Intravenous immune globulin versus plasma exchange in Guillain-Barré syndrome

Cost-minimization analysis of the direct costs of TPE and IVIg in the treatment of Guillain-Barré syndrome

Background

Controlled trials have found therapeutic plasma exchange (TPE) and intravenous immunoglobulin (IVIg) infusion therapy to be equally efficacious in treating Guillain-Barré syndrome (GBS). Due to increases in the price of IVIg compared to human serum albumin (HSA), used as a replacement fluid in TPE, we examined direct hospital-level expenditures for TPE and IVIg for meaningful cost-differences between these treatments.

Methods

Using financial data from our two institutions, hospital cost profiles for IVIg and 5% albumin were established. Reimbursement amounts were obtained from publicly available Medicare data resources to determine payment rates for TPE, non-tunneled central catheter line placement, and drug infusion therapy. A model was developed which allows hospitals to input cost and reimbursement amounts for both IVIg and TPE with HSA that results in real-time valuations of these interventions.

Results

The direct cost of five IVIg infusion sessions totaling 2.0 grams per kilogram (g/kg) body weight was $10,329.85 compared to a series of five TPE procedures, which had direct costs of $4,638.16.

Conclusions

In GBS patients, direct costs of IVIg therapy are more than twice that of TPE. Given equivalent efficacy and similar severity and frequencies of adverse events, TPE appears to be a less expensive first-line therapy option for treatment of patients with GBS.

Treatment of Guillain-Barré syndrome: a cost-effectiveness analysis

Acute Guillain-Barré syndrome is the most common cause of neuromuscular paralysis. Plasma exchange and intravenous immune globulin (IV IgG) are both effective treatments for this condition and the purpose of this report was to compare the cost-effectiveness of these two modalities. A MEDLINE search was performed to identify randomized studies that compared the use of IV IgG and plasma exchange for treatment of acute Guillain-Barré syndrome to determine if one modality was more effective and/or safer for the management of this condition. A decision analysis was structured around the alternatives facing neurologists who must choose a treatment regimen for patients diagnosed with acute Guillain-Barré syndrome who require active therapy. Cost information was obtained directly from product manufacturers and hospital sources. Two head-to-head trials comparing the effectiveness of plasma exchange and IV IgG for treatment of acute Guillain-Barré syndrome determined that there was insufficient evidence to suggest one therapy was more effective than the other; therefore, a cost minimization analysis was performed. The costs per patient of plasma exchange and IV IgG for the treatment of acute Guillain-Barré syndrome were $6,204 and $10,165, respectively. A sensitivity analysis determined the model was sensitive to the cost of IV IgG. The cost savings per patient treatment for the use of plasma exchange varied from $304 to $6,625 depending on the IV IgG product selected. Plasma exchange and IV IgG are both effective treatments for Guillain-Barré syndrome. However, our analysis determined plasma exchange on average was almost $4,000 less costly per patient than IV IgG. Further research is required to determine the impact of patient and physician preferences on the treatment of this disorder.

Treatment of the adult Guillain-Barré syndrome: indications for plasma exchange

The Guillain-Barré syndrome is the most common cause of acute flaccid paralysis. Currently, 5% of patients die and 10% are left with severe motor sequelae at one year. Multidisciplinary teams, trained to specific treatments, are required to manage these patients. Oral and intravenous steroid treatment of GBS has been disappointing. Two large randomized clinical trials comparing plasma exchange (PE) to standard supportive treatment have shown a short-term and a one-year benefit of PE. Appropriate number of exchanges and indications of PE are now more precisely known. Patients with mild forms of the disease (able to walk) should receive two PEs, while a further two exchanges should be done in case of deterioration or in advanced forms (loss of walking ability, mechanical ventilation). A greater number of exchanges does not appeared beneficial. More recently, two randomized trials produced some evidence that intravenous immune globulin (IVIg, 0.4 g/kg daily for five days) and PE had equivalent efficiency in advanced forms. The combination of PE with IVIg did not yield a significant advantage, but did increase cost and risk. In advanced forms, the choice between PE and IVIg depends on the contraindications of each treatment.

[Treatment of Guillain-Barré syndrome in adults: role of plasma exchange]

PURPOSE

To review recent data on treatment of Guillain-Barré syndrome, especially indications of plasma exchange.

DATA SYNTHESIS

Guillain-Barré syndrome is the most common cause of acute flaccid paralysis. The current mortality is 5%, sever motor sequelae persist after 1 year in 10% of cases. Multidisciplinary teams are required to treat these patients, trained to all specific treatments. Oral and intravenous steroids have proven ineffective. Two large randomized clinical trials comparing plasma exchange (PE) with no treatment have shown a short-term and a 1-year benefit. Appropriate number of exchanges and indications are now more precisely known. In mild form (walking possible), patients should receive two PEs. A further two exchanges should be done in case of deterioration or in advanced forms (loss of walking ability, mechanical ventilation). More exchanges are not beneficial. Recently two new randomized trials have produced evidence that intravenous immune globulin (IVIg) (0.4 g/kg/d for 5 days) were as effective as five PEs in advanced forms. The combination of PE with IVIg did not confer a significant advantage, while increasing cost and risks.

CONCLUSION

The combination of PE with IVIg did not confer, in advanced forms, the choice between PE and IVIg depends of the contra-indications of each treatment.

Appropriate number of plasma exchanges in Guillain-Barré syndrome. The French Cooperative Group on Plasma Exchange in Guillain-Barré Syndrome

Plasma exchange (PE) is the standard treatment in Guillain-Barré syndrome (GBS) patients who have lost the ability to walk. The effect of exchanges before this stage and the optimal number of exchanges for the other patients are still unknown. We randomized 556 GBS patients according to severity and number of exchanges as follows: Zero versus 2 PEs for patients who could walk-with or without aid-but not run, or who could stand up unaided (mild group); 2 versus 4 PEs for patients who could not stand up unaided (moderate group); and 4 versus 6 PEs for mechanically ventilated patients (severe group). In the mild group, 2 PEs were more effective than none for time to onset of motor recovery (median, 4 vs 8 days, respectively). In the moderate group, 4 PEs were more beneficial than 2 for time to walk with assistance (median, 20 vs 24 days) and for 1-year full muscle-strength recovery rate (64% vs 46%). Six PEs were no more beneficial than 4 in the severe cases. Patients with mild GBS on admission should receive 2 PEs. Patients with moderate and severe forms should benefit from 2 further exchanges.

Natural history and treatment effects in Guillain-Barré syndrome: a multicentre study

A retrospective multicentre study was performed to investigate the natural history and treatment effects in childhood Guillain-Barré syndrome in a large number of patients. Structured questionnaires were sent to 155 paediatric hospitals for details of patients who conformed to internationally accepted diagnostic criteria and who were treated from spring 1989 to summer 1994. Sixty nine hospitals reported data of 175 patients aged 11 months to 17.7 years. At the height of the disease 26% of the patients remained able to walk, but 16% had to be artificially ventilated. The median time from onset of symptoms to first recovery was 17 days, to walk unaided 37 days, and to be free of symptoms 66 days. There was a large group with a benign and a smaller one with a more protracted course. At long term follow up, 98/106 patients were free of symptoms and the remainder were able to walk unaided. Maximum disability grade was the most powerful prognostic factor. In children unable to walk but not yet tetraplegic, immunoglobulins were able to accelerate recovery. Corticosteroids were less potent. Plasmapheresis could not be evaluated because it was administered only in the most severe cases. The natural history of Guillain-Barré syndrome in children is extremely variable and more benign than in adults. Treatment with immunoglobulins should be considered in patients unable to walk. Corticosteroids are not as effective and should be withheld except when, in protracted courses, suspicion of chronic inflammatory demyelinating polyneuropathy arises.

Acute neuromuscular respiratory paralysis

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