What is the recommended treatment for a female patient with Myasthenia Gravis (MG)?

Treatment of Myasthenia Gravis in Female Patients

All female patients with myasthenia gravis should be started on pyridostigmine as first-line symptomatic therapy, with corticosteroids added for inadequate symptom control, while strictly avoiding medications that worsen neuromuscular transmission. 1, 2

Initial Symptomatic Treatment

• Start pyridostigmine at 30 mg orally three times daily, gradually titrating upward based on clinical response to a maximum of 120 mg four times daily 1, 2
• This acetylcholinesterase inhibitor increases acetylcholine concentration at the neuromuscular junction and may provide sufficient control in mild disease 3, 4
• Monitor for cardiac side effects, particularly in elderly females, as pyridostigmine can rarely precipitate myocardial ischemia through coronary vasospasm or arrhythmogenic effects 5, 6

Escalation to Immunosuppressive Therapy

For Grade 2 symptoms (mild generalized weakness interfering with activities of daily living), add corticosteroids directly if pyridostigmine provides insufficient control 1:

• Initiate prednisone at 0.5-1.5 mg/kg orally daily 7, 1
• Begin tapering 3-4 weeks after initiation based on symptom improvement 7, 1
• Approximately 66-85% of patients show positive response to corticosteroids 8

For patients requiring steroid-sparing agents or with contraindications to corticosteroids, azathioprine serves as third-line immunosuppressive therapy 8, 3

Management of Severe Disease (Grade 3-4)

Patients with myasthenic crisis, respiratory compromise, severe dysphagia, or rapidly progressive symptoms require immediate hospitalization with ICU-level monitoring 7, 1:

• Permanently discontinue any immune checkpoint inhibitors if applicable 7
• Administer IVIG at 2 g/kg total dose over 5 days (0.4 g/kg/day) OR plasmapheresis for 3-5 days 7, 1
• Continue corticosteroids and pyridostigmine concurrently (though pyridostigmine may be held if intubation required) 1
• Perform frequent pulmonary function assessments with negative inspiratory force and vital capacity monitoring 7, 1
• Consider rituximab for refractory cases not responding to IVIG or plasmapheresis 7

Important: IVIG should NOT be used for chronic maintenance therapy in myasthenia gravis—it is reserved only for acute exacerbations or crisis situations 1

Critical Medications to Avoid

Educate all female patients to strictly avoid the following medications that worsen myasthenic symptoms 7, 1:

• β-blockers 7, 1
• Intravenous magnesium 7, 1
• Fluoroquinolone antibiotics 7, 1
• Aminoglycoside antibiotics 7, 1
• Macrolide antibiotics 7, 1
• Barbiturate-containing medications like Firocet (butalbital/acetaminophen) 1, 9

Thymectomy Consideration

For female patients with acetylcholine receptor antibody-positive generalized MG up to age 65, thymectomy provides clear benefit and should be strongly considered 3, 10

Diagnostic Confirmation

Before initiating treatment, confirm diagnosis with 7, 8:

• Acetylcholine receptor (AChR) antibodies and antistriated muscle antibodies
• If AChR antibodies negative, test for MuSK and LRP4 antibodies 7, 8
• Electrodiagnostic studies with repetitive nerve stimulation and/or single-fiber EMG 8, 10
• Pulmonary function testing with negative inspiratory force and vital capacity 7, 1

Special Considerations for Women

• Pregnancy planning is critical: certain immunosuppressive therapies have teratogenic potential and require careful selection 3
• IVIG may be preferred over plasmapheresis in pregnant women due to fewer monitoring requirements 1
• Approximately 50-80% of patients with initial ocular symptoms will develop generalized disease within a few years, requiring vigilant monitoring 8

Monitoring and Follow-up

• Regular neurological follow-up to adjust treatment as disease activity changes 1
• Educate patients to immediately report worsening bulbar symptoms (speech, swallowing), respiratory difficulties, or diplopia 1
• Plan activities around medication timing for optimal strength 1