How Antibody Status Guides Targeted Therapy Selection in MG

In ‘How Antibody Status Guides Targeted Therapy Selection in MG,’ our panel explores the clinical reasoning behind selecting among FcRn-targeted therapies, complement inhibitors, and B-cell–depleting approaches. Faculty identify antibody status as an important branching point because therapeutic options differ across acetylcholine receptor–positive, MuSK-positive, LRP4-positive, and seronegative disease. In particular, the complement-independent biology of MuSK-positive MG affects whether complement inhibition is mechanistically appropriate.

The experts then broaden the discussion to patient characteristics that influence advanced treatment selection. Age, reproductive considerations, comorbidities, concomitant medications, and the degree of immunosuppression associated with different approaches can all alter the balance of risks and benefits. Women of childbearing potential require particularly careful planning because pregnancy and preconception considerations may narrow treatment options.

Prior disease course and response to rescue therapy also enter the decision. Faculty describe patients with severe or recurrent disease who have responded particularly well to plasma exchange and discuss how that experience may support consideration of FcRn-targeted therapy, given that both approaches reduce circulating pathogenic IgG. Practical issues also influence selection, including the feasibility and timing of meningococcal vaccination before complement inhibition. Together, these factors reinforce the idea that choosing an advanced therapy is not simply a comparison of efficacy but a patient-specific decision integrating disease biology, previous response, safety, and treatment feasibility.

Our next episode, ‘Recognizing Inadequate Response to FcRn Inhibitors in MG,’ will examine how depth and durability of response reveal when an FcRn strategy should be reconsidered and how real-world switching experience may broaden treatment options.