From the Guidelines
Corticosteroids, such as prednisone 0.5 mg/kg orally daily, are a crucial component in the management of myasthenia crisis, particularly for patients with G2-G4 symptoms. The use of corticosteroids in myasthenia crisis is supported by recent guidelines, including the 2021 ASCO guideline update 1. This guideline recommends administering corticosteroids to patients with myasthenia gravis, with the dose and duration of treatment depending on the severity of symptoms.
Key Considerations
- For patients with G2 symptoms, corticosteroids can be used alongside pyridostigmine, with a starting dose of 30 mg PO three times a day, and gradually increased to a maximum of 120 mg PO four times a day as tolerated and based on symptoms 1.
- For patients with G3-4 symptoms, corticosteroids should be continued, with a taper starting 3-4 weeks after initiation, and weaned based on symptom improvement 1.
- In addition to corticosteroids, other treatments such as IVIG or plasmapheresis may be necessary for patients with severe symptoms or those who are refractory to corticosteroids 1.
Monitoring and Side Effects
- Patients on corticosteroids require close monitoring for side effects, including hyperglycemia, hypertension, electrolyte disturbances, and increased infection risk.
- Gastric protection with proton pump inhibitors is recommended, and osteoporosis prophylaxis should be considered for long-term use.
- Frequent pulmonary function assessment and daily neurologic review are essential for patients with severe symptoms or those requiring ICU-level monitoring 1.
From the FDA Drug Label
Anticholinesterases Concomitant use of anticholinesterase agents (e.g., neostigmine, pyridostigmine) and corticosteroids may produce severe weakness in patients with myasthenia gravis. If possible, anticholinesterase agents should be withdrawn at least 24 hours before initiating corticosteroid therapy. If concomitant therapy must occur, it should take place under close supervision and the need for respiratory support should be anticipated
The use of corticosteroids in myasthenia crisis requires careful consideration due to the potential for severe weakness when combined with anticholinesterase agents. It is recommended to withdraw anticholinesterase agents at least 24 hours before initiating corticosteroid therapy, if possible. If concomitant therapy is necessary, it should be done under close supervision with anticipation of the need for respiratory support 2.
From the Research
Steroids in Myasthenia Crisis
- The use of corticosteroids in myasthenia crisis is a topic of discussion, with some studies suggesting that they should be avoided initially 3.
- According to a study published in 2004, beginning treatment with corticosteroids can be a precipitating factor for myasthenic crisis 4.
- However, there is no direct evidence in the provided studies that discusses the efficacy of steroids in myasthenia crisis.
- Other treatment options such as plasmapheresis and intravenous immunoglobulin (IVIG) have been compared in several studies, with some suggesting that plasmapheresis may offer superior short-term symptom improvement in MG compared to IVIG 5.
- A study published in 1993 reported that four patients with myasthenic crisis who failed to respond to intravenous gamma-globulin subsequently responded to intensive plasma exchange, suggesting that plasmapheresis may be a viable option in certain cases 6.
- Another study published in 2009 found no significant difference in the outcome of patients treated with plasmapheresis or IVIG for myasthenia gravis crisis 7.