I declare no competing interests.
David N Durrheim [email protected]
University of Newcastle, Callaghan, NSW, Australia 1
Willison WJ, Jacobs BC, van Doorn PA. Guillain-Barré Syndrome. Lancet 2016; 388: 717–27. WHO. Performance of acute ﬂaccid paralysis surveillance and incidence of poliomyelitis, 2016. Wkly Epidemiol Rec 2016; 91: 336–40. Olivé JM, Castillo C, Castro RG, de Quadros CA. Epidemiologic study of Guillain-Barré syndrome in children <15 years of age in Latin America. J Infect Dis 1997; 175(suppl 1): S160–64. McGrogan A, Madle GC, Seaman HE, de Vries CS. The epidemiology of Guillain-Barré syndrome worldwide. A systematic literature review. Neuroepidemiology 2009; 32: 150–63. Global Polio Eradication Initiative. http://www.polioeradication.org/ dataandmonitoring/poliothisweek.aspx (accessed Oct 27, 2016).
As Hugh Willison and colleagues describe, 1 intravenous immuno globulin (IVIg) and plasma exchange (PLEX) are equally efficacious in treating Guillain-Barré syndrome and the therapeutic decision is largely justified by greater convenience. Because PLEX is cheaper than IVIg, it has been suggested that PLEX should be considered first-line therapy for Guillain-Barré syndrome in resourceconstrained environments.2 However, countries such as Canada3 and Australia4 spend more than 15% of their entire blood service budget on IVIg and restricting cost-savings to resource-constrained environments might be short sighted. Studies show that PLEX costs less than half of IVIg in treating Guillain-Barré syndrome in the USA,5 and in Canada PLEX is about 25% cheaper than IVIG for treating crisis in myasthenia gravis.6 Thus, the two www.thelancet.com Vol 389 January 21, 2017
unknowns to be addressed are: ﬁrst, the actual cost diﬀerence between these two therapies for each geographical and disease setting; and second, the value of the perceived greater convenience of IVIg over PLEX in treating a patient in these geographies. Guillain-Barré syndrome is the ideal ﬁrst disease to attempt these types of analyses since the patients are easily identified and in controlled hospital settings. Furthermore, there is a natural extension of these Guillain-Barré syndrome comparison analyses to the treatment of chronic inflammatory demyelinating polyneuropathy and in the acute and chronic treatment of myasthenia gravis, for which PLEX could be a similarly suitable alternative to IVIg. Structured studies to provide actionable data by comparing the cost-eﬀectiveness of IVIg and PLEX in these diseases are needed as much in resource-rich settings than in resourceconstrained environments; rising health-care costs are a ubiquitously shared concern. EJB reports personal fees from Terumo BCT, and previous employment from Terumo BCT and Grifols (Talecris), outside the submitted work. All remaining authors declare no competing interests.
Eric J Buenz, *Gareth J Parry, Annemarei Ranta [email protected]
Nelson Marlborough Institute of Technology, Nelson 7010, New Zealand (EJB, GJP); Capital & Coast District Health Board, Wellington, New Zealand (GJP, AR); and University of Otago, Wellington, New Zealand (AR) 1
Willison HJ, Jacobs BC, van Doorn PA. Guillain-Barée syndrome. Lancet 2016; 388: 717–27. Hughes R. Give or take? Intravenous immunoglobulin or plasma exchange for Guillain-Barré syndrome. Crit Care 2011; 15: 174 Robinson P, Anderson D, Brouwers M, Feasby TE, Hume H. Evidence-based guidelines on the use of intravenous immune globulin for hematologic and neurologic conditions. Transfus Med Rev 2007; 21(suppl 1): S3–8. National Blood Authority of Australia. Intravenous immunoglobulin supply and demand, 2016. http://www.blood.gov.au/ pubs/ivig/intravenous-immunoglobulinsupply-and-demand.html (accessed April 10, 2016) Winters JL, Brown D, Hazard E, Chainani A, Andrzejeski C Jr. Cost-minimization analysis of the direct costs of TPE and IVIg in the treatment of Guillain-Barré syndrome. BMC Health Serv Res 2011; 11: 101.
Furlan JC, Barth D, Barnett C, Bril V. Cost-minimization analysis comparing intravenous immunoglobulin with plasma exchange in the management of patients with myasthenia gravis. Muscle Nerve 2016; 53: 872–76.
Authors’ reply We thank Eric Buenz and colleagues for their comments on the treatment of Guillain-Barré syndrome. On the basis of evidence that intravenous immunoglobulins (IVIg) and plasma exchange (PLEX) are equally eﬃcacious in treating Guillain-Barré syndrome, we suggested that—because of the high costs of IVIg—PLEX should be considered as first-line therapy especially in resource-constrained environments.1 We agree that rising health-care costs are also relevant in resource-rich countries like Canada and Australia. In this respect, there are several relevant issues in the decision to treat Guillain-Barré syndrome with PLEX or IVIg. First, the actual costs for IVIg vary substantially between countries and even between hospitals depending on local policy and price negotiations. Second, the availability and experience of using PLEX varies greatly between centres. The rapid availability, greater convenience, and the good side-effect profile— including the lower number of multiple complications and the fact that IVIg in Guillain-Barré syndrome is more likely to be completed than PLEX—is likely to favour the use of IVIg for treatment of this condition from a medical point of view.2 The budget spend on IVIg could be increasing over time and we agree that Guillain-Barré syndrome is a disease in which in-hospital related costs can be calculated quite accurately. A much larger budget is probably spent on IVIg in patients with chronic neuromuscular diseases requiring long-term treatment compared with treatment of Guillain-Barré syndrome, which only requires one or a few courses of IVIg. Chronic disorders like chronic inﬂammatory demyelinating polyneuropathy (CIDP) often require repeated IVIg infusions once every
Although there has been tremendous progress towards the polio eradication goal, the recent conﬁrmation5 of wild poliovirus type 1 from two children with AFP in Borno state, Nigeria—the first detections of wild-type virus in Africa since July, 2014—is a stark reminder that complacency cannot be tolerated. AFP surveillance must be honed everywhere.