Treatment with Medication

Compared to other neuromuscular diseases, myasthenia is different in that it is an autoimmune disease with available medical treatments. Most people will still experience symptoms such as fatigue, but treatment can reduce many symptoms—such as double vision or drooping eyelids—and lessen the fluctuating nature of the disease. Up to 5% become completely symptom-free for at least one year after completing medical treatment

Medication Must Be Tailored to the Individual

Once the diagnosis is made, it is crucial to initiate medication quickly to achieve the best possible function. The various treatment options must be carefully combined and tailored to the individual’s disease pattern, development, and severity. Frequent outpatient checkups are required in the first six months, preferably with the same experienced neurology specialist. Later, checkups are less frequent but should occur at least once a year.

Treatment should be managed by regional and/or highly specialized neurological departments and follow international standards.

Delaying Treatment Increases the Risk of Poorer Outcomes
Individuals with myasthenia who are so concerned about side effects that they delay starting the necessary treatment. This increases the risk of the disease progressing and becoming more chronic.

Some national treatment guidelines recommend that within the first year of diagnosis, it should be clarified which treatment is needed to relieve symptoms most effectively.

Multiple Treatment Options
Several treatment strategies exist and are often combined:

A. Symptomatic Treatment

It reduces fatigue and weakness but does not affect the underlying autoimmune cause.

Pyridostigmine (Mestinon®)
This medication prevents the breakdown of the neurotransmitter acetylcholine, which muscles need to activate and function normally. Mestinon is often insufficient alone and is typically combined with one or more immunosuppressive treatments.

Beta-2 adrenergic antagonists (Terbutaline® or Salbutamol)

This treatment represent the first line treatment for most congenital myasthenia, and may have a role in the treatment of acquired MG. It is mostly used in low doses. It is shown to improve the quantitative MG score and the fatigue responses on the nerves.

B. Immunosuppressive Treatment

These treatments suppress the immune system and thus the production of antibodies targeting the muscle receptors. About 80% of the patient group should be treated with some immunosuppressive treatment. Options include:

  • Steroids: Prednisone is often the first drug used,
  • Non steroidal drugs: first line choice: Imurel® (azathioprine), which reduces antibody production. Mycophenolate, Methotrexate and Tacrolimus are secondary choices.
  • Rituximab®: it works by eliminating the immature, naïve and memory B-cells, but not the plasma cells. It has shown itself to have a good impact on mild, moderate and up to some severe cases of MG. it should be considered a first line drug for newly diagnosed MG patients.
  • Other medications: Newer or alternative immunosuppressants include CellCept®, Sendoxan®, Enbrel®, and MabThera®. These are typically used if standard treatments are not tolerated or are ineffective.

IVIG: Intravenous immunoglobulin temporarily reduces the harmful antibodies and provides short-term symptom relief.

Plasmapheresis: A blood purification treatment that removes antibodies for a limited period. It is used when other treatments are insufficient.

Note: IVIG and plasmapheresis are short-term “booster” treatments, offering rapid but temporary effects (lasting less than a month).

Surgery

Surgical removal of the thymus gland (thymectomy) is often performed in younger patients, but like other treatments, its effectiveness varies and depends on the subtype of myasthenia.

Treatment Takes Time to Work

Mestinon has an immediate effect, and IVIG or plasmapheresis typically work within days or weeks. However, the effects of other treatments may not be noticeable for 3–6 months or longer. Waiting for the right treatment to take effect can be frustrating.

Important! Immunosuppressive Treatment Increases Infection Risk

As mentioned, myasthenia can, in rare cases, cause breathing difficulties (myasthenic crisis), often triggered by infections. Since immunosuppressive drugs can mask a fever, even a small rise in temperature should be taken seriously and treated with antibiotics if needed.

It’s also important to monitor breathing during flu or respiratory infections. If breathing is affected, medical attention is needed immediately. Respiratory muscles can become severely fatigued. People with myasthenia gravis should always carry an information card with their diagnosis in case of an emergency.