Myasthenia gravis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


The mainstays of medical therapy for myasthenia gravis are: Symptomatic treatments (An oral anticholinesterase like pyridostigmine), chronic immunomodulating treatments (glucocorticoids and immunosuppressive drugs), rapid immunomodulating treatments (plasmapheresis and intravenous immune globulin).

Medical Therapy

The mainstays of medical therapy for myasthenia gravis are:

Symptomatic treatments

Chronic immunomodulating treatments

  1. Azathioprine: Azathioprine, a purine analogue which inhibits the nucleic acids synthesis, can cause improvement in about 90 percent of myasthenia gravis patients but the onset of this effect takes at least 6 to 12 month.[16][17][18][19] Azathioprine can cause macrocytosis (increased MCV) and malignancies such as non-hodgkin lymphoma.[20][21]
  2. Mycophenolate: Mycophenolate mofetil, a purine synthesis blocker in lymphocytes, is proven to be effective in reducing the symptoms of MG patients and their need to glucocorticoids.[22][23]
  3. Cyclosporine: Cyclosporine, an immunomodulatory agent which blocks the production of interleukin-2 and inhibits the function of T helper cells, can cause improvement in about 90 percent of MG patients after 1 to 2 months of start but the maximum effect will appear after 7 months.[24][25][26] This drug can cause nephrotoxicity[27], tremor, nausea, myalgias, gingival hyperplasia, hypertrichosis and malignancies such as squamous cell skin cancer and lymphoma.[26]
  4. Tacrolimus: Tacrolimus, an immunosuppressive macrolid can significantly reduce the requirement to prednisolone and MG symptoms in almost 67 to 87 percent of patients with less nephrotoxicity than cyclosporine.[27][28][29] the side effects of this drug include hyperglycemia, hypomagnesemia, paresthesias and tremor.[30]
  5. Rituximab: Rituximab, a monoclonal antibody against B cell membrane marker CD20 can be used in refractory myasthenia gravis. This drug is also effective in patients with anti MuSK antibody.[31][32][33][34]
  6. Methotrexate: Methotrexate is an immunosuppressant agent which suggested to be effective as a second line immunosuppressant for MG patients.[35][36]
  7. Etanercept: Etanercept is made of TNF receptor linked to Fc portion of human IgG1. This drug can inhibit TNF-alpha which is a proinflammatory cytokine, and improve the symptoms of MG patients.[37]
  8. Cyclophosphamide: Cyclophosphamide is an alkylating agent which inhibits the proliferation of B and T cells. Monthly high dose intravenous administration of this drug is proved to be more effective than daily oral type.[38] the side effects of this drug include anorexia, nausea and vomiting, leukopenia, alopecia and hemorrhagic cystitis and it can also increase the risk of malignancies.[38][39]

Rapid immunomodulating treatments


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  20. Witte AS, Cornblath DR, Schatz NJ, Lisak RP (November 1986). "Monitoring azathioprine therapy in myasthenia gravis". Neurology. 36 (11): 1533–4. PMID 3762975.
  21. Herrlinger U, Weller M, Dichgans J, Melms A (May 2000). "Association of primary central nervous system lymphoma with long-term azathioprine therapy for myasthenia gravis?". Ann. Neurol. 47 (5): 682–3. PMID 10805346.
  22. Chaudhry V, Cornblath DR, Griffin JW, O'Brien R, Drachman DB (January 2001). "Mycophenolate mofetil: a safe and promising immunosuppressant in neuromuscular diseases". Neurology. 56 (1): 94–6. PMID 11148242.
  23. Ciafaloni E, Massey JM, Tucker-Lipscomb B, Sanders DB (January 2001). "Mycophenolate mofetil for myasthenia gravis: an open-label pilot study". Neurology. 56 (1): 97–9. PMID 11148243.
  24. Tindall RS, Rollins JA, Phillips JT, Greenlee RG, Wells L, Belendiuk G (March 1987). "Preliminary results of a double-blind, randomized, placebo-controlled trial of cyclosporine in myasthenia gravis". N. Engl. J. Med. 316 (12): 719–24. doi:10.1056/NEJM198703193161205. PMID 3547126.
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  29. Evoli A, Di Schino C, Marsili F, Punzi C (January 2002). "Successful treatment of myasthenia gravis with tacrolimus". Muscle Nerve. 25 (1): 111–4. PMID 11754194.
  30. Ponseti JM, Azem J, Fort JM, López-Cano M, Vilallonga R, Buera M, Cervera C, Armengol M (May 2005). "Long-term results of tacrolimus in cyclosporine- and prednisone-dependent myasthenia gravis". Neurology. 64 (9): 1641–3. doi:10.1212/01.WNL.0000160392.32894.6D. PMID 15883336.
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