9 Treatment Options for Myasthenia Gravis: Medication, Surgery, and More | MGteam

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9 Treatment Options for Myasthenia Gravis: Medication, Surgery, and More

Posted on January 23, 2024

Although there’s no cure for myasthenia gravis (MG), several treatment options are available that can help you improve your strength and quality of life. With proper treatment, most people diagnosed with myasthenia gravis can manage their symptoms and have an average life expectancy.

Continue reading to learn more about nine different treatment options for this autoimmune disease so you can make the most informed decisions about your treatment.

1. Acetylcholinesterase Inhibitors

Your muscles and nerves communicate by releasing neurotransmitters (chemical messengers). Acetylcholine is a neurotransmitter that tells your muscles when to contract. The muscles in people with myasthenia gravis can’t properly use acetylcholine, which causes muscle weakness.

Acetylcholinesterase (AChE) inhibitors — also called cholinesterase inhibitors and anticholinesterase medications — work by blocking an enzyme known as acetylcholinesterase. This enzyme (a type of protein) is responsible for breaking down acetylcholine, which stops your muscles from using it. By blocking the breakdown of acetylcholine, these medications improve MG symptoms.

Examples of AChE inhibitors include pyridostigmine (Mestinon) and neostigmine methylsulfate (Bloxiverz).

Acetylcholinesterase inhibitors are available in different formulations, including tablets and syrups taken orally (by mouth) and as an injection. Possible side effects include:

  • Stomach cramps and nausea
  • Diarrhea
  • Flatulence (passing gas)
  • Increased sweating
  • Muscle twitching
  • Excessive salivation
  • Hypotension (low blood pressure)

The side effects of acetylcholinesterase inhibitors can be bothersome for some people. To help manage these side effects, your doctor may prescribe other medications, such as glycopyrrolate or hyoscyamine.

2. Corticosteroids

Doctors often recommend corticosteroids as a first treatment for people with myasthenia gravis. This is especially true for people with severe muscle weakness or for those who don’t respond to AChE inhibitors. Corticosteroids are immunosuppressive medications, which means they work by suppressing the immune system. Researchers believe they may help reduce harmful antibodies (immune system proteins) in people with myasthenia gravis.

Examples of corticosteroids include prednisone and methylprednisolone. These medications are available as pills that you take by mouth. If you’re in the hospital, you may receive corticosteroids as an intravenous (into the vein) injection.

Corticosteroids can rapidly help to improve MG symptoms within a few days or weeks. The quick action of corticosteroids makes them useful over the short term for people with severe or life-threatening symptoms. However, corticosteroids taken long-term can cause side effects, such as:

  • Weight gain
  • Increased appetite
  • Osteoporosis (weak bones)
  • New or worsening diabetes
  • New or worsening high blood pressure
  • Development of cataracts (a disease that causes cloudy areas in the lens of your eye)
  • Development of glaucoma (a disease that damages your optic nerve)
  • Trouble sleeping
  • Mood changes

3. Immunosuppressants

Your health care provider may recommend other types of immunosuppressive medications to avoid the potential side effects of corticosteroids.

Examples of immunosuppressant drugs include:

These medications also come in different formulations, both oral and injectable.

While you’re taking an immunosuppressant medication, your doctor will closely monitor you for any side effects, such as:

  • Serious infections
  • Stomach upset
  • Liver problems
  • Kidney problems

4. Targeted Therapies

Targeted therapies, as the name suggests, target different parts of the immune system that contribute to myasthenia gravis. They’re classified based on which part of the immune system they target.

Complement Inhibitors

Targeted therapies called complement inhibitors help to decrease inflammation caused by part of your immune system known as the complement system. Studies show that an overactive complement system plays a role in myasthenia gravis.

Complement inhibitors used to treat myasthenia gravis include:

Eculizumab and ravulizumab-cwvz are types of medications known as biologics, human-made versions of antibodies. Biologic treatments are given by injection, either subcutaneously (under the skin) or by infusion into a vein. In the cases of eculizumab and ravulizumab-cwvz, both are infused intravenously. Zilucoplan is a molecule taken by subcutaneous injection.

Neonatal Fc Receptor Blockers

Neonatal Fc receptors (FcRn) blockers help your body get rid of destructive acetylcholine receptor antibodies, which attack the tissues and cause myasthenia gravis symptoms. The FcRn blockers currently available include efgartigimod alfa-fcab (Vyvgart) — an antibody fragment and is infused by IV —and rozanolixizumab-noli (Rystiggo), a biologic and injected under the skin.

Rituximab is another biologic that is sometimes used to treat myasthenia gravis, although it hasn’t yet been approved by the U.S. Food and Drug Administration (FDA) for this purpose. Rituximab can decrease autoantibody production that causes myasthenia gravis by targeting and blocking the immune cells that make them. Rituximab is taken by IV infusion.

Like immunosuppressants, targeted medications also decrease the activity of your immune system. This means biologics can potentially increase a person’s risk for infection. To learn more about the specific side effects of each targeted medication, talk to your doctor.

5. Surgery

A thymectomy (surgical removal of the thymus gland) is a surgical treatment for myasthenia gravis. The thymus gland is found in the middle of the chest, above the heart. This gland plays a role in making antibodies, including the harmful antibodies that cause myasthenia gravis. Thymus gland problems are often associated with myasthenia gravis.

Your doctor may recommend a thymectomy to improve your long-term prognosis (outlook) with myasthenia gravis. The goals of thymectomy are to improve muscle weakness, reduce the amount of medication a person needs, and help to achieve remission (when there isn’t any evidence of disease). Most people with myasthenia gravis see benefits from a thymectomy within a year. You can have a thymectomy even if you don’t have problems with your thymus gland, such as a thymoma (thymus gland tumor).

Potential thymectomy complications include:

  • Myasthenic crisis (life-threatening worsening of MG symptoms)
  • Injury to the heart
  • Injury to surrounding nerves or blood vessels
  • Collapsed lung
  • Pneumonia (lung infection)
  • Lymphatic fluid or blood in between the lungs and chest wall

6. Plasma Exchange

Plasma exchange — also known as plasmapheresis — is a procedure in which autoantibodies are removed from your blood plasma (the liquid component of blood). When the harmful autoantibodies are filtered out of your plasma, there may be less damage to the neuromuscular junction (where your nerves and muscles meet).

During this procedure, a machine separates the plasma from the blood and replaces it with fluid. The blood is then returned to the recipient’s body.

Plasma exchange can be helpful for people who have sudden worsening symptoms of myasthenia gravis. Your doctor may also recommend this procedure to help you get stronger before surgery. It can also be used as an ongoing MG treatment if other treatments don’t work.

Most people treated with plasma exchange see their symptoms improve. You may notice improvements after the first treatment, or it may take a few treatments to see results. It’s important to note that symptom improvement with plasma exchange is temporary and may last several weeks or months.

Your body will continue to make new antibodies to replace the ones that were filtered out. When this happens, symptoms can return.

Plasma exchange is a safe procedure, but it may have some side effects, such as:

  • Low levels of calcium or magnesium in your blood
  • Hypothermia (low body temperature)
  • Hypotension
  • Catheter-associated complications, including infection and blockage

7. Intravenous Immunoglobulin

Intravenous immunoglobulin (IVIG) is a concentrated injection of antibodies you receive as an infusion into your vein, usually over several hours. The IVIG antibodies can help to temporarily improve MG symptoms by altering the way your immune system makes antibodies.

Your doctor may prescribe IVIG if you have worsening MG symptoms, before surgery, or if other treatments aren’t working.

The side effects of IVIG are usually not serious and may include:

  • Headache
  • Tiredness
  • Fever and chills
  • Flushing during the infusion

8. Lifestyle Changes

Lifestyle changes may help you manage some of the symptoms of MG.

Regular physical activity can help improve your muscle strength and fitness. Make sure to set reasonable goals and allow time for rest while exercising. Talk to your doctor before starting a new exercise plan.

An eye patch may be helpful to avoid eye strain and improve double vision in people with ocular myasthenia gravis (a form of the condition that affects the eyes).

If your MG symptoms interfere with chewing and swallowing, you may find it helpful to make the some of the following changes to your meal routine:

  • Plan your meal times when you feel strongest.
  • Eat smaller, more frequent meals.
  • Chew your food well.
  • Avoid foods that require lots of chewing, like raw fruits and vegetables.
  • Take breaks as needed while eating.
  • Eat soft foods rich in potassium, such as bananas, mashed potatoes, and avocados, to replace what is lost in diarrhea.
  • Avoid salty foods to prevent edema (swelling caused by too much fluid).

Talk to your doctor about what assistive devices may be helpful for you, such as grab bars in the bathroom or electric appliances.

9. Clinical Trials

Clinical trials are studies that help researchers and doctors find new, safe, and effective treatments for conditions like myasthenia gravis. They can focus on studying new medications or exploring new ways to take older medications. Talk to your doctor to find out if you qualify to participate in MG clinical trials. You can also check the Myasthenia Gravis Foundation of America’s list of active clinical trials for myasthenia gravis.

Find Your Team

On MGteam — the social network for people living with myasthenia gravis and their loved ones — members come together to ask questions, give advice, and share their stories with others who understand life with myasthenia gravis.

What treatments have you tried for myasthenia gravis? How have they worked? Share your experience in the comments below, or start a conversation by posting on your Activities page.

    Posted on January 23, 2024
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    Luc Jasmin, M.D., Ph.D., FRCS (C), FACS is a board-certified neurosurgery specialist. Learn more about him here.
    Emily Wagner, M.S. holds a Master of Science in biomedical sciences with a focus in pharmacology. She is passionate about immunology, cancer biology, and molecular biology. Learn more about her here.

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