Sequencing Targeted Therapies in Myasthenia Gravis

Clinical decision-making for transitioning between myasthenia gravis treatments requires comprehensive assessment of treatment response, adverse effects, and achievement of minimal symptom expression within reasonable timeframes. The standard approach typically begins with conventional symptomatic therapy while awaiting antibody results and disease characterization, followed by rapid progression through treatment options to prevent crisis development and optimize disease control. Current guidelines from 2016-2020 predate many targeted therapies, creating variability in clinical practice patterns and highlighting the need for updated treatment algorithms.

Treatment transition decisions center on 3 primary factors: achievement of minimal symptom expression, successful corticosteroid tapering to 5 mg or less daily, and acceptable adverse event profiles. Patients requiring continued high-dose prednisone (20-30 mg) or experiencing significant treatment-related adverse effects warrant consideration for therapeutic changes. The timeframe for assessing treatment response typically ranges from 2 to 3 months for targeted therapies, allowing sufficient time for clinical benefit while preventing prolonged exposure to ineffective treatments.

Vaccination planning, particularly meningococcal vaccination for complement inhibitor eligibility, requires early discussion and implementation, as current protocols mandate 6-month waiting periods after vaccination. This preparation enables rapid treatment transitions when needed and expands available therapeutic options. Treatment selection increasingly emphasizes shared decision-making approaches, incorporating patient preferences regarding administration routes, dosing frequency, and lifestyle factors. Sequential therapy approaches may include switching between FcRn inhibitors for inadequate responses or tolerability issues, progressing to complement inhibition for AChR-positive patients, or considering combination therapies for optimal disease control and minimal symptom expression achievement.