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Myasthenia Gravis: Treatments


Myasthenia Gravis: Treatment in Pregnancy

Pyridostigmine (Mestinon) 7
  • Usual doses
    • Adults
      • Pills
        • 60 mg tid to 120 mg q3h
        • Higher does
          • Virtually never effective
          • Often have side effects
      • Timespan pills
        • 90 to 180 mg qhs
        • Use only at bedtime
        • Many cholinergic side effects if used more often than qhs
      • Liquid: 60 mg pyridostigmine bromide per teaspoonful (5 mL)
    • Childhood: Anti-AChE drugs
  • Indications
    • Autoimmune MG
      • Most AChR Ab+ patients: First line treatment
      • MuSK Ab+ patients: Often less helpful
    • Congenital MG: Some syndromes
    • Fatigue syndromes without MG: 30 mg 2x to 3x per day
    • Orthostatic hypotension: With spared peripheral noradrenergic axons 6
  • Advantages
    • Rapid onset of benefit
    • Few serious side effects
    • Inexpensive
    • May be discontinued when immunomodulation becomes effective
  • Disadvantages
    • Cholinergic symptoms & crisis: Especially with timespan tablets
    • Effective in only some patients
    • Less complete benefit: Severe MG; Ocular MG
    • Comparison to corticosteroids or other immunomodulating agent treatment
      • Often less effective over long term
      • More likelihood of MG relapse when given alone
  • Other Management: Do not use tensilon to gauge pyridostigmine dosing
  • External link: 1935 Anti-AChE Rx (YouTube)


By Unknown (wellcomeimages.org)

Prednisone
Azathioprine (Imuran)
Cyclosporine A
Tacrolimus (FK506) 1
Mycophenolate mofetil (CellCept)
Cyclophosphamide 10
Plasma Exchange
Human Immune Globulin
Thymectomy
Eculizumab 4
Rituximab 5

Neonatal Fc Receptor Antagonists
Return to Myasthenic Syndromes

References
1. J Neurol Sci 2010 Online October, Eur J Neurol 2017;24:270-275, J Neurol Sci 2016;369:294-302, Neuromuscul Disord 2021 Feb 23, Eur J Neurol 2024:e16466
2. Int J Neurosci. 2014 Jan 16
3. Rheumatology (Sunnyvale) 2018;8(2), Clin Exp Rheumatol 2019 Jan 2
4. Front Immunol 2020;11:917
5. Expert Opin Biol Ther 2021 Feb 10, Neurol Sci 2023 Oct 13
6. Auton Neurosci 2020;229:102721
7. Neuromuscul Disord 2022;32:790-799
8. J Clin Neuromuscul Dis 2023;24:199-206
9. J Manag Care Spec Pharm 2024;30:517-527
10. J Neurol Neurosurg Psychiatry 2024 Jul 4, J Neurol Neurosurg Psychiatry 2024 Jul 4

9/5/2024