Guillain-Barre Syndrome Medication: Immunomodulatory Agents, Low Molecular Weight Heparin, Analgesics, Anticonvulsants, Tricyclic Antidepressants (original) (raw)

Medication Summary

Immunomodulatory therapy, such as plasmapheresis or the administration of intravenous immunoglobulins (IVIGs), is frequently used in patients with Guillain-Barré syndrome (GBS). [153] The efficacy of plasmapheresis and IVIGs appears to be about equal in shortening the average duration of disease. [128, 129, 130, 131, 154] Combined treatment has not been shown to produce a further, statistically significant reduction in disability.

A study by Lin et al indicated that the pretreatment severity score has the strongest association with therapeutic outcome in patients with GBS who undergo double-filtration plasmapheresis, with a higher score being linked to a poorer outcome. The study involved 60 GBS patients who underwent first-line therapy with the procedure. [155]

The decision to use immunomodulatory therapy is based on the disease's severity and rate of progression, as well as on the length of time between the condition's first symptom and its presentation. Risks, such as thrombotic events associated with IVIG, should be taken into consideration. [156, 157] Patients with severe, rapidly progressive disease are most likely to benefit from treatment, with faster functional recovery. [158]

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Immunomodulatory Agents

Class Summary

These medications are used to improve the clinical and immunologic aspects of GBS. They may decrease autoantibody production and increase the solubilization and removal of immune complexes.

Intravenous immunoglobulin (Bivigam, Carimune NF, Gammagard S/D, Gamunex-C, Hizentra, Octagam, Privigen)

IVIG is derived from fractionated, purified human plasma collected from a large pool of multiple donors. The product is treated with solvents and detergents to inactivate any blood-borne virus. IVIG may work via several mechanisms, including the blockage of macrophage receptors, the inhibition of antibody production, the inhibition of complement binding, and the neutralization of pathologic antibodies.

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Low Molecular Weight Heparin

Class Summary

Low ̶ molecular-weight heparin (LMWH) is used in the prophylaxis of deep venous thrombosis (DVT). The first LMWH to become available in the United States was enoxaparin (Lovenox). LMWH has been used widely in pregnancy, although clinical trials are not yet available to demonstrate that it is as safe as unfractionated heparin.

Reversible elevation of hepatic transaminase levels occurs occasionally. Heparin-associated thrombocytopenia has been observed with LMWH.

Enoxaparin (Lovenox)

Enoxaparin enhances the inhibition of factor Xa and thrombin by increasing antithrombin III activity. It also slightly affects thrombin and clotting time and preferentially increases the inhibition of factor Xa.

This agent has a wide therapeutic window; the prophylactic dose is not adjusted based on the patient's weight. Enoxaparin is safer and more effective than unfractionated heparin for prophylaxis of venous thromboembolism. The average duration of treatment is 7-14 days.

Dalteparin (Fragmin)

Dalteparin is an LMWH with antithrombotic properties. It enhances the inhibition of Factor Xa and thrombin by increasing antithrombin. It has a minimal effect on activated partial thromboplastin time (aPTT).

Tinzaparin

Tinzaparin is an LMWH with antithrombotic properties. It enhances the inhibition of Factor Xa and thrombin by increasing antithrombin. It has a minimal effect on aPTT.

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Analgesics

Class Summary

Pain medications may be required in inpatient and outpatient settings. A tiered pharmacologic approach that starts with nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, with narcotic agents added as needed, is usually recommended.

Acetaminophen (Tylenol, AspirinFree Anacin, Cetafen, Feverall, Mapap Extra Strength)

Acetaminophen is the drug of choice for the treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, as well as in those with upper GI disease or who are taking oral anticoagulants.

Ibuprofen (Motrin, Advil, Neoprofen, Provil)

Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. It is used to provide relief of cervical myofascial pain.

Indomethacin (Indocin)

Indomethacin is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)

Naproxen is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Diclofenac (Voltaren-XR, Cataflam, Zipsor, Cambia)

Diclofenac inhibits prostaglandin synthesis by decreasing COX enzyme activity, which, in turn, decreases formation of prostaglandin precursors.

Ketoprofen

Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.

Celecoxib (Celebrex)

Celecoxib primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient. It is extensively metabolized in liver primarily via cytochrome P450 2C9.

Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.

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Anticonvulsants

Class Summary

Anticonvulsants may be used to alleviate painful dysesthesias, which frequently accompany peripheral neuropathies. Although they have many different mechanisms of action, their use for alleviating neuropathic pain probably depends on their general tendency to reduce neuronal excitability.

Gabapentin (Gralise, Neurontin)

Gabapentin is a membrane stabilizer, a structural analogue of the inhibitory neurotransmitter gamma-amino butyric acid (GABA), which paradoxically is thought not to exert an effect on GABA receptors. Gabapentin appears to exert action via the alpha(2)delta1 and alpha(2)delta2 auxiliary subunits of voltage-gaited calcium channels

It is used to manage pain and provide sedation in neuropathic pain.

Carbamazepine (Carbatrol, Equetro, Epitol, Tegretol, Tegretol-XR)

Carbamazepine is a sodium channel blocker that typically provides substantial or complete relief of pain in 80% of individuals with some forms of painful paresthesia. It reduces sustained, high-frequency, repetitive neural firing and is a potent enzyme inducer that can induce its own metabolism. Due to potentially serious blood dyscrasias, undertake benefit-to-risk evaluation before the drug is instituted.

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Tricyclic Antidepressants

Class Summary

Tricyclic antidepressants are effective in painful paresthesias. Whereas the drugs in this category are administered in similar dosages, their sedative properties vary. Amitriptyline may be given if the patient suffers from insomnia, whereas nortriptyline and desipramine are better choices when sedation becomes a problem.

Amitriptyline

Amitriptyline is an analgesic for certain chronic and neuropathic pain. It blocks the reuptake of norepinephrine and serotonin, which increases their concentration in the CNS. Amitriptyline decreases pain by inhibiting spinal neurons involved in pain perception. It is highly anticholinergic. The drug is often discontinued because of somnolence and dry mouth.

Cardiac arrhythmia, especially in overdose, has been described; monitoring the QTc interval after reaching the target level is advised. Up to 1 month may be needed to obtain clinical effects.

Nortriptyline (Pamelor)

Nortriptyline has demonstrated effectiveness in the treatment of chronic pain.

By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, this drug increases the synaptic concentration of these neurotransmitters in the CNS.

Pharmacodynamic effects such as the desensitization of adenyl cyclase and down-regulation of beta-adrenergic receptors and serotonin receptors also appear to play a role in its mechanisms of action.

Desipramine (Norpramin)

This is the original TCA used for depression. These agents have been suggested to act by inhibiting reuptake of noradrenaline at synapses in central descending pain-modulating pathways located in the brainstem and spinal cord.

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Author

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Coauthor(s)

Joyce L Oleszek, MD Professor, Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine; Co-Director, Rhizotomy Program, Children’s Hospital Colorado

Joyce L Oleszek, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Chief Editor

Milton J Klein, DO, MBA Community Medical Staff Physiatrist, Heritage Valley Health System-Sewickley Hospital

Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Angela Cha-Kim, MD Assistant Professor, Director of Spinal Cord Injury, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center

Angela Cha-Kim, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Paraplegia Society

Disclosure: Nothing to disclose.

Heather Rachel Davids, MD Physician, Department of Anesthesiology, Interventional Pain Medicine, University of Colorado Health Sciences Center

Heather Rachel Davids, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

J Stephen Huff, MD Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Edward A Michelson, MD Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Andrew C Miller, MD Fellow, Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center (UPMC); Attending Physician, Department of Emergency Medicine, UPMC St Margaret's Hospital

Andrew C Miller, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Aishwarya Patil, MD Physiatrist (Rehabilitation Physician), Vice Chair, Immanuel Rehabilitation Center

Aishwarya Patil, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and Association of Physicians of India

Disclosure: Nothing to disclose.

Razi M Rashid, MD, MPH Resident Physician, Department of Neurology, Northwestern University Hospital

Disclosure: Nothing to disclose.

Daniel D Scott, MD, MA Associate Professor, Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine; Attending Physician, Department of Physical Medicine and Rehabilitation, Denver Veterans Affairs Medical Center, Eastern Colorado Health Care System

Daniel D Scott, MD, MA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, National Multiple Sclerosis Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment