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Prophylactic anticoagulation in Guillain-Barré syndrome: too much of a good thing?
  1. J B Lilleker1,
  2. E A Lim1,
  3. M Jones1,2,
  4. A M T Richardson1,2
  1. 1Greater Manchester Neurosciences Centre, Salford Royal NHS Foundation Trust, Salford, UK
  2. 2Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
  1. Correspondence to Dr J B Lilleker, Greater Manchester Neurosciences Centre, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK; james.lilleker{at}nhs.net

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Background

Guillain-Barré syndrome (GBS) comprises a group of acute onset immune mediated polyradiculoneuropathies that are the leading cause of acute onset paralysis in the developed world.1 Management incorporates supportive care of the paralysed patient and immunomodulatory treatment. Active prevention and early treatment of complications, including venous thromboembolism (VTE), may help to improve outcomes.

Over 25 000 people die in the UK each year as a result of VTE complicating a hospital admission.2 As a result, national guidelines have been produced to support decision-making regarding the most appropriate strategy of VTE prophylaxis, taking into account the bleeding risk associated with the use of anticoagulation.2 Prolonged flaccid limb weakness and the use of intravenous immunoglobulin are risk factors for the development of VTE in patients with GBS.3 While consensus statements regarding VTE prophylaxis in those with GBS do exist, these are often based on evidence from studies involving postoperative patients and as such do not specifically address the risk-benefit profile of various VTE prophylaxis regimens in GBS.4

At a recent mortality review meeting at our institution, we discussed the case of a 45-year-old patient with GBS in the intensive treatment unit (ITU) who died as a result of bleeding from his tracheostomy. Given his acute severe flaccid paralysis, he was prescribed ‘high dose’ (175 units/kg of subcutaneous tinzaparin per day equivalent) low molecular weight heparin (LMWH) for VTE prophylaxis, as per local practice. Concern was raised that this anticoagulant regimen may have contributed to the occurrence of bleeding and that other patients may be similarly at risk. We, therefore, performed an audit to assess the use of VTE prophylaxis in this patient group.

Methods

Consecutive patients admitted with GBS (excluding those with Miller Fisher syndrome and Miller Fisher-GBS overlap) to our institution between …

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