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If pyridostigmine (Mestinon) isn’t doing enough to control your myasthenia gravis, your doctor may recommend corticosteroids. Also called steroids, medications such as prednisone have long been an important part of myasthenia gravis treatment because they suppress the immune response that interferes with communication between nerves and muscles.
However, steroids come with trade-offs, especially at higher doses or with long-term use. Doctors generally aim for the lowest effective dose and try to reduce steroid use once myasthenia gravis is under better control.
Here’s what to know about steroids for myasthenia gravis, including when they’re used, how they work, what side effects they may cause, and what other treatments you and your doctor may consider.
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Pyridostigmine is often the first medication used to relieve myasthenia gravis symptoms. Unlike steroids, it doesn’t suppress the immune system. Instead, pyridostigmine temporarily improves communication between nerves and muscles.
If pyridostigmine doesn’t provide enough relief, steroids are a common next step. Treatment guidelines recommend steroids or another immune-suppressing treatment when someone hasn’t reached their treatment goals with pyridostigmine alone.
Steroids may be used for generalized myasthenia gravis, which affects muscles beyond the eyes. They may also be considered for ocular myasthenia gravis when symptoms such as double vision or drooping eyelids don’t respond well enough to pyridostigmine.
Treatment is different during a severe myasthenia gravis flare-up or a myasthenic crisis. Because steroids take time to work and can temporarily worsen weakness when first started, doctors may use faster-acting treatments such as intravenous immunoglobulin (IVIG) or plasma exchange. These treatments are especially important when swallowing or breathing is affected.
Myasthenia gravis is an autoimmune disease, meaning the immune system mistakenly makes antibodies that interfere with communication between nerves and muscles.
Corticosteroids suppress several parts of this immune response. In myasthenia gravis, that can reduce the immune attack at the point where nerves communicate with muscles, known as the neuromuscular junction. As the attack decreases, muscle strength and function can improve.
Prednisone is one of the most commonly used oral corticosteroids for myasthenia gravis. Prednisolone is also used. IV corticosteroids such as methylprednisolone may be used in selected situations.
There’s no single prednisone dose that’s right for everyone with myasthenia gravis. Doctors may start with a lower dose and gradually increase it, or they may use another approach depending on the severity of myasthenia gravis and a person’s other health conditions.
Your doctor will consider the severity of your symptoms and your overall health when deciding how to start treatment. People with severe weakness may need closer monitoring. Once myasthenia gravis is stable, the goal is generally to taper steroids to the lowest dose that keeps symptoms controlled or stop them when possible.
How long you’ll need a steroid varies. Once symptoms are under good control, your doctor will usually try to gradually lower the dose. Some people can eventually stop steroids, while others need a low maintenance dose or another medication to keep myasthenia gravis controlled.
Don’t suddenly stop prednisone on your own. After you’ve taken steroids for a while, your body needs time to adjust as the dose comes down. Your neurologist can give you a tapering schedule based on your needs.
Steroids can be effective, but their potential side effects are one reason doctors try to limit the dose and duration of treatment. In general, risks increase with higher doses and longer use.
Side effects that can occur relatively soon after starting prednisone or another corticosteroid include:
For people with myasthenia gravis, there’s another short-term concern: Symptoms can temporarily worsen when corticosteroids are first started. Let your care team know promptly if you notice a significant increase in weakness.
Severe difficulty breathing or swallowing can be signs of a myasthenic crisis and require emergency medical care.
Long-term corticosteroid use, particularly at higher doses, can raise the risk of complications such as:
Not everyone who takes prednisone will develop these problems. However, because of these risks, long-term treatment requires ongoing monitoring.
Depending on your dose, treatment duration, age, and other risk factors, your care team may monitor your blood pressure, blood sugar, eye health, and bone health. Preventing steroid-related bone loss can be particularly important during prolonged treatment.
If side effects are bothering you, tell your doctor rather than changing the dose yourself. It may be possible to reduce your steroid exposure or consider another treatment.
The number of available treatments for myasthenia gravis has expanded considerably in recent years. These treatments aren’t interchangeable, and newer doesn’t automatically mean better for everyone. Each option comes with its own potential benefits, risks, monitoring needs, and practical considerations.
Which options make sense for you depends on factors such as your type of myasthenia gravis, symptom severity, antibody status, other health conditions, previous treatments, and treatment goals.
Pyridostigmine helps improve communication between nerves and muscles and can provide quick symptom relief. It treats myasthenia gravis symptoms rather than suppressing the immune system.
Medications such as azathioprine, mycophenolate mofetil, tacrolimus, and cyclosporine reduce immune system activity in different ways. They may be used instead of or alongside corticosteroids, and some can help reduce the amount of steroids needed over time.
Newer treatments target specific parts of the immune system involved in myasthenia gravis. These include complement inhibitors and FcRn blockers, which block a protein called the neonatal Fc receptor (FcRn). Eligibility may depend on factors such as your myasthenia gravis antibody status and the medication’s approved use.
Rituximab targets B cells, immune cells involved in producing antibodies. It may be considered for certain people with myasthenia gravis, including those whose symptoms haven’t responded well enough to other treatments.
Inebilizumab-cdon (Uplizna) is a newer B-cell therapy approved for certain people with generalized myasthenia gravis who test positive for acetylcholine receptor (AChR) or muscle-specific kinase (MuSK) antibodies.
Both IVIG and plasma exchange can improve myasthenia gravis symptoms quickly by changing the effects or amount of harmful antibodies in the bloodstream. These approaches are often used for severe flare-ups, myasthenic crisis, or other situations in which faster symptom relief is needed.
Thymectomy (surgery to remove the thymus) may be recommended for people with myasthenia gravis who also have a thymoma (thymus tumor). This procedure can also improve outcomes in selected people with generalized, AChR antibody-positive myasthenia gravis who don’t have a thymoma.
Controlling weakness is important, but it’s not all that matters when choosing a treatment for myasthenia gravis. Tell your doctor what you want treatment to help you do. That could mean getting through a workday with less fatigue, swallowing comfortably, returning to an activity you enjoy, or experiencing fewer medication side effects.
Be open about anything that makes your current treatment difficult to follow. Cost, complicated dosing, injections or infusions, transportation, side effects, and concerns about long-term steroid use are all important to consider.
If prednisone is controlling your myasthenia gravis but the side effects are becoming difficult to live with, ask about your options. Other treatments for myasthenia gravis may help you manage myasthenia gravis while reducing your need for steroids.
Talk with your neurologist about your treatment goals, whether your steroid dose can eventually be reduced, and what alternatives might work for you. The aim is to control symptoms while keeping side effects and the burden of treatment as low as possible.
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