Considerations for Approaching the Management of gMG


An expert comments on the impact of factors such as disease course, antibody status, and patient adherence on the management of gMG.

James F. Howard Jr, MD: The management of a [patient with myasthenia gravis] is not a cookbook. To do so leads to failure. One’s management strategy must take into account a number of issues. One is the disease pattern. How quickly did it come on? What muscle groups are involved? I’m going to treat somebody who has ocular disease only vs someone who comes in with difficulty with speech, swallowing, for instance. There’s a need for rapidity in the latter group. Our choices of therapy also depend upon the comorbidities of the individual. It’s unlikely I want to use high-dose corticosteroids, which is a very good therapy but fraught with many adverse event profiles. If they’re morbidly obese, if they have brittle diabetes, if they have osteoporosis, if they have hypertension, etc. I’m not going to want to use intravenous immunoglobulin in the individual who has coronary artery or cerebrovascular disease or renal artery disease and renal insufficiency, for instance. Antibody status plays a role. There are certain therapeutics, for instance—cholinesterase inhibitors are not tolerated by patients who have the MuSK form of myasthenia gravis, [or] muscle-specific kinase. They respond very nicely to drugs like rituximab, whereas the patient with AChR [acetylcholine receptor] myasthenia gravis does not have such a great response. So all of this must be factored in. And then, of course, in the US we have to take into account the financial resources of the individual, what their insurance is. Yes, we can often get a medication paid for, but can I get an insurance company, or can the patient afford, to pay for those studies that are necessary to monitor for safety, liver function studies, and the immunologic studies for things like a hybrid of the renal studies or the cycling films, etc? And then one has to take into [account] the reliability of the patient. Are they going to take their medication? And this is true in all diseases, of course, but in a patient [with myasthenia]—should they stop their medication? One may have acute exacerbations that may lead to hospitalization, intensive care stay, respiratory support, potentially death in some instances. So myasthenia gravis is a snowflake disease. Yes, there are common themes, common threads, but each individual is unique, and we pattern our treatment based on these inherent differences that come from all angles, if you will. And we put it all into the formula and then decide for this given individual. Is this the best treatment strategy? For another, it may be totally different or have a significant tweak on the process.

Transcript is AI-generated and edited for clarity and readability.

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