Today’s Treatments for Myasthenia Gravis

If you have a flare-up with more intense symptoms, your doctor may refer you to a hospital or clinic for one of the following treatments to stop the flare. 

In plasmapheresis, or plasma exchange, you are connected to a machine through a tube that goes into a vein (an IV). The machine removes the liquid part of your blood, called plasma, removes all the antibodies that are causing the flare, and then puts the "clean" plasma back into your body. You may have the procedure every other day for a few weeks, but you could feel improvements in muscle strength in a few days. 

With IV immunoglobulin (IVIg), you receive healthy antibodies collected from blood plasma donations. They help reduce the number of antibodies that cause MG symptoms. You can receive the IV infusion over three to five days in emergencies or every three to six weeks as maintenance therapy. 

In MG, abnormal antibodies prevent a neurotransmitter called acetylcholine from attaching to the muscle to tell it to contract. 

Pyridostigmine bromide (Mestinon), an acetylcholinesterase inhibitor, boosts your acetylcholine levels, so there's more of it to make its way to muscles and help them contract.  

This medicine works quickly, but it wears off fast, too, so you'll take the tablets several times a day. It's also available as a longer-acting IV injection (Regonol) that you receive at a hospital or clinic. 

This drug can cause side effects that should go away, including an upset stomach, nausea, vomiting, diarrhea, cold sweats, and blurred vision. 

In MG, the immune system mistakenly produces antibodies that attack the body. Medications to calm this overactive immune system can reduce antibody production and slow down attacks.

Corticosteroids, such as prednisone, quickly tamp down the immune system and reduce symptoms. But long-term use brings side effects, including weight gain, bruising, acne, muscle weakness, mood swings, water retention, and extra body hair. They can raise the risk of diabetes, osteoporosis, high blood pressure, and infections. Doctors will try to taper you off these medications or get you down to the lowest possible dose that maintains benefits without causing side effects. 

Nonsteroidal immunosuppressants, such as azathioprine, cyclosporine, and mycophenolate, prevent the body from making autoantibodies, but they do it without steroids. Taken once or twice a day as a liquid or tablet, they can make big improvements in symptoms and reduce flares without many of the risks and side effects that corticosteroids bring.

Still, when you're on any immune suppressant, your risk of getting serious infections is greater, and you'll have to take certain precautions to avoid them. 

In MG, B cells play a big role in making the bad-acting antibodies that attack your muscles. Rituximab, which is also used to treat certain cancers, is a lab-grown antibody custom-made to attack B cells and prevent them from wreaking havoc in your immune system.

This medication is most often used for people with MG who have MUSK antibodies and who haven't improved on other treatments. You'll receive this treatment in periodic cycles, through an IV, in a clinic. Another B-cell–targeting option is Uplizna (inebilizumab), which is approved for adults with generalized MG who have certain antibodies and is given by IV just twice a year after initial doses.

In MG, proteins called neonatal Fc receptors latch onto symptom-causing antibodies and protect them, helping them live longer. Targeted biologic medications that block these receptors can help kill off these bad antibodies.

Medications on the market include:

• Efgartigimod alfa-fcab (Vyvgart)
• Efgartigimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)
• Rozanolixizumab-noli (Rystiggo)
• Nipocalimab-aahu (Imaavy)

Which one your doctor recommends might depend on which kind of MG antibodies you have. You'll receive these medications through periodic injections at a clinic. 
 

Proteins in the immune system called complement proteins also play a key role in the communication malfunction between muscles and nerves in MG. Lab-grown antibodies that attack complement protein C5 can restore this communication and reduce flares and symptoms.

Medications on the market include: 

• Eculizumab (Soliris)
• Ravulizumab-cwvz (Ultomiris)
• Zilucoplan (Zilbrysq)

You can inject zilucoplan yourself at home. The others require periodic clinic visits for IV infusions. Each of these medications greatly lowers your body's natural defenses against bacterial meningitis. You'll have to get a vaccine before you can start this medication. 
 

The thymus gland, which is at the center of your chest behind your breastbone, also helps produce the antibodies that cause MG symptoms.

Sometimes, the thymus becomes enlarged or develops a tumor if you have MG. But even if you don't have these problems, you can benefit from thymectomy (removal of the thymus). People with MG who have a thymectomy may have overall less severe MG symptoms over the course of their disease and may not need to use corticosteroids as often.

With MG, it's important to ease fatigue and improve muscle strength. These tips may help:

• Get regular exercise, but talk to your doctor first to learn what's safe and right for you.
• Avoid extreme heat, which can trigger symptoms. Apply cold compresses to your neck and face when you do get too hot. 
• Make sure your diet includes plenty of healthy carbs (such as brown rice, sweet potatoes, and whole-wheat bread) and lean protein (like chicken and fish) to sustain your energy throughout the day.
• Schedule naps and breaks throughout the day.
• Schedule the most important activities for times of day when you know you feel your best. 

There's plenty of reason for hope and optimism around the future of MG. Hundreds of clinical trials are underway around the world, where researchers are exploring such issues as better ways to regulate the immune system without suppressing it and the best timing of a thymectomy for the best results. The ongoing expansion of treatment options means more effective and personalized care may be available for each person with MG.