Original research: Second IVIg course in Guillain-Barré syndrome with poor prognosis: the non-randomised ISID study.

To compare disease course in patients with Guillain-Barré syndrome (GBS) with a poor prognosis who were treated with one or with two intravenous immunoglobulin (IVIg) courses. From the International GBS Outcome Study, we selected patients whose modified Erasmus GBS Outcome Score at week 1 predicted a poor prognosis. We compared those treated with one IVIg course to those treated with two IVIg courses. The primary endpoint, the GBS disability scale at 4 weeks, was assessed with multivariable ordinal regression. Of 237 eligible patients, 199 patients received a single IVIg course. Twenty patients received an 'early' second IVIg course (1-2 weeks after start of the first IVIg course) and 18 patients a 'late' second IVIg course (2-4 weeks after start of IVIg). At baseline and 1 week, those receiving two IVIg courses were more disabled than those receiving one course. Compared with the one course group, the adjusted OR for a better GBS disability score at 4 weeks was 0.70 (95%CI 0.16 to 3.04) for the early group and 0.66 (95%CI 0.18 to 2.50) for the late group. The secondary endpoints were not in favour of a second IVIg course. This observational study did not show better outcomes after a second IVIg course in GBS with poor prognosis. The study was limited by small numbers and baseline imbalances. Lack of improvement was likely an incentive to start a second IVIg course. A prospective randomised trial is needed to evaluate whether a second IVIg course improves outcome in GBS.

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Competing interests: CV, BvdB, EV, HL, KB, SHS, ZI report no disclosures. DRC is a consultant for Acetylon, Alcobra Pharma, Alnylam Pharmaceuticals, Annexon Biosciences, Akros Pharma, Biotest Pharmaceuticals, Boehringer Ingelheim, Cigna HealthManagement, CSL Behring, DP Clinical, Grifols, Hansa Medical, Karos Pharmaceuticals, Neurocrine Biosciences, Novartis, Octapharma, Pharnext, Seattle Genetics, Sun Pharmaceuticals, and Syntimmune. He is on the data and safety monitoring board for Sanofi, Pledpharma, Pfizer, Johnson Roche, Sanofi Genzyme, Teva,TG Therapeutics and UCB. GC has received honoraria from CSL Behring. BCJ has received funding for research projects from Prinses Beatrix Spierfonds, Horizon 2020,GBS-CIDP Foundation International, Grifols, CSL Behring and Annexon. He is on the Medical Advisory Board for the GBS-CIDP Foundation International, and a member of the Inflammatory Neuropathy Consortium. RH has current consultancies with LFB and former consultancies with Novartis. PvD has received honoraria for consulting, lectures and serving on steering committees from Octapharma, Kedrion, CSL Behring, Grifols, and Hansa (all honoraria to departmental research fund), and is currently receiving grants from Prinses Beatrix Spierfonds, Sanquin Blood supply, Shire and Grifols. He is President Elect of the Peripheral Nerve Society, member of the Inflammatory Neuropathy Consortium, Medical Advisory Board for the GBS-CIDP Foundation International, editorial board for the Journal of the Neurological Sciences and Journal of Neuromuscular Diseases. He is PI of the RCT investigating the effect of methylprednisolone in GBS (MP/IVIg RCT in GBS) and the RCT investigating the effect of a second dose IVIg in GBS (SID-GBS study).