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CC BY-NC-ND 4.0 · Neurology International Open 2018; 2(02): E84-E92
DOI: 10.1055/s-0043-124983
Review
Eigentümer und Copyright ©Georg Thieme Verlag KG 2018

Treatment Standards and Individualized Therapy of Myasthenia Gravis

Peter Paul Urban
1   Neurologische Klinik, Asklepios Klinik Barmbek, Hamburg
,
Christian Jacobi
2   Neurologische Klinik, Krankenhaus Nordwest GmbH, Frankfurt am Main
,
Sebastian Jander
3   Klinik für Neurologie, Universitätsklinikum Düsseldorf
› Author Affiliations
Further Information

Publication History

Publication Date:
03 April 2018 (online)

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Abstract

A wide range of established treatment options is currently available for myasthenia gravis. These include cholinesterase inhibitors for symptomatic treatment and a broad spectrum of immunosuppressive, immunomodulating or cell-depleting options to modify the underlying immunological process. Appropriate use allows the great majority of patients to lead a normal life. Specialized centers integrating outpatient and in-hospital resources as well as interdisciplinary competences offer important advantages for optimum individualized therapy.

Key words

myasthenia gravis - neuromuscular disorder - treatment
 

  • References

  • 1 Gilhus NE, Verschuuren JJ. Myasthenia gravis: subgroup classification and therapeutic strategies. Lancet Neurol 14: 1023-1036
    PubMedGoogle Scholar
  • 2 Aeschlimann JA, Reinert M. Pharmacological action of some analogues of physiostigmine. J Pharmacol Exp Ther 1931; 43: 413-444
    PubMedGoogle Scholar
  • 3 Remen L. Zur Pathogenese und Therapie der Myasthenia gravis pseudoparalytica. Dtsch Z Nervenheilkunde 1932; 128: 66-78
    PubMedGoogle Scholar
  • 4 Walker MB. Treatment of myasthenia gravis with physostigmine. Lancet 1934; 1: 1200-1201
    PubMedGoogle Scholar
  • 5 Nair VP, Hunter JM. Anticholinesterases and anticholinergic drugs. Continuing Education in Anaesthesia, Critical Care & Pain 2004; 4: 164-168
    CrossrefPubMedGoogle Scholar
  • 6 Maggi L, Mantegazza R. Treatment of myasthenia gravis. Focus on Pyridostigmine. Clin Drug Investig 2011; 31: 691-701
    CrossrefPubMedGoogle Scholar
  • 7 Deutsche Gesellschaft für Neurologie (DGN). Leitlinien der DGN: Diagnostik der Myasthenia gravis und des Lambert-Eaton-Syndroms.(29.06.2015). Im Internet: http://www.dgn.org/leitlinien/ 3005-ll-68-ll-diagnostik-und-therapie-der-myasthenia-gravis-unddes-lambert-eaton-syndroms
    PubMed
  • 8 Mehndiratta MM, Pandey S, Kuntzer T. Acetylcholinesterase inhibitor treatment for myasthenia gravis. Cochrane Database Syst Rev 2014; CD006986 10.1002/14651858.CD006986.pub3
    PubMedGoogle Scholar
  • 9 Punga RA, Stalberg E. Acetylcholinesterase inhibitors in myasthenia gravis: To be or not to be?. Muscle Nerve 2009; 39: 724-728
    CrossrefPubMedGoogle Scholar
  • 10 Wolfe GI, Kaminski HJ, Aban IB. et al. Randomized trial of thymectomy in myasthenia gravis. N Engl J Med 2016; 375: 511-522
    CrossrefPubMedGoogle Scholar
  • 11 Pascuzzi RM, Coslett HB, Johns TR. Long-term corticosteroid treatment of myasthenia gravis: report of 116 patients. Ann Neurol 1984; 15: 291-298
    CrossrefPubMedGoogle Scholar
  • 12 Schneider-Gold C, Gajdos P, Toyka KV. et al. Corticosteroids for myasthenia gravis. Cochrane Database Syst Rev 2005; 2 CD002828
    PubMedGoogle Scholar
  • 13 Seybold ME, Drachman DB. Gradually increasing doses of prednisone in myasthenia gravis. Reducing the hazards of treatment. N Engl J Med 1974; 290: 81-84
    CrossrefPubMedGoogle Scholar
  • 14 Palace J, Newsom-Davis J, Lecky B. A randomized double-blind trial of prednisolone alone or with azathioprine in myasthenia gravis. Myasthenia Gravis Study Group. Neurology 1998; 50: 1778-1883
    CrossrefPubMedGoogle Scholar
  • 15 Gronseth GS, Barohn RJ. Practice parameter: thymectomy for autoimmune myasthenia gravis (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; 55: 7-15
    CrossrefPubMedGoogle Scholar
  • 16 Iorio R, Damato V, Alboini PE. et al. Efficacy and safety of rituximab for myasthenia gravis: a systematic review and meta-analysis. J Neurol 2015; 262: 1115-1119
    CrossrefPubMedGoogle Scholar
  • 17 Hohlfeld R, Michels M, Heininger K. et al. Azathioprine toxicity during long-term immunosuppression of generalized myasthenia gravis. Neurology 1988; 38: 258-261
    CrossrefPubMedGoogle Scholar
  • 18 Hohlfeld R, Toyka KV, Besinger UA. et al. Myasthenia gravis: reactivation of clinical disease and of autoimmune factors after discontinuation of long-term azathioprine. Ann Neurol 1985; 17: 238-242
    CrossrefPubMedGoogle Scholar
  • 19 Pedersen EG, Pottegard A, Hallas J. et al. Myasthenia and risk of cancer: a population-based case-control study. Eur J Neurol 2014; 21: 773-778
    CrossrefPubMedGoogle Scholar
  • 20 Pedersen EG, Pottegard A, Hallas J. et al. Risk of non-melanoma skin cancer in myasthenic patients treated with azathioprine. Eur J Neurol 2014; 21: 454-455
    CrossrefPubMedGoogle Scholar
  • 21 Muscle Study Group . A trial of mycophenolate mofetil with prednisone as initial immunotherapy in myasthenia gravis. Neurology 2008; 71: 394-399
    CrossrefPubMedGoogle Scholar
  • 22 Sanders DB, Hart IK, Mantegazza R. et al. An international, phase III, randomized trial of mycophenolate mofetil in myasthenia gravis. Neurology 2008; 71: 400-406
    CrossrefPubMedGoogle Scholar
  • 23 Hehir MK, Burns TM, Alpers J. et al. Mycophenolate mofetil in AchR-antibody-positive myasthenia gravis: outcomes in 102 patients. Muscle Nerve 2010; 41: 593-598
    CrossrefPubMedGoogle Scholar
  • 24 Meriggioli MN, Ciafaloni E, Al-Hayk KA. et al. Mycophenolate mofetil for myasthenia gravis. Neurology 2003; 61: 1438-1440
    CrossrefPubMedGoogle Scholar
  • 25 Hobbson-Webb LD, Hehir M, Crum B. et al. Can mycophenolate mofetil be tapered safely in myasthenia gravis? A retrospective, multicenter analysis. Muscle Nerve 2015; 52: 211-215
    CrossrefPubMedGoogle Scholar
  • 26 Lim AKH, Donnan G, Chambers B. et al Mycophenolate mofetil substitution for cyclosporine-dependent myasthenia gravis and nephrotoxicity. Intern Med J 2007; 37: 55-59
    CrossrefPubMedGoogle Scholar
  • 27 Oskarsson B, Rocke DM, Dengel K. et al. Myasthenia gravis exacerbation after discontinuing mycophenolate. Neurology 2016; 86: 1-5
    CrossrefPubMedGoogle Scholar
  • 28 Heckmann JM, Rawoot A, Bateman K. et al. A single-blinded trial of methotrexate versus azathioprine as steroid-sparing agents in generalized myasthenia gravis. BMC Neurology 2011; 11: 97
    CrossrefPubMedGoogle Scholar
  • 29 Pasnoor M, He J, Herbelin L. et al. A randomized controlled trial of methotrexate for patients with generalized myasthenia gravis. Neurology 2016; 87: 57-64
    CrossrefPubMedGoogle Scholar
  • 30 Braun J, Kaestner P, Flaxenberg P. et al. MC-MTX.6/RH Study Group. Comparison of the clinical efficacy and safety of sucutaneous versus oral administration of methotrexate patients with active rheumatoid arthritis. Arthritis Rheum 2008; 58: 73-81
    CrossrefPubMedGoogle Scholar
  • 31 Nagane Y, Suzuki S, Suzuki N. et al. Two-year treatment with cyclosporine microemulsion for responder myasthenia gravis patients. Eur Neurol 2010; 64: 186-190
    CrossrefPubMedGoogle Scholar
  • 32 Tindall RSA, Rollins JA, Phillips JT. et al. Preliminary results of a double blind, randomized, placebo-controlled trial of cyclosporine in myasthenia gravis. N Engl J Med 1987; 316: 719-724
    CrossrefPubMedGoogle Scholar
  • 33 Ciafoloni E, Nikhar NK, Massey JM. et al. Retrospective analysis of the use of cyclosporine in myasthenia gravis. Neurology 2000; 55: 448-450
    CrossrefPubMedGoogle Scholar
  • 34 Ponseti JM, Gamez J, Azem J. et al. Tacrolimus for myasthenia gravis: a clinical study of 212 patients. Ann NY Acad Sci 2008; 1132: 254-263
    CrossrefPubMedGoogle Scholar
  • 35 Cruz JL, Wolff ML, Vanderman AJ. et al. The emerging role of tacrolimus in myasthenia gravis. Ther Adv Neurol Disord 2015; 8: 92-103
    CrossrefPubMedGoogle Scholar
  • 36 Nagaishi A, Yukitake M, Kuroda Y. Long-term treatment of steroid-dependent myasthenia gravis patients with low-dose tacrolimus. Inter Med 2008; 47: 731-736
    CrossrefPubMedGoogle Scholar
  • 37 Eienbröker C, Seitz F, Spengler A. et al. Intravenous immunoglobulin maintainance treatment in myasthenia gravis: a randomized, controlled trial sample size simulation. Muscle Nerve 2014; 50: 999-1004
    CrossrefPubMedGoogle Scholar
  • 38 Liew WKM, Powell CA, Sloan SR. et al. Comparison of plasmapheresis and intravenous immunoglobulin as maintenance therapies for juvenile myasthenia gravis. JAMA Neurol 2014; 71: 575-580
    CrossrefPubMedGoogle Scholar
  • 39 Zinman L, NG E, Bril V. et al. IV immunoglobulin in patients with myasthenia gravis: a randomized controlled trial. Neurology 2007; 68: 837-841
    CrossrefPubMedGoogle Scholar
  • 40 Kupersmith MJ, Latkany R, Homel P. Development of generalized disease at 2 years in patients with ocular myasthenia gravis. Arch Neurol 2003; 60: 243-248
    CrossrefPubMedGoogle Scholar
  • 41 Köhler W. Sieb JP. Hrsg Myasthenia gravis. Bremen: Uni-Med Verlag; 2012
    Google Scholar
  • 42 Engel AG. ed. Myasthenia gravis and Myasthenic Disorders. Oxford: Oxford University Press; 2012
    Google Scholar