Guillain-Barre Syndrome (GBS) resistant to intravenous immunoglobulin treatment: stick or switch systematic review

<h3>Introduction</h3> Management options in GBS after failure to respond to IVIG are either a further course of IVIg or plasma exchange (PEX). This systematic review aims to evaluate the current literature on the use of IVIg or PEX in patients who are resistant to first line IVIg treatment. <h3>Methods</h3> We searched several databases up until 26.10.2023. Studies of any design published in English were included. Data extracted from each study included treatment choices, time interval between disease modifying therapies, concurrent treatments, and other clinically relevant data. <h3>Results</h3> We included three observational studies, one RCT and 38 case reports/case series. Of all the patients, 70.8% received a second course of IVIg, 27.3% received PEX, and 1.9% received both IVIg and PEX. Observational studies and the RCT failed to demonstrate superiority of a repeat course of IVIG in any clinically relevant measure. IVIG was associated with an increased risk of thromboembolic events in the RCT. The only observational study to investigate PEX following IVIG failure found a similar lack of clinical benefit. <h3>Conclusions</h3> Current evidence suggests there is no beneficial effect of further IVIg or PEX if initial IVIG treatment fails.