Current trends in the management of myasthenia gravis: plasmapheresis and immunosuppressive therapy

Myasthenia gravis presenting as isolated respiratory failure

A patient with myasthenia gravis presenting as respiratory failure was unusual in his lack of peripheral neuromuscular involvement, negative results on many commonly used diagnostic tests, and lack of response to firstline therapeutic measures. Review of the pertinent literature revealed no previously described presentation of myasthenia gravis in this manner.

Immunosuppressive drugs: azathioprine in the treatment of myasthenia gravis

Azathioprine may be tried for treatment of severe myasthenia gravis, in a dose of 2 mg/kg BW. With careful monitoring the side reactions may be controlled. The therapeutic response will occur after a time delay of 4-8 months. About one-third of patients with type II MG (severe, late onset, HLA B8-) will proceed to a complete but azathioprine-dependent remission, and the remaining two-thirds to a marked improvement. In type I MG (early onset, HLA B8+) azathioprine is less effective but will help keep down the need for corticosteroids or plasmapheresis.

Plasmapheresis in the treatment of ventilator-dependent myasthenia gravis patients. Report of four cases

During a 42-month period, we used plasmapheresis to treat four cases of myasthenia gravis with refractory respiratory failure. All four patients were ventilator dependent for prolonged periods and were not responding to management with cholinesterase inhibitors and corticosteroids. All four patients rapidly responded to the plasmapheresis; respiratory muscle strength returned sufficiently to allow discontinuation of assisted mechanical ventilation and removal of the artificial airway. In our experience, plasmapheresis is indicated in the treatment of the myasthenia gravis patient with respiratory failure which is refractory to conventional drug therapy.

Therapeutic apheresis. Applications and future directions

The past 10-15 years have been witness to major technological achievements in the field of therapeutic apheresis. Concurrently, a large number of diseases, primarily with an immunological basis, have been treated with apheresis. In this paper, we review the various applications of therapeutic apheresis, adverse reactions associated with the mode of therapy, and future research directions. Several representative diseases are also discussed in detail.

Anti-acetylcholine receptor antibodies in myasthenia gravis. Part 2. Clinical and serological follow-up of individual patients

Circulating antibodies to acetylcholine receptor protein (anti-AChR) were measured in the sera collected from 75 patients (53 women, 22 men, ages 9-83 year, 20 with a thymoma) with myasthenia gravis (MG) during 5-44 (mean 25) months. The clinical state of each patient was graded on a 6-point scale. Anti-AChR concentrations were measured by a radioimmunoassay with human antigen. We analysed the relation between the change in clinical state and the change in anti-AChR concentration in 155 periods (1-7, mean 2.1 per patient). The change in clinical state is given as the difference in score at the onset and at the end of this period. The change in anti-AChR concentration is expressed as the percentage of the original concentration at the onset of the period. The results were analysed in relation to the therapy and to the severity of the MG at the onset of each period. A strong correlation between a change in anti-AChR concentration and a change in clinical condition existed during treatment with prednisone or immunosuppression and in the period after thymectomy, while a weaker correlation was present in periods without immunosuppression. In only 3 patients did the changes in anti-AChR concentration precede the clinical change. No changes in anti-AChR concentrations were found if improvement was due to the effect of anticholinesterases or if deterioration was caused by infection or emotion. The serial measurement of anti-AChR may be a valuable method of following the basic trend of the MG in severely affected patients.