Plasma exchange as a cost-effective option for treating Guillain–Barré syndrome

Saad and colleagues show that plasma exchange (PLEX) is superior to intravenous immunoglobulin (IVIG) for the treatment of Guillain–Barré syndrome (GBS) in children [Saad et al. 2016], similar to an earlier prospective randomized evaluation [El-Bayoumi et al. 2011]. These findings are interesting; however, the authors neglect to address the issue of cost of therapy in their report. This cost component is important because PLEX [Raphael et al. 2012] and IVIG [Hughes et al. 2014] are established as equivalent in efficacy and safety in adults with GBS. Perhaps rightfully so, physicians primarily focus on efficacy of the therapy for patients. Yet the reality is that budgets are limited, and we need to take cost of therapy into account when developing treatment plans for patients.

In an attempt to assess treatment options for GBS in New Zealand, we analysed the treatment paradigm of GBS for Capital & Coast District Health Board (CCDHB) -domiciled patients treated at Wellington Hospital. The number of GBS cases was small, with a total of 40 patients treated between 2011 and 2015. These patients were all treated with IVIG, based largely on its perceived greater convenience, despite PLEX being available as a therapeutic option. Since PLEX is reported to be cheaper than IVIG for treating GBS in the United States [Winters et al. 2011], we explored the costs of PLEX and IVIG in New Zealand for treating GBS.

Throughout New Zealand, the charges of administering PLEX and IVIG are standardized. Specifically, the cost to the hospital for administration of PLEX, including replacement fluid, is 10,083 NZD and the total cost to the hospital for IVIG is 14,158 NZD, assuming an average 80 kg New Zealand patient. Thus, PLEX is 4075 NZD cheaper for treating a GBS patient. This difference results in a projected annualised 32,600 NZD savings for the CCDHB (extrapolated to PLEX being ~ 342,300 NZD cheaper for treating GBS in all of New Zealand). To place that cost difference in perspective, the 32,600 NZD annualized cost savings is more than the annual cost of the flu vaccines for all of the ~3200 CCDHB staff.

New Zealand is a small country and when compounded, these potential cost savings can have an important impact across our health sector [Jones et al. 2014]. This projected cost minimization needs to be confirmed in a New Zealand-based prospective clinical study, which would determine total costs associated with caring for the patient, such as duration of intensive care unit (ICU) and hospital stay when treated with IVIG or PLEX as well as adverse events associated with IVIG (such as headache, fever, chest pain, black stools, swelling, or malaise) and PLEX (such as fever, chills, urticarial, muscle cramps, and paresthesias). However, it is noteworthy that Saad and colleagues report a shorter ICU and hospital stay when patients are treated with PLEX compared with IVIG. If these projected cost-savings of treating GBS with PLEX withstand that comprehensive clinical analysis, this prospective GBS study should be viewed as a proof-of-concept, or feasibility study, for extending PLEX as an alternative to IVIG in other autoimmune diseases such as chronic inflammatory demyelinating polyneuropathy and myasthenia gravis: particularly, since PLEX has already been reported to be cheaper than IVIG for treating myasthenia gravis in Canada [Furlan et al. 2016].

Physicians excel at treating patients but when there are two equally efficacious therapies; cost needs to become a factor in deciding the treatment paradigm.