At a NeurologyLive Clinical Forum in Philadelphia, Chafic Karam, MD, chief of neuromuscular medicine at Penn Medicine, discussed treatment sequencing in myasthenia gravis.
On October 6, 2026, NeurologyLive convened a Clinical Forum in Philadelphia bringing together neuromuscular specialists to discuss the evolving treatment landscape for generalized myasthenia gravis (MG). The program was led by Chafic Karam, MD, chief of the Neuromuscular Division and professor of clinical neurology at Penn Medicine, who framed the evening around a question the field still has not settled.
“Until this day, we still don’t have a consensus what’s the best way to treat patients and manage them,” Karam told the group, noting that despite myasthenia being the most common neuromuscular disorder treated in his clinic, physicians continue to debate how and when to use an expanding array of therapies.
Much of the early discussion centered on delays in diagnosis. Karam noted that many new MG diagnoses at his institution are made in the emergency department, often after a patient has progressed to respiratory failure or severe decompensation, and that the delay is especially pronounced in young women, whose symptoms are frequently attributed to generalized fatigue. The group also discussed limitations of the MG-ADL, the disability scale most commonly used to track response to treatment.
Paul Melnick, MD, an attendee, pointed out that patients with significant head drop or extensor weakness can score well on the MG-ADL “but still have significant symptom burden.” Karam agreed, adding later that the scale weighs ocular symptoms the same as respiratory failure, calling it “a good tool” that the field is nevertheless moving away from.
A large portion of the forum focused on the three FDA-approved FcRn inhibitors, efgartigimod, rozanolixizumab, and nipocalimab, which lower circulating IgG by blocking the receptor that normally recycles it back into the bloodstream. Karam walked through pivotal trial data for each, including a 68% MG-ADL response rate for efgartigimod compared with 30% on placebo, and a statistically significant MG-ADL improvement for nipocalimab in a 153-patient trial. The panel also reviewed the three approved complement inhibitors, eculizumab, ravulizumab, and zilucoplan, noting that these therapies require meningococcal vaccination and are not expected to benefit patients with MuSK antibody-positive disease.
The group worked through a case of a 54-year-old woman with type 2 diabetes and an MG-ADL of 6, debating whether to escalate with prednisone and azathioprine or bridge with IVIG or an FcRn inhibitor given her diabetes. Several attendees favored avoiding high-dose steroids in her case. “I would have probably offered her some IVIG and given her azathioprine, and then wait and see how she does with the IVIG,” one attendee said, while Melnick noted that newer biologics are increasingly used as a bridge while slower-acting immunosuppressants take effect.
The conversation also touched on a persistent puzzle in MG research: antibody titers often do not track with disease severity or treatment response. “This is a longstanding observation that antibody levels don’t correlate with disease severity,” said Sami Khella, MD, an attendee, suggesting the quality of a patient’s antibodies, not just their quantity, may better explain outcomes.
Looking ahead, attendees pointed to a pipeline that includes CAR-T therapy, BTK inhibitors, and additional complement and B-cell-targeted agents. “I think it’s time to maybe think about using these newer drugs sooner than before, where you would just go from one immunosuppressant to the other,” one attendee said, reflecting a broader sentiment in the room that the sequencing of MG therapy, not just the available options, is due for reconsideration.
A couple of notes on sourcing: the transcript header and content line up cleanly with “10/6, Philadelphia” as you described, no mismatch to flag this time. I named Sami Khella, MD, and Paul Melnick, MD, directly since the transcript identifies them by name consistently and confidently throughout (not a phonetic guess), unlike the generic “Speaker 1/2/3/4” attendees I kept anonymous. If you’d rather I anonymize Khella and Melnick too (e.g., if they weren’t meant to be quoted on record), just say so and I’ll revise. Also, Karam’s Penn Medicine profile didn’t list a specific department name beyond “Neurology,” so I used “Penn Medicine” as the institution — let me know if you’d prefer “Perelman School of Medicine” instead.
