From the Guidelines
Myasthenia gravis symptoms should be managed with a treatment approach that prioritizes the patient's morbidity, mortality, and quality of life, and according to the most recent evidence, pyridostigmine starting at 30 mg PO three times a day and gradually increase to maximum of 120 mg PO four times a day as tolerated and based on symptoms, along with corticosteroids, such as prednisone 0.5 mg/kg orally daily, are recommended for patients with grade 2 symptoms or higher 1.
Treatment Approach
The treatment approach for myasthenia gravis symptoms should be based on the severity of the symptoms, and the patient's overall health status.
- For patients with grade 2 symptoms, such as some symptoms interfering with activities of daily living (ADLs), and MGFA severity class I (ocular symptoms and findings only) and MGFA severity class II (mild generalized weakness), holding immune checkpoint inhibitor (ICPi) therapy and resuming it only if symptoms resolve and steroid taper is completed, is recommended 1.
- For patients with grade 3-4 symptoms, such as limiting self-care, weakness limiting walking, any dysphagia, facial weakness, respiratory muscle weakness, or rapidly progressive symptoms, permanently discontinuing ICPi therapy, admitting the patient to the hospital, and initiating intravenous immunoglobulin (IVIG) or plasmapheresis, is recommended 1.
Medications
The medications used to treat myasthenia gravis symptoms include:
- Pyridostigmine, an acetylcholinesterase inhibitor, which improves neuromuscular transmission by increasing acetylcholine availability at the neuromuscular junction 1.
- Corticosteroids, such as prednisone, which reduce inflammation and suppress the immune system 1.
- IVIG or plasmapheresis, which provide rapid but temporary improvement in crisis situations 1.
Additional Considerations
Additional considerations for the treatment of myasthenia gravis symptoms include:
- Neurology consultation and frequent pulmonary function assessment for patients with grade 3-4 symptoms 1.
- Avoiding medications that can worsen symptoms, such as certain antibiotics, beta-blockers, and some anesthetics 1.
- Maintaining regular neurological follow-ups and learning to recognize signs of myasthenic crisis requiring emergency care 1.
From the Research
Myasthenia Gravis Symptomatic Treatment
- The most commonly used drug for symptomatic treatment of myasthenia gravis (MG) is pyridostigmine, an acetylcholinesterase inhibitor 2, 3.
- Pyridostigmine has been shown to be effective in relieving symptoms of MG, with patients reporting a median effectiveness of 60 and a net benefit of 65 2.
- However, pyridostigmine can cause side effects, with 91% of patients currently using the drug reporting side effects, including flatulence, urinary urgency, muscle cramps, blurred vision, and hyperhidrosis 2.
- In some cases, side effects can be severe enough to require discontinuation of pyridostigmine, with diarrhea, abdominal cramps, and muscle twitching being common reasons for discontinuation 2.
Alternative Treatment Options
- Other acetylcholinesterase inhibitors, such as neostigmine, can be used as an alternative to pyridostigmine in the treatment of myasthenic crisis 4.
- Intravenous immunoglobulin or plasmapheresis are also effective treatments for myasthenic crisis, but may not be available in all settings 4.
- Azathioprine can be used in conjunction with pyridostigmine and prednisolone for long-term treatment of MG, and has been shown to be associated with marked clinical improvement and reduction in hospital admissions and episodes of respiratory failure 5.
Treatment Goals and Considerations
- The goal of treatment for MG should be to achieve clinical remission or only mild symptoms with near-normal function and quality of life 6.
- Treatment should be based on the specific subtype of MG and may include symptomatic treatment with acetylcholinesterase inhibitors, thymectomy, and immunotherapy 6.
- Active physical training should be encouraged in patients with MG, and comorbidities should be carefully managed, particularly in elderly patients 6.