From the Guidelines
Hospitalization is warranted for patients with myasthenia gravis who experience any grade of symptoms that may lead to respiratory compromise, with a strong consideration for inpatient care in patients with grade 2 symptoms or higher, as they can deteriorate quickly 1. When considering hospitalization for myasthenia gravis, it's crucial to assess the severity of symptoms and the potential for rapid progression to respiratory compromise.
- Key indicators for hospitalization include:
- Respiratory distress or difficulty breathing
- Inability to swallow (dysphagia)
- Significant worsening of muscle weakness affecting daily functioning
- Severe side effects from medications
- Need for close monitoring during treatment initiation, such as plasma exchange, intravenous immunoglobulin (IVIG), or high-dose corticosteroids
- According to the guidelines, patients with grade 2 symptoms (some symptoms interfering with activities of daily living, mild generalized weakness) may resume treatment if symptoms resolve and steroid taper is completed, but inpatient admission should be strongly considered due to the potential for rapid deterioration 1.
- For patients with grade 3-4 symptoms (limiting self-care, weakness limiting walking, any dysphagia, facial weakness, respiratory muscle weakness, or rapidly progressive symptoms), permanent discontinuation of immune checkpoint inhibitors, admission for ICU-level monitoring, and initiation of treatments like IVIG or plasmapheresis are recommended 1.
- The primary goal of hospitalization is to prevent respiratory failure and provide close monitoring and prompt intervention when necessary, emphasizing the importance of a clear emergency plan for patients with myasthenia gravis 1.
From the Research
Hospitalization Criteria for Myasthenia Gravis
When considering hospitalization for someone with myasthenia gravis, several factors come into play. The primary concern is the risk of myasthenic crisis, a life-threatening condition characterized by respiratory failure due to severe muscle weakness. Key indicators for hospitalization include:
- Respiratory compromise or failure, as this is a medical emergency requiring immediate attention 2
- Severe muscle weakness, particularly if it affects the bulbar muscles (those used for swallowing and speaking), as this can lead to aspiration pneumonia or respiratory failure 2
- Infection, as this can precipitate a myasthenic crisis 2
- Inability to manage symptoms with current medication regimen, suggesting a need for more intensive treatment or monitoring 3, 4
- Need for plasmapheresis or intravenous immunoglobulin (IVIG) therapy, which are often administered in a hospital setting due to their complexity and potential side effects 4, 5
Management and Treatment Considerations
In the hospital, management of myasthenia gravis, especially during a crisis, involves:
- Discontinuation of acetylcholinesterase inhibitors, as they can worsen the condition in the context of a myasthenic crisis 2, 3
- Use of noninvasive positive-pressure ventilation as a first-line approach for respiratory support, with intubation considered if necessary 2
- Avoidance of certain medications, such as depolarizing paralytics, and cautious use of nondepolarizing agents if intubation is required 2
- Consideration of IVIG or plasmapheresis for rapid reduction of antibody levels and improvement of symptoms, with the choice between them depending on individual patient factors and disease characteristics 4, 5