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Walgaard C, Jacobs BC, Lingsma HF, Steyerberg EW, van den Berg B, Doets AY, Leonhard SE, Verboon C, Huizinga R, Drenthen J, Arends S, Budde IK, Kleyweg RP, Kuitwaard K, van der Meulen MFG, Samijn JPA, Vermeij FH, Kuks JBM, van Dijk GW, Wirtz PW, Eftimov F, van der Kooi AJ, Garssen MPJ, Gijsbers CJ, de Rijk MC, Visser LH, Blom RJ, Linssen WHJP, van der Kooi EL, Verschuuren JJGM, van Koningsveld R, Dieks RJG, Gilhuis HJ, Jellema K, van der Ree TC, Bienfait HME, Faber CG, Lovenich H, van Engelen BGM, Groen RJ, Merkies ISJ, van Oosten BW, van der Pol WL, van der Meulen WDM, Badrising UA, Stevens M, Breukelman AJJ, Zwetsloot CP, van der Graaff MM, Wohlgemuth M, Hughes RAC, Cornblath DR, van Doorn PA. Second intravenous immunoglobulin dose in patients with Guillain-Barré syndrome with poor prognosis (SID-GBS): a double-blind, randomised, placebo-controlled trial. Lancet Neurol 2021; 20:275-283. [PMID: 33743237 DOI: 10.1016/s1474-4422(20)30494-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND Treatment with one standard dose (2 g/kg) of intravenous immunoglobulin is insufficient in a proportion of patients with severe Guillain-Barré syndrome. Worldwide, around 25% of patients severely affected with the syndrome are given a second intravenous immunoglobulin dose (SID), although it has not been proven effective. We aimed to investigate whether a SID is effective in patients with Guillain-Barré syndrome with a predicted poor outcome. METHODS In this randomised, double-blind, placebo-controlled trial (SID-GBS), we included patients (≥12 years) with Guillain-Barré syndrome admitted to one of 59 participating hospitals in the Netherlands. Patients were included on the first day of standard intravenous immunoglobulin treatment (2 g/kg over 5 days). Only patients with a poor prognosis (score of ≥6) according to the modified Erasmus Guillain-Barré syndrome Outcome Score were randomly assigned, via block randomisation stratified by centre, to SID (2 g/kg over 5 days) or to placebo, 7-9 days after inclusion. Patients, outcome adjudicators, monitors, and the steering committee were masked to treatment allocation. The primary outcome measure was the Guillain-Barré syndrome disability score 4 weeks after inclusion. All patients in whom allocated trial medication was started were included in the modified intention-to-treat analysis. This study is registered with the Netherlands Trial Register, NTR 2224/NL2107. FINDINGS Between Feb 16, 2010, and June 5, 2018, 327 of 339 patients assessed for eligibility were included. 112 had a poor prognosis. Of those, 93 patients with a poor prognosis were included in the modified intention-to-treat analysis: 49 (53%) received SID and 44 (47%) received placebo. The adjusted common odds ratio for improvement on the Guillain-Barré syndrome disability score at 4 weeks was 1·4 (95% CI 0·6-3·3; p=0·45). Patients given SID had more serious adverse events (35% vs 16% in the first 30 days), including thromboembolic events, than those in the placebo group. Four patients died in the intervention group (13-24 weeks after randomisation). INTERPRETATION Our study does not provide evidence that patients with Guillain-Barré syndrome with a poor prognosis benefit from a second intravenous immunoglobulin course; moreover, it entails a risk of serious adverse events. Therefore, a second intravenous immunoglobulin course should not be considered for treatment of Guillain-Barre syndrome because of a poor prognosis. The results indicate the need for treatment trials with other immune modulators in patients severely affected by Guillain-Barré syndrome. FUNDING Prinses Beatrix Spierfonds and Sanquin Plasma Products.
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Affiliation(s)
- Christa Walgaard
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Immunology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Bianca van den Berg
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Alexandra Y Doets
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sonja E Leonhard
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Christine Verboon
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ruth Huizinga
- Department of Immunology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Judith Drenthen
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Samuel Arends
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | - Ruud P Kleyweg
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Krista Kuitwaard
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | | | | | - Frederique H Vermeij
- Department of Neurology, Franciscus en Vlietland Hospital, Rotterdam, Netherlands
| | - Jan B M Kuks
- Department of Neurology, University Medical Center Groningen, Groningen, Netherlands
| | - Gert W van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Paul W Wirtz
- Department of Neurology, Haga Hospital, Den Haag, Netherlands
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Anneke J van der Kooi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Cees J Gijsbers
- Department of Neurology, Franciscus en Vlietland Hospital, Rotterdam, Netherlands
| | | | - Leo H Visser
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Roderik J Blom
- Department of Neurology, Diakonessenhuis, Utrecht, Netherlands
| | - Wim H J P Linssen
- Department of Neurology, Onze Lieve Vrouwen Gasthuis-West, Amsterdam, Netherlands; Zaans Medical Center, Zaandam, Netherlands
| | | | | | | | - Rita J G Dieks
- Department of Neurology, Röpke-Zweers Hospital, Hardenberg, Netherlands
| | - H Job Gilhuis
- Department of Neurology, Reinier de Graaf Hospital, Delft, Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, Den Haag, Netherlands
| | | | | | - Catharina G Faber
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Harry Lovenich
- Department of Neurology, St Jans Hospital, Weert, Netherlands
| | | | - Rutger J Groen
- Department of Neurology, Haaglanden Medical Center, Den Haag, Netherlands
| | - Ingemar S J Merkies
- Department of Neurology, Spaarne Gasthuis, Haarlem, Netherlands; Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Bob W van Oosten
- Department of Neurology, Amsterdam University Medical Centers, VUmc, Amsterdam, Netherlands
| | - W Ludo van der Pol
- Department of Neurology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Umesh A Badrising
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands; Department of Neurology, van Weel-Bethesda Hospital, Dirksland, Netherlands
| | - Martijn Stevens
- Department of Neurology, Tergooi Hospitals, Blaricum, Netherlands
| | | | | | | | - Marielle Wohlgemuth
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Richard A C Hughes
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - David R Cornblath
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands.
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