Myasthenia Gravis medications & treatments
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Myasthenia gravis (MG) is an autoimmune disorder that causes weakness in your voluntary muscle groups, especially those that control the eyes, mouth, throat, and limbs. According to the Myasthenia Gravis Foundation of America, it affects approximately 36,000 to 60,000 people in the United States. This number should probably be higher as this condition is underdiagnosed. It most commonly occurs in women aged 20 to 30 and men over 50. MG can, however, affect people of all ages; around 10% of cases are teenagers. It occurs equally in men and women as well as in all racial and ethnic groups.
While MG is very rare in infants, a mother with MG can pass on antibodies to the fetus. This condition, called neonatal myasthenia gravis, is typically temporary, with the infant’s symptoms disappearing within 2 to 3 months after birth.
What is myasthenia gravis?
Myasthenia gravis (MG) is a chronic neuromuscular disease caused by blocked or impaired communication between your nerve cells and muscles (neuromuscular junction). It is an autoimmune disorder which means your immune system is attacking itself. This results in weakness and rapid fatigue of your skeletal muscles. These muscles are responsible for various functions such as chewing, talking, breathing, and moving your limbs.
Myasthenia gravis causes
- Antibodies. In MG, proteins produced by your immune system called antibodies disrupt or destroy acetylcholine receptors (AChR) where nerve cells connect with the muscles they control. This prevents your muscles from contracting and results in muscle weakness.
- Thymus gland. This gland, located beneath your upper breastbone, helps control your immune system function. It produces a type of white blood cell called T-lymphocytes that fight off cancer, viruses, and infections. Researchers believe that dysfunction in this gland can lead to it producing antibodies that attack acetylcholine receptors causing MG symptoms. People with MG often have a thymus gland that is larger than normal and around 1 in 10 people will have a tumor on it (thymoma). These tumors are typically not malignant.
How is myasthenia gravis diagnosed?
In mild cases of myasthenia gravis, the diagnosis can be delayed for months or even years. It is often misdiagnosed as its symptoms can be indicative of other conditions. To properly diagnose myasthenia gravis, your doctor or neurologist will look at your symptoms, review your medical history, perform a physical exam, and run some diagnostic procedures.
Myasthenia gravis symptoms
Common symptoms of myasthenia gravis can include:
- Droopy eyelids (ptosis)
- Double vision (diplopia)
- Weakness of the eye muscles (ocular myasthenia)
- Muscle weakness
- Difficulty chewing and swallowing
- Slurred speech
- Change in facial expression
- Shortness of breath
- Trouble holding your head up
After reviewing your symptoms and your medical history, your doctor might use several tests to confirm the diagnosis of MG, including:
- Physical and neurologic exams. This will be used to check your muscle strength and tone, reflexes, sense of touch, balance, and coordination.
- Blood test. This test checks for abnormal antibody levels that might be present in your blood. Almost 85% of MG patients will have a high level of acetylcholine receptor antibodies while 6% will have muscle-specific kinase (MuSK) antibodies. Some patients will not have either of these antibodies present in their blood.
- Repetitive nerve stimulation. This nerve conduction study uses electrodes attached to your skin to send small electrical impulses to the muscle to see how well it responds to repeated stimulation. In MG, the ability to send signals worsens with fatigue.
- Single-fiber electromyography (EMG). This involves inserting an electrode into a muscle to test a single muscle fiber. It is used to detect impaired nerve-to-muscle communication problems.
- Imaging tests. Using a CT scan or an MRI, your doctor can check for any tumors on your thymus gland.
- Edrophonium test. This test involves an injection of a medicine called edrophonium chloride to see if you have a temporary improvement in muscle strength. This rarely used test is typically used to see if you have muscle weakness in your eyes.
What are some myasthenia gravis treatment options?
Although there is no cure, there are therapies that can manage your myasthenia gravis symptoms, alone or in combination. Treatments include:
- Cholinesterase inhibitors. Medications such as Mestinon (pyridostigmine) are the first-line treatment for MG. They increase the amount of acetylcholine available at the neuromuscular junction which helps boost the communication between the nerves and muscles. This will improve muscle contraction and decrease muscle weakness.
- Corticosteroids. Usually used as a second-line therapy, meds such as Deltasone (prednisone) are used to decrease the number of antibodies produced by your immune system.
- Immunosuppressants. If corticosteroids aren’t effective, your doctor may prescribe other medications that decrease the number of antibodies your body produces. Examples include Imuran (azathioprine), Cellcept (mycophenolate mofetil), and Sandimmune (cyclosporine).
- Monoclonal antibodies. IV medications such as Soliris (eculizumab) and Rituxan (rituximab) target the process by which acetylcholine antibodies damage the neuromuscular junction. They are typically prescribed when other therapies have failed.
- Thymectomy. The surgical procedure to remove your thymus gland can help improve your MG symptoms, even if you don’t have a tumor present. Symptoms will typically improve in the first few months after surgery but can take up to 2 years to see the full benefit.
- Plasmapheresis. Also called plasma exchange (PLEX), it uses a filtering process similar to dialysis to clean out the abnormal antibodies and replace them with normal antibodies from donated plasma. Plasmapheresis can be used to treat a myasthenic crisis, but your improvement will be short-term and will require repeated procedures every few weeks.
- Intravenous immunoglobulin (IVIg). IVIg therapy is an injection of highly concentrated antibodies that changes your immune system response. It binds to the abnormal antibodies and removes them from your bloodstream. It is usually used for a myasthenic crisis or in severe cases. You will typically see improvements in about a week and they will last up to 6 weeks.
What is the best medication for myasthenia gravis?
The best medication for the treatment of myasthenia gravis will depend on the individual’s specific medical myasthenia gravis, medical history, and medications that the individual is already taking that may potentially interact with myasthenia gravis medications and the individual’s potential response to the treatment. It is advisable to always speak with your healthcare provider about the best medication for you. The table below includes a list of the most prescribed or over-the-counter myasthenia gravis medications approved by the Food and Drug Administration (FDA).
Best medications for myasthenia gravis
|Drug name||Drug class||Administration route||Standard dosage||Common side effects
|Deltasone (prednisone)||Corticosteroid||Oral||Up to 60mg daily. Usually tapered off over a couple of weeks.||Increased heart rate, mood changes, increased appetite, fluid retention, weight gain
|Trexall (methotrexate)||Immunomodulator||Injection||Up to 25mg intramuscularly per week.||Bone marrow suppression, nausea, fever, mouth sores
|Imuran (azathioprine)||Immunosuppressant||Oral||2mg-3mg/kg of body weight once daily.||Low white blood cell count, infection, nausea, abdominal pain
|CellCept (mycophenolate mofetil)||Immunosuppressant||Oral||1000mg to 1500mg twice daily.||Elevated blood sugar, cholesterol, and magnesium, shortness of breath, back pain, infection
|Sandimmune (cyclosporine)||Immunosuppressant||Oral||3-6mg/kg/day in 2 divided doses.||Tremor, kidney damage, high blood pressure, infection, headache
|Prograf (tacrolimus)||Immunosuppressant||Oral||1mg in the morning and 2mg in the evening.||Tremor, high blood pressure, low phosphate levels, infection, headache, diarrhea, nausea
|Cytoxan (cyclophosphamide)||Immunosuppressant||Injection||0.5-1g/m2 via IV infusion monthly.||Bone marrow suppression, infertility, hair loss, nausea
|Mestinon (pyridostigmine)||Cholinesterase inhibitor||Oral||180mg to 1500mg once daily or divided every 12 hours.||Increased sweating, diarrhea, muscle cramps, nausea
|Bloxiverz (neostigmine)||Cholinesterase inhibitor||Oral||15mg to 375mg daily divided every 6 to 8 hours.||Headache, increased sweating, nausea, diarrhea
|Rituxan (rituximab)||Monoclonal antibody||Injection||1g via IV infusion, repeat in 2 weeks, then 1g every 6 months depending on clinical response.||Headache, nausea, chills, low blood pressure, anemia
|Soliris (eculizumab)||Monoclonal antibody||Injection||900mg via IV infusion once weekly for 4 weeks, 1200mg on week 5, then 1200mg every 2 weeks thereafter.||Headache, common cold, back pain, nausea, cough, fatigue
Your healthcare provider will determine the right dosage based on your response to the treatment, medical myasthenia gravis, weight, and age. Other possible side effects may exist; this is not a complete list.
What are the most common side effects of myasthenia gravis medications?
As with all medicines, those used for myasthenia gravis will have some side effects, depending on the class you are taking:
- Anticholinesterase inhibitors commonly cause increased sweating, diarrhea, nausea, and muscle cramps.
- Corticosteroids can cause an increased appetite, mood changes, fluid retention, an increase in blood pressure, and acne.
- Immunosuppressants can cause an increased risk of infections, nausea, headache, vomiting, and hair loss.
What are some home remedies for myasthenia gravis?
Along with medications, some lifestyle changes can help you manage your condition, including:
- Make the most of your energy and plan your activities when you are feeling your best. For most people, that’s earlier in the day or after they have taken their medicine.
- Sit down if you have to do lengthy activities or chores such as washing dishes or folding laundry.
- Take rest breaks or naps during the day to help conserve your energy.
- Maintain a sleep schedule.
- Reduce stress through meditation, yoga, or deep breathing exercise.
- Exercise regularly as tolerated to increase your muscle strength, improve your mood, and increase your energy.
- Eat a nutritious, balanced diet.
Frequently asked questions about myasthenia gravis
Is there a cure for myasthenia gravis?
There is currently no cure for MG, but with treatment and self-care measures, you can manage your condition and live a relatively normal life.
What are some complications of myasthenia gravis?
MG can have some serious complications such as:
- Myasthenic crisis is a life-threatening complication where you have severe weakness in the muscles that control your breathing. You need immediate medical attention which can require a ventilator to help with breathing until treatments get the symptoms under control.
- About 10 to 15 percent of people that have MG have a tumor on their thymus gland. Doctors will surgically remove the gland to help improve their MG symptoms.
- Depression, anxiety, and panic disorders
- Heart disease
- Other autoimmune diseases
What is the life expectancy if you have myasthenia gravis?
For the majority of people with MG, their life expectancy is not any less than someone without the condition.
Is myasthenia gravis inherited?
MG is not considered an inherited condition. Mothers can pass a temporary form of MG to their newborn that usually resolves within a few months.
What medications should I avoid if I have myasthenia gravis?
Some medications can cause a worsening your MG symptoms including:
- Fluoroquinolone antibiotics such as Cipro (ciprofloxacin) and Levaquin (levofloxacin)
- Anticonvulsants such as carbamazepine, gabapentin, phenobarbital, and phenytoin
- Beta-blockers such as Lopressor (metoprolol) and Tenormin (atenolol)
- Antipsychotics such as Haldol (haloperidol) Zyprexa (olanzapine), and Seroquel (quetiapine)
- Macrolide antibiotics such as Ery-Tab (erythromycin), Zithromax (azithromycin), and Biaxin (clarithromycin)
- Statins such as Lipitor (atorvastatin) and Zocor (simvastatin)
- Benzodiazepines such as Ativan (lorazepam) and Xanax (alprazolam)
- Opioids such as Lortab (hydrocodone/APAP) and Roxicodone (oxycodone)
Related resources for myasthenia gravis
The content on this website is intended for information purposes only. It does not constitute medical advice. The information on this website should not be relied upon and is not a substitute for professional medical advice. You should always speak to your doctor regarding the risks and benefits of any treatment.