patients requiring ventilation.

Level of Evidence:1⁺

Citation/s: Plasma exchange for Guillain Barre syndrome. Cochrane Database of Systematic Reviews 2004

Lead author's name and fax: J-C Raphael, Service de Reanimation Medicale, Hopital Raymond, Paris. jean-claude.raphael@rpc.ap-hop-paris.fr

Three-part Clinical Question: Does plasma exchange improve outcome in patients with Guillain Barre syndrome?

Search Terms: 1 guillain barre syndrome (16) (in Cochrane Database of Systematic Reviews)

The Review:

Data Sources: : Cochrane Library, Medline, Checked reference lists and contacted authors.

Study Selection: RCTs and quasi-randomised studies involving adults and children with GBS of all degrees of severity. Only series evaluating plasma exchange alone were included.

Data Extraction: Method of allocation, allocation concealment, patient blinding, observer blinding, explicit diagnostic criteria, follow-up. Primary endpoint: time to recover walking with aid after randomisation (GBS disability grade=3). Secondary endpoint: improvement in GBS disability grade by 1 (principle endpoint used in studies).

Multiple independent reviews of individual reports. Tested for heterogeneity.

The Evidence: 6 eligible trials (total of 649 patients). Comparing plasma exchange versus supportive therapy alone.

Primary endpoint: 2 trials reported on median time to walking with aid; 2 weeks shorter in patients receiving plasma exchange.

Secondary endpoints: 5 trials reported on improvement in disability score at one month (most commonly reported endpoint) - for every 5 patients given plasma exchange, compared to supportive therapy alone, one more patient has improvement in GBS disability score by one at 28 days after therapy (95% CI 3 to 6).

For every 8 patients given plasma exchange, compared to supportive therapy alone, one less patient needed ventilation in the 28 days after therapy (95% CI 5 to 15).

One trial (161 patients) 4 versus 6 plasma exchanges: no difference in any outcome measure.

EBM comments:

1) Do the methods allow accurate testing of the hypothesis? - YES

2) Do the statistical tests correctly test the results to allow differentiation of statistically significant results? - YES

3) Are conclusions valid in light of the results? - YES

4) Did results get omitted, and why? - NO

5) Did they suggest areas of further research? Need RCTs to: define role in children; management of GBS present for > 30 d prior to plasma exchange; and as comparison to determine optimal dose of immunoglobulin.

6) Did they make any recommendations based on the results and were they appropriate? - YES - plasma exchange is the one therapy shown to be of benefit in comparison to placebo. Mild GBS 2 session PE better than placebo, moderate to severe GBS 4 sessions PE better than 2. Treatment with PE is associated with risk of relapse: patients need close observation over subsequent weeks.

7) Is the study relevant to my clinical practice? GBS is condition seen infrequently in ICU. Useful data on demographics and outcome of GBS (to tell our patients and their relatives).

8) What level of evidence does this study represent? Level 1+ evidence

9) What grade of recommendation can I make on this result alone? Grade A recommendation

10) What grade of recommendation can I make when this study is considered along with other available evidence? This systematic review has reviewed the available evidence to date.

11) Should I change my practice because of these results? Plasma exchange is the one treatment that has been shown to be better than supportive therapy alone. A technique limited to certain centres. . Seems to reduce overall cost of care – but very limited evidence in this area. Risk of relapse increased after plasma exchange – need close observation in first few weeks.

12) Should I audit my current practice because of these results? Difficult: low incidence, limited data to collect / available to collect for individual practitioner unit; unless solely neurological service..

Appraised by: Malcolm Daniel, Department of Anaesthesia, Glasgow Royal Infirmary, G4 0SF.; Monday, June 28, 2004

E-mail: md23s@udcf.gla.ac.uk

Kill or Update By: August 2007

Printer Friendly Version