Dr Ericka Wong discusses treatment options available to patients with initial myasthenia gravis, patients with acute exacerbation, and patients with refractory myasthenia gravis.
Ericka Wong, MD: In the outpatient setting for initial symptoms, if they’re mild, I typically start with pyridostigmine. If they have moderate symptoms, then I might consider starting a low dose of prednisone along with pyridostigmine and then titrating as I need to. If they’re unable to be titrated off the steroids or they have comorbidities that prevent them from being on steroids, then I consider the steroids sparing immunosuppressants.
For acute exacerbations, I separate this into 2 categories: outpatient vs inpatient. If I feel like they need to be admitted to the hospital, then they get admitted to the hospital. For example, if they have significant weakness or bulbar symptoms, then they often get admitted. These patients will get IVIG [intravenous immunoglobulin], plasma exchange, and often an increased dose of steroids if they’re already on them. For outpatient, If I feel like they’re stable enough to be managed as outpatient, then sometimes, if they’re not on a steroid, I’ll start on a low dose, 10 to 20 mg, and titrate up over the next few weeks. If they’re already on a dose of steroids, I might increase that dose. I’ve also given IVIG and plasma exchange as outpatient if they’re stable enough to wait several weeks to get it approved and administered in their home.
Refractory disease is tough, and if they’re not responding to 1 or more immunosuppressants, I consider other medications, like rituximab or eculizumab or even IVIG, if they’re not having response to steroids or other oral steroid-sparing immunosuppressants.
Transcript Edited for Clarity