Guideline sources The following summarized guidelines for the evaluation and management of guillain-Barr syndrome (GBS) are prepared by our editorial team based on guidelines from the American Society for Apheresis (ASFA 2019), the American Association of Family Physicians (AAFP 2013), and the American Academy of Neurology (AAN 2011; 2003). 1 2 3 4 Guidelines 1. Screening and diagnosis Diagnostic criteria: Use the following diagnostic criteria to establish the diagnosis of GBS: progressive, relatively symmetrical weakness with decreased or absent myotatic reflexes symptoms reached maximal intensity within 4 weeks of onset other possible causes are excluded. B 2. Diagnostic procedures https://web.pathway.md/diseases/recO8rzqWME3KEOd4 1/3 7/1/23, 12:05 AM Guillain-Barr syndrome Pathway Lumbar puncture: perform lumbar puncture in all patients with suspected GBS. Recognize that CSF protein levels may be normal in early disease, but they are elevated in 90% of patients by the end of the second week of symptoms. B 3. Medical management Intravenous immunoglobulin: As per AAFP 2013 guidelines, administer IVIG in patients with GBS requiring assistance with walking within 2 weeks of symptom onset. B As per AAN 2003 guidelines: Administer IVIG in patients with GBS requiring assistance with walking within 2 A or 4 weeks from the onset of neuropathic symptoms. B Recognize that the effects of IVIG and plasmapheresis are equivalent. Corticosteroids: do not use corticosteroids for the treatment of patients with GBS. D Supportive care: Initiate anticoagulation and offer graduated compression stockings to prevent venous thrombosis in hospitalized patients with acute GBS. B Monitor hospitalized patients with acute GBS for autonomic disturbances, including changes in BP and HR (especially bradycardia) and respiratory, bowel, and bladder dysfunction. B 4. Therapeutic procedures Plasmapheresis: As per AAFP 2013 guidelines, perform plasmapheresis (starting within 7 days of symptom onset) as first-line therapy in patients with GBS. A As per AAN 2011 guidelines, perform plasmapheresis in patients with GBS. A As per AAN 2003 guidelines: Perform plasmapheresis in non-ambulant patients within 4 weeks of onset B and in ambulant patients within 2 weeks of onset. B Recognize that the effects of plasmapheresis and IVIG are equivalent. Immunoadsorption: insufficient evidence to recommend immunoadsorption in patients with GBS. I Combination therapy: do not administer sequential treatment with plasmapheresis followed by IVIG D or immunoadsorption followed by IVIG in patients with GBS. D Liquopheresis: insufficient evidence to recommend CSF filtration in patients with GBS. I 5. Specific circumstances https://web.pathway.md/diseases/recO8rzqWME3KEOd4 2/3 7/1/23, 12:05 AM Guillain-Barr syndrome Pathway Pediatric patients: offer plasmapheresis or IVIG in pediatric patients with severe GBS. B Clinical findings Symptoms Past medical history Abdominal pain Recent gastrointestinal infection Constipation Recent upper respiratory infection Excessive sweating Recent vaccination Facial weakness Low back pain Neurological exam Nausea Shortness of breath Ataxia Urinary retention Hyperreflexia Weakness in the legs Hyporeflexia Ophthalmoplegia Vital signs Paraparesis Paraplegia Hypertension Proximal muscle weakness Hypotension Ptosis Lab findings Quadraplegia CSF protein ECG findings Cardiac arrhythmias References 1. R A C Hughes, E F M Wijdicks, R Barohn et al. Practice parameter: immunotherapy for Guillain-Barr syndrome: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2003 Sep 23;61 6 736 40. Open 2. Anne D Walling, Gretchen Dickson. Guillain-Barr syndrome. Am Fam Physician. 2013 Feb 1;87 3 191 7. Open 3. Anand Padmanabhan, Laura Connelly-Smith, Nicole Aqui et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher. 2019 Jun;34 3 171 354. Open 4. Cortese I, Chaudhry V, So YT et al. Evidence-based guideline update: Plasmapheresis in neurologic disorders: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2011 Jan 18;76 3 294 300. Open https://web.pathway.md/diseases/recO8rzqWME3KEOd4 3/3