How Is Myasthenia Gravis Treated?

The goal of treating myasthenia gravis (MG) is to reduce or improve muscle weakness without causing side effects. Some people’s symptoms can improve to the point that they may only feel weakness on occasion. Some people even go into remission, which means they have no signs or symptoms of MG. Other people can struggle to find a treatment that works for them.

There are several ways to treat MG. Some of these treatments are symptomatic, meaning they help control muscle weakness and other symptoms of MG. Others target the underlying immune dysregulation by calming the body’s immune system. These treatments include:¹

• Acetylcholinesterase inhibitors
• Steroids and other immunosuppressants
• Plasmapheresis
• Intravenous immunoglobulin (IVIG)
• Thymectomy
• Lifestyle and alternative treatments
• Biologics

It may take some time to find the right combination of treatments that work for you. That is because MG can be very different from person to person. No one treatment works for everyone. And certain people with MG may need specific treatments, including:

• Children
• People who are pregnant
• Older adults
• People with rare subtypes of MG

Acetylcholinesterase inhibitors

Acetylcholinesterase inhibitors are a type of drug that improves nerve signals to the muscles. These drugs work against MG by making the signals from your nerves to your muscles last longer. The number of doses you will need each day depends on your symptoms. Pyridostigmine (Mestinon®) is the drug usually recommended for people with MG.^1,2

Steroids and other immunosuppressants

Steroids are drugs that help calm (suppress) an overactive immune system. Steroids are also called corticosteroids. Your doctor may prescribe them if your muscle weakness does not get better after taking acetylcholinesterase inhibitors.

Some people cannot take steroids or need a stronger drug to calm their immune system (immunosuppressant). If that happens to you, your doctor can prescribe other drugs that suppress the immune system, such as:¹

• Azathioprine (Azasan®, Imuran®)
• Cyclosporine (Gengraf®, Neoral®, Sandimmune®)
• Methotrexate (Rheumatrex®, Trexall®)
• Mycophenolate mofetil (CellCept®, Myfortic®)
• Tacrolimus (Astagraf® XL, Envarsus® XR, Prograf®)

Plasma exchange

Plasma is one of the building blocks of blood. Among its many jobs, plasma carries antibodies, which are chemicals the body makes to fight germs. In an autoimmune condition like MG, antibodies incorrectly attack healthy tissue. Plasma exchange (plasmapheresis) is a process in which a machine circulates your blood, removing excess antibodies in your plasma and replacing it with healthy plasma.¹

Plasma exchange is most often used when symptoms are temporarily severe, sometimes called a flare. It can also be used on a regular basis if someone’s MG is more serious or not responding to other treatments. Plasma exchange starts to work in days. But the effects are temporary, usually lasting for weeks.¹

Intravenous immunoglobulin (IVIG)

IVIG is an injection into your veins (intravenous or IV). The injection contains healthy antibodies. IVIG is most often given to people who have severe symptoms for a short period of time. It helps reduce the body’s attack on the nervous system.¹

IVIG can be used on a regular basis if someone’s MG is more serious or not responding to other treatments. Like plasmapheresis, it begins working in days and brings temporary relief for a few weeks.¹

Thymectomy

Thymectomy is a surgery to remove the thymus gland. This surgery is not an option for everyone with MG. However, even in people who do not have a thymoma, a thymectomy can help reduce symptoms and the need for immunosupressant drugs. Thymectomy is always recommended for people with thymoma, a tumor on the thymus gland. Sometimes it is also a treatment option for people with MG who do not have a thymoma.¹

Lifestyle and alternative treatments

Diet, exercise, rest, and stress reduction can all help you manage the symptoms of MG. Knowing your triggers can also help reduce flares. Some very serious, well-studied triggers include:³

• Other illness, including flu, cold, surgery, and heart or kidney problems
• Taking certain over-the-counter or prescription drugs, especially antibiotics

Other lifestyle triggers for MG symptoms include:³

• Drinking alcohol
• Emotional stress
• Foods that require a lot of chewing
• Forgetting to take your MG drugs
• Hot foods
• Large meals
• Too much exercise, or "powering through" when you are tired
• Warm weather

Biologics

About 1 out of 10 people with generalized MG develop what is called refractory MG. Refractory MG is a serious condition in which symptoms do not improve after the use of:⁴

• Steroids and other immunosuppressants
• IVIG
• Plasmapheresis

In these cases, doctors may prescribe biologics. Biologics are a type of drug made from living organisms. These drugs also help suppress the immune system.⁴

The biologics eculizumab (Soliris®) and efgartigimod (Vyvgart®)may be prescribed to people with refractory MG who have anti-acetylcholine receptor (AChR) antibodies. The biologic rituximab (Rituxan®) may be given to people with refractory MG who have muscle-specific kinase antibodies. Both drugs are given by IV.⁴

The biologic ravulizumab-cwvz (Ultomiris®) may be prescribed to adults with generalized MG who have anti-AChR antibodies. Eight out of 10 people with MG are in this group.⁵

Ravulizumab-cwvz is a type of biologic known as a C5 complement inhibitor. It works by curbing the C5 protein in part of your immune system called the complement cascade. When the complement cascade is triggered in an uncontrolled way – as in generalized MG – it overreacts. This overreaction causes an attack on healthy cells.⁶