Guideline for the management of myasthenic syndromes

Treatment Patterns and Disease Burden of Juvenile Myasthenia Gravis in the United States: A Cohort Study Using Health Care Claims Databases

BACKGROUND AND OBJECTIVES

Juvenile myasthenia gravis (JMG) is a rare disorder defined as MG in patients younger than 18 years. Generalized JMG is more common in postpubertal than prepubertal patients. There are no formal international JMG treatment guidelines, and knowledge on treatment patterns and disease burden is limited. The aim of this study was to describe treatment patterns and health care resource utilization (HCRU) for patients with JMG and explore differences in disease presentation between prepubertal-onset (younger than 12 years) and postpubertal-onset (12-17 years) patients.

METHODS

Patients with JMG, newly diagnosed from 2008 to 2021, were identified from the US Merative MarketScan® Research Databases. Patients were followed from the first JMG claim (diagnosis/treatment with acetylcholinesterase inhibitors, immunoglobulin [Ig], or plasma exchange [PLEX]). The primary outcome was JMG-related treatment changes during follow-up, assessed descriptively. Rates of MG exacerbation, thymectomy, and acute intravenous immunoglobulin/PLEX treatment were assessed. HCRU was evaluated.

RESULTS

A total of 630 patients (64.1% female; mean [SD] age 9.07 [5.73] years; 57.6% prepubertal onset) were followed for a median (range) of 2.4 (0-13) years. Corticosteroids were started at a median (range) of 1.28 (0-37.02) and 3.19 (0-87.68) months from diagnosis for postpubertal-onset and prepubertal-onset patients, respectively. The rate of thymectomy was highest during treatment with maintenance Ig/PLEX (incidence rate [IR]; [95% CI] per 100 patient-years: 34.62 [14.41-83.17] for postpubertal-onset and 24.24 [9.10-64.60] for prepubertal-onset patients). MG exacerbations were most frequent during the first year of follow-up in both subgroups (34.1% and 30.3%). In postpubertal-onset patients, exacerbation was highest during treatment with maintenance Ig/PLEX and nonsteroid immunosuppressant therapy ([NSIST], mostly polytherapy) (IR [95% CI] 105.81 [68.99-162.29] and 91.22 [65.80-126.47]). For prepubertal-onset patients, exacerbation was most frequent during NSIST (polytherapy) and biologic treatment (IR [95% CI] 140.44 [115.45-170.85] and 142.95 [46.10-443.23]). JMG-related hospitalizations occurred in 36.0% and 30.0% of postpubertal-onset and prepubertal-onset patients, in the first year of follow-up.

DISCUSSION

Patients with JMG escalated rapidly through the treatment hierarchy. Postpubertal-onset patients escalated more quickly to later-line treatments than prepubertal-onset patients. However, some patients continued to experience high HCRU, highlighting the need for new JMG treatments to provide rapid disease control. A limitation is that treatment escalation reasons were not evaluated.

Clinical outcome and peripheral CD4+ T profile in impending myasthenic crisis: A prospective cohort study

Impending Myasthenic Crisis (MC) is defined as a rapid worsening of myasthenia gravis (MG) that can progress to respiratory failure within days to weeks. The clinical data regarding the outcome and peripheral immune profile is limited. This multicenter cohort enrolled 37 patients with impending MC who were given timely rescue therapies from six university hospitals (n = 272). The transformation rate in the impending MC cohort to manifest MC was 24.32 % (9/37). Compared with those who have transformed to MC, the untransformed patients manifested a shorter hospital stay (13.98 ± 15.22 vs. 22.00 ± 16.03 days, P = 0.004), a lower baseline MG Quality of Life 15 (QOL-15) (23.42 ± 14.32 vs. 38.44 ± 13.56, P = 0.006), and shorter disease duration (29.30 ± 46.05 vs. 88.00 ± 71.43 months, P = 0.003). Peripheral CD4+ T profiling revealed an elevated Th17 proportion in impending crisis compared with healthy controls (22.33 ± 6.58 vs. 15.06 ± 4.35, P = 0.0006). Impending MC can be effectively prevented from transforming into manifest MC with rescue therapies.

Safety and effectiveness of efgartigimod for intravenous infusion in patients with generalized myasthenia gravis: an interim analysis of Japanese post-marketing surveillance

BACKGROUND

Efgartigimod for intravenous infusion (efgartigimod-IV) is approved in Japan for generalized myasthenia gravis (gMG). Post-marketing surveillance was mandated by regulatory authorities to assess the safety and effectiveness of efgartigimod in patients with gMG.

RESEARCH DESIGN AND METHODS

Patients with gMG who received efgartigimod-IV between May 2022 and September 2023 were registered. The interim analysis data were cutoff in June 2024 and included patients whose institutions agreed to publication.

RESULTS

The safety analysis set consisted of 373 patients: 53.35% (n = 199) anti-acetylcholine receptor antibody positive, 14.21% (n = 53) anti-muscle-specific receptor kinase antibody positive, and 31.64% (n = 118) double-seronegative. Adverse drug reaction and serious adverse drug reaction were reported in 21.45% (80/373) and 4.29% (16/373) of patients, respectively. Although six deaths were reported, none of them were related to efgartigimod. The effectiveness analysis set consisted of 246 patients. After three weeks from the first administration, mean score of MG-Activities of Daily Living decreased from 7.5 to 4.4: -3.1 points improvement (standard deviation: 2.95, p < 0.001). No remarkable differences were observed in the response to efgartigimod between the subgroups of patient baseline characteristics, e.g. autoantibody profiles.

CONCLUSIONS

In real-world settings, efgartigimod-IV was well tolerated and effective in patients with gMG.

Efficacy and Safety of Tacrolimus Therapy in Patients With Juvenile Myasthenia Gravis: A Single-Arm Meta-Analysis

BACKGROUND

Numerous guidelines recommend off-label use of tacrolimus (TAC) to treat myasthenia gravis (MG) in adults. This study aimed to evaluate whether TAC is beneficial in pediatric patients with juvenile MG (JMG).

METHODS

We conducted a systematic literature search using the keywords "Myasthenia Gravis," "TAC," "juveniles," and their synonyms. PubMed, Embase, Web of Science, Cochrane Library, and Chinese databases were searched for articles published until April 1, 2024. Two reviewers independently identified and extracted relevant retrospective/prospective comparison studies or randomized controlled trials and assessed the risk of bias for each study. Eligible studies were subsequently included in a meta-analysis that evaluated the clinical outcomes of TAC treatment for JMG using fixed- and random-effects models.

RESULTS

Of the 203 articles initially identified, nine were included in the meta-analysis. These studies included 313 children diagnosed with JMG, with ages ranging from 0 to 13.5 years. Among the included studies, two were comparison trials, whereas the remaining seven employed a single-group pretest-post-test design. Two studies were deemed to be of high quality, and seven were of moderate quality. The pooled overall response rate of the definite responder rate to TAC treatment in JMG was calculated as 3.92 (95% confidence interval: 2.06 to 7.45, I2 = 71%, P < 0.001).

CONCLUSIONS

This meta-analysis found that TAC improved symptoms and MG-related scores in patients with JMG with minimal adverse effects. These findings underscore the importance of TAC therapy for the treatment of JMG.

The efficacy and safety between efgartigimod and intravenous immunoglobulin in elderly generalized myasthenia gravis patients

The study examines efgartigimod and intravenous immunoglobulin (IVIg) in elderly patients with generalized myasthenia gravis (GMG), focusing on changes in Myasthenia Gravis Activities of Daily Living (MG-ADL) scores, pyridostigmine dosage, and minimal symptom expression (MSE) over an 8-week period. Among 74 enrolled patients, efgartigimod showed greater reduction in MG-ADL scores compared to IVIg at weeks 4 and 8, with no serious adverse events, suggesting its superior efficacy and safety in elderly Chinese patients with acetylcholine receptor antibody-positive (AChR-Ab(+)) GMG.

The role of fatty acid metabolism on B cells and B cell-related autoimmune diseases

Fatty acid metabolism plays a critical role in regulating immune cell function, including B cells, which are central to humoral immunity and the pathogenesis of autoimmune diseases. Emerging evidence suggests that fatty acid metabolism influences B cell development, activation, differentiation, and antibody production, thereby impacting B cell-related autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and multiple sclerosis (MS). In this review, we discuss the mechanisms by which fatty acid metabolism modulates B cell biology, including energy provision, membrane composition, and signaling pathways. We highlight how alterations in fatty acid synthesis, oxidation, and uptake affect B cell function and contribute to autoimmune pathogenesis. Additionally, we explore the therapeutic potential of targeting fatty acid metabolism in B cells to treat autoimmune diseases. Understanding the interplay between fatty acid metabolism and B cell immunity may provide novel insights into the development of precision therapies for B cell-mediated autoimmune disorders.

Early prediction of refractory myasthenia gravis based on response to treatment within the first year of diagnosis

BACKGROUND

The long lead time required to diagnose refractory myasthenia gravis (MG) can prevent early attempts at new treatments. Herein, we aimed to predict refractory MG by comparing treatment responses during the early stages between patients with refractory and non-refractory MG.

METHODS

We retrospectively investigated the medical records of patients with acetylcholine receptor antibody-positive generalized MG. Refractory MG was defined as (1) inability to lower prednisolone below 20 mg/day, (2) requiring regular intravenous immunoglobulin or plasmapheresis, or (3) Myasthenia Gravis Activities of Daily Living score ≥ 6 after treatment with corticosteroids and ≥ 1 oral immunosuppressant for ≥ 12 months.

RESULTS

Of 133 patients, 29 (21.8%) and 104 (78.2%) had refractory and non-refractory MG, respectively. The median duration from the diagnosis of MG to that of refractory MG was 31 months. During the first year following diagnosis, the proportion of patients who achieved a lowest effective prednisolone dose of ≤ 20 mg was lower in the refractory group than in the non-refractory group (69.0% vs. 92.0%). Conversely, the proportions of patients who initiated oral immunosuppressive therapy (58.6% vs. 22.5%), required rescue interventions (48.3% vs. 22.1%), or experienced a myasthenic crisis (34.5% vs. 14.4%) were significantly higher in the refractory group. The risk of refractory MG was 18.7-fold higher in patients who failed to achieve lowest effective prednisolone dose under 20 mg/day and started oral immunosuppressant during the first year than those with neither of these conditions.

CONCLUSIONS

The refractory group displayed distinct clinical features during the early disease stages, including frequent crises and higher levels of immunosuppressive treatment. These features can be used for early prediction of refractory MG.

Assessing therapeutic decisions in generalized myasthenia gravis: Study protocol

BACKGROUND

The therapeutic landscape in generalized myasthenia gravis (gMG) has been continuously evolving in recent years, with over five products approved, each with different efficacy, safety, and administration profiles. With the availability of new targeted treatments, physicians are faced with the challenge of therapeutic decision-making tailored to traditional therapeutic goals, individual preferences, and personal experience, seeking optimal disease control with a positive safety profile. In this context of uncertainty and multiple novel choices, this study aims to provide insights into the preferred treatment choices of neurologists managing gMG and to identify demographic, professional or behavioral factors influencing the decision-making process.

METHODS

This is a non-interventional, cross-sectional, web-based study involving 150 neurologists treating gMG patients in collaboration with the Spanish Society of Neurology. The primary endpoint will be to assess preferences for different gMG treatment attributes using a conjoint analysis to create hypothetical treatment scenarios. Therapeutic inertia, described as the lack of treatment initiation or intensification when therapeutic goals are not met, will be evaluated as a secondary endpoint through 7 case scenarios simulating real gMG clinical practice situations. Neurologists will also answer a survey composed of demographic, professional, and behavioral characteristics (user resistance behavior, care-related regret, burnout, risk attitude, empathy, work fulfilment, and personality traits) to recognize possible factors influencing decisions.

CONCLUSIONS

The study findings will contribute to better understanding of decision-making in gMG under a changing therapeutic landscape with multiple new targeted options, and will identify which factors have a role in affecting those decisions.

Longitudinal Improvement in Respiratory Function Following Plasma Exchange in Patients with Severe Myasthenia Gravis

BACKGROUND

There are no data on the effect size and timing of plasma exchange (PLEX) in patients with myasthenic crisis (MC).

METHODS

We retrospectively analyzed measurements of forced vital capacity (FVC) and negative inspiratory force (NIF) in the days before and after PLEX (administered every other day) in patients with MC admitted to a tertiary hospital over 4 years. For multiple measurements in one day, the average value was used. The day immediately before the first treatment with PLEX was considered baseline. Using time as a continuous or categorical variable in mixed-effects multiple linear regressions, we estimated predicted values for these tests.

RESULTS

Twenty-two patients (mean age 67.3 years, 51.9% male patients) with 27 MC episodes and 508 measurements (234 FVC and 274 NIF; from 5 days before to 20 days after PLEX) were included. Presence of antibodies was detected in 70.4%. Intubation and mechanical ventilation occurred in 36.6% of patients. The mean number of PLEX was 5.1 (range 3-11). NIF values decreased before the first PLEX but increased after by on average 1 cm H2O/day (95% confidence interval [CI] 0.68-1.32, p < 0.001). FVC fluctuated before the first PLEX but then increased by on average 51.2 mL/day (95% CI 35.8-66.1, p < 0.001). The maximum increase in NIF occurred during the day of the first PLEX (9.2 cm H2O, 95% CI 3.3-15.1, p = 0.002) and rather slowed after day 10. FVC increase compared to baseline became significant the second day after the first PLEX (287 mL, 95% CI 7.5-567.6, p = 0.04) and continued overall to increase (with fluctuations) up to day 17.

CONCLUSIONS

Significant increases in bedside respiratory measurements are observed as soon as the first PLEX day but with more variability on FVC than NIF, which may either reflect more FVC technique inconsistencies or more consistent effect of the treatment on NIF.

Long-Term Efficacy and Safety of Ravulizumab in Adults With Anti-Acetylcholine Receptor Antibody-Positive Generalized Myasthenia Gravis: Final Results From the Phase 3 CHAMPION MG Open-Label Extension

BACKGROUND

Ravulizumab, an anti-complement C5 monoclonal antibody, was efficacious with acceptable safety in the randomized controlled period (RCP) and interim open-label extension (OLE) periods of the CHAMPION MG phase 3 trial in adults with anti-acetylcholine receptor antibody-positive (AChR-Ab+) generalized myasthenia gravis (gMG). Here, we report final results from the OLE.

METHODS

Patients who completed the 26-week RCP could enter the OLE and receive ravulizumab for up to 4 years. Efficacy and safety were assessed throughout the OLE.

RESULTS

Among all ravulizumab-treated patients (n = 169; median [range] ravulizumab treatment, 759.0 [14.0, 1265.0] days), 161 entered the OLE (ravulizumab-ravulizumab: n = 78; placebo-ravulizumab: n = 83). Sustained improvements were observed in Myasthenia Gravis Activities of Daily Living (MG-ADL) total scores (ravulizumab-ravulizumab, least squares mean [95% CI] change from RCP baseline at week 164: -4.0 [-5.3, -2.8]; p < 0.0001; placebo-ravulizumab, change from OLE baseline after 138 weeks of treatment: -2.1 [-3.3, -0.9]; p = 0.0005). One hundred and forty-one out of 160 (88.1%) patients achieved a ≥ 2-point improvement in MG-ADL total score, and 59/141 (41.8%) achieved a score of 0 or 1; once achieved, 32/59 (54.2%) sustained this status for > 50% of their remaining time in the study. Similar improvements were observed in Quantitative Myasthenia Gravis and Myasthenia Gravis Quality of Life-15 revised scores, and Neurological Quality of Life Fatigue subscale scores. Clinical deterioration event rates were reduced in the OLE versus placebo in the RCP. Corticosteroid usage was reduced in the OLE. Ravulizumab was well tolerated; no meningococcal infections were reported.

CONCLUSION

Ravulizumab demonstrated clinically meaningful and durable efficacy and safety in adults with AChR-Ab+ gMG.

Real-World Case Series of Ravulizumab Use in Patients with Myasthenia Gravis in Romania

Background and Objectives: Ravulizumab, a long-acting C5 complement inhibitor, was approved in the US and Europe in 2022 as an add-on therapy for the standard treatment of AChR-positive generalized MG (gMG). We share our real-world experience with adult patients receiving this therapy in Romania. Materials and Methods: Six AChR-positive gMG patients received ravulizumab through an Early Access Program (January 2023-October 2024). Patient outcomes were assessed at the therapy start and q8w using Quantitative MG (QMG), MG Activities of Daily Living (MG-ADL), and MG Quality of Life 15-item revised (MG-QoL15r) scales. Results: Age at disease onset ranged from 15 to 35 years. Four of the six patients were women. Two patients had gMG severity level of IIa, and four patients of IIb according to the Myasthenia Gravis Foundation of America (MGFA) classification. Five patients experienced rapid and sustained improvements in MG symptoms with MG-ADL score reductions ranged from -3 to -5 at 26 weeks post-ravulizumab start (except for those with a low baseline score: three and one). QMG score dropped in three patients (-2 to 12) during the treatment period, increased in two (+2 and +8), and remained stable in one (zero). Three patients showed sustained improvement in MG symptoms after ≥60 weeks. MG-QoL15r significantly dropped (-22 to -10) throughout the treatment period. One patient experienced ravulizumab-associated adverse events (vomiting, diarrhea, chills) that resolved within 24 h following symptomatic management, two to three episodes of myasthenic exacerbations during treatment, and discontinued it. Conclusions: All cases presented here had early-onset AChR antibody-positive, non-thymomatous MG. Despite differences in disease duration and underlying conditions, clinically meaningful and sustained improvements in gMG symptoms, and reduced corticosteroid doses were observed in all patients except one after adding ravulizumab to the treatment plan.

New and Emerging Biological Therapies for Myasthenia Gravis: A Focussed Review for Clinical Decision-Making

Myasthenia gravis (MG) is a rare autoimmune disease characterised by exertion-induced muscle weakness that can lead to potentially life-threatening myasthenic crises. Detectable antibodies are directed against specific postsynaptic structures of the neuromuscular junction. MG is a chronic condition that can be improved through therapies, but to date, not cured. Standard treatment has been unchanged for decades and includes symptomatic treatment with acetylcholine-esterase inhibitors and disease-modifying treatment with steroids, steroid-sparing immunosuppressants and thymectomy. Overall, a relevant proportion of patients does not achieve a satisfactory clinical improvement under standard treatment. Additionally, long-term therapy with steroids can cause significant side effects and latency to clinical improvement with standard steroid-sparing immunosuppressants and after thymectomy can take months to years. In recent years, treatment of MG has changed fundamentally due to improved evidence from phase 3 trials and the regulatory approval of complement inhibitors and FcRn inhibitors as add-on treatment options. This provides new optimism for substantially more patients reaching minimal manifestation status and has led to a shift in treatment strategy with more targeted therapies being employed early in the course of the disease, especially in patients with high disease activity. In this focussed review, we provide an overview of the diagnosis, classification and standard treatment of MG, followed by data from randomised controlled trials on the modern drugs already available for therapy and those still in the final stages of clinical development. In the second part, we provide an overview of real-world data for already approved therapies and outline how the availability of new biologicals is changing both clinical decision-making and patient journey.

Advances in sulodexide-based long-term anticoagulation for a myasthenia gravis patient with giant thymoma

This case report describes a geriatric male patient with myasthenia gravis (MG) secondary to giant thymoma, presenting with progressive muscle weakness and ptosis. The diagnosis of MG was confirmed through pathology, imaging, and laboratory evaluations. Considering the significant surgical risks associated with the giant thymoma, adjuvant chemotherapy was initiated. Unfortunately, 2 weeks following chemotherapy, the patient developed acute respiratory failure and sudden loss of consciousness. Emergency endotracheal intubation was performed, and he was then transferred to the intensive care unit (ICU) and treated with immunoglobulin, plasmapheresis, prednisone, and pyridostigmine. During ICU hospitalization, the patient developed severe lower limb edema accompanied by increased skin temperature, particularly on the left side. Ultrasound imaging confirmed extensive thrombosis in the left iliac and femoral veins, with thrombosis involving 50%-67% of the venous lumen. To prevent the risk of pulmonary embolism (PE), an inferior vena cava filter was implanted, and low-molecular weight heparin (LMWH) was prescribed for anticoagulation. Unfortunately, the patient later experienced intermittent melena and heparin-induced thrombocytopenia (HIT), with hemoglobin levels decreasing to 55 g/L and platelet counts decreasing to 57 × 109/L. Given the adverse events associated with LMWH, sulodexide (SDX) was substituted as a novel anticoagulant with multiple benefits, including reduced thrombosis and bleeding risk, anti-inflammatory effects, and vascular endothelium protection. SDX demonstrated excellent efficacy and safety, with no adverse effects observed during the 3-year follow-up period. In conclusion, SDX should be considered an ideal potential option for long-term anticoagulation in patients with complex conditions such as MG with both thrombotic and bleeding risks.

Myasthenia gravis in 2025: five new things and four hopes for the future

The last 10 years has brought transformative developments in the effective treatment of myasthenia gravis (MG). Beginning with the randomized trial of thymectomy in myasthenia gravis that demonstrated efficacy of thymectomy in nonthymomatous MG, several new treatment approaches have completed successful clinical trials and regulatory launch. These modalities, including B cell depletion, complement inhibition, and blockade of the neonatal Fc receptor, are now in use, offering prospects of sustained remission and neuromuscular protection in what is a long-term disease. In this review, we update our clinico-immunological review of 2016 with these important advances, examine their role in treatment algorithms, and focus attention on key issues of biomarkers for prognostication and the growing cohort of older patients, both those with long-term disease, and late-onset MG ('LOMG'). We close by expressing our four hopes for the next 5-10 years: improvements in laboratory medicine to facilitate rapid diagnosis, effective strategies for neuromuscular protection, more research into and better understanding of pathophysiology and treatment response in older individuals, and the potentially transformative role of therapies aimed at delivering a durable response such as chimeric antigen receptor (CAR) T cells. Our postscript summarizes some emerging themes in the field of serological and online biomarkers, which may develop greater stature in the next epoch.

Patterns and predictors of therapeutic response to efgartigimod in acetylcholine receptor-antibody generalized myasthenia gravis subtypes

Background

Efgartigimod is an approved biologic for generalized myasthenia gravis (gMG), which is an autoimmune disease and can potentially be life-threatening. However, the therapeutic response to efgartigimod among the acetylcholine receptor gMG (AChR-gMG) subtypes remains inconclusive.

Objective

To explore the patterns and predictors for the therapeutic response to efgartigimod among AChR-gMG subtypes.

Design

This prospective, observational study included AChR-gMG patients treated with efgartigimod at 15 centers in China with a follow-up for at least 20 weeks.

Methods

The primary outcome was the proportion of minimal symptom expression (MSE) responders, denoted by a Myasthenia Gravis Activities of Daily Living (MG-ADL) score of 0 or 1 within 4 weeks and maintained for ⩾4 weeks. AChR antibody-positive MG (AChR-MG) subtypes were classified into early onset myasthenia gravis (EOMG), late-onset myasthenia gravis (LOMG), and thymoma-associated myasthenia gravis (TAMG). The predictive factors for MSE responders were identified by univariate and multivariate logistic regression analysis.

Results

One hundred sixteen patients were included with a median follow-up duration of 238 days (172.5-306.3). There were 50 (43.1%) patients with EOMG, 28 (24.1%) with LOMG and 38 (32.8%) with TAMG. After efgartigimod initiation, 35 (30.2%) patients were MSE responders, and the proportion of MSE responders was highest in the LOMG group (42.9%). The MG-ADL score reduction in the LOMG group was more significant than in the EOMG group by weeks 16 and 20 (both p = 0.022). Response patterns to efgartigimod among the AChR-MG subtypes differed as measured by the proportion of improved patients and MSE. LOMG presented sustained symptom control, while EOMG and TAMG showed more fluctuations. Eight TAMG patients (21.1%) switched to another biologic (p = 0.005). Baseline MG-ADL was an independent predictor for therapeutic response to efgartigimod (p < 0.001).

Conclusion

Our findings revealed patterns of treatment responses among AChR-gMG subtypes, with LOMG patients potentially presenting a more sustained response. These findings likely provide preliminary data for precision therapy in MG in the era of biologics.

Trial registration

NCT04535843.

Ravulizumab and Efgartigimod in Myasthenia Gravis: A Real-World Study

BACKGROUND AND OBJECTIVES

Biologics that target pathogenic antibodies (Abs) and their effector functions such as the complement inhibitor ravulizumab and the neonatal Fc receptor agonist efgartigimod have recently been approved for the treatment of acetylcholine receptor (AChR)-Ab-positive myasthenia gravis (MG), but comparative studies are lacking.

METHODS

In a prospective, exploratory real-world study, we assessed clinical efficacy, safety, and biological effects of ravulizumab and efgartigimod treatment initiation. Myasthenia Gravis-Activities of Daily Living and Quantitative Myasthenia Gravis scores were used as clinical endpoints. Ab effector functions were determined by AChR-Ab-dependent complement activation and phagocytosis assays and systemic complement activation profiling.

RESULTS

We observed similar moderate short-term efficacy of ravulizumab and efgartigimod in achieving clinical improvement. Ravulizumab reduced systemic terminal complement activation, but neither treatment showed significant effects on complement pathways proximal to C5 or functional capacities of AChR-Abs. Both treatment modalities were well tolerated with no serious adverse events reported.

DISCUSSION

Clinical benefits obtained with ravulizumab and efgartigimod can be remarkably heterogeneous in daily clinical practice. Neither treatment relevantly changed effector functions of pathogenic AChR-Abs, supporting the concept that durable disease control in MG requires continuous administration of both fast-acting agents.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that in AChR-Ab-positive patients with generalized MG, ravulizumab and efgartigimod provide comparable modest improvement in MG functional scales.

Eculizumab in thymoma-associated myasthenia gravis: a real-world cohort study

Background

Thymoma-associated myasthenia gravis (TAMG) is a subtype of myasthenia gravis (MG) that is associated with more severe symptoms and a relatively poor prognosis. Eculizumab, an inhibitor to target human C5 component of the complement cascade, is considered a treatment option for refractory generalized MG (gMG).

Objectives

To explore the safety and efficacy of eculizumab in patients with TAMG.

Design

This is an observational multicenter real-world cohort study to assess TAMG who were treated with eculizumab from June 2023 to June 2024.

Data sources and methods

Clinical features associated with thymoma-associated multi-organ autoimmunity (TAMA), Myasthenia Gravis Activities of Daily Living (MG-ADL) score, and the incidence of treatment-emergent adverse events (TEAEs) were prospectively collected.

Results

Overall, 42 patients with gMG were treated with eculizumab at 5 research centers, of whom 22 patients with TAMG were finally included. This cohort had a mean age of 51.5 ± 12.1 years and an average disease duration of 4.0 ± 4.3 years. Regarding thymomas, the World Health Organization (WHO) histological classification was primarily B2 and B3 (63.7%), and Masaoka staging was predominantly IV (45.5%). Nine participants (40.9%) switched from efgartigimod to eculizumab aiming at a better clinical improvement and reducing steroid use. By week 12, the MG-ADL score decreased to 4.8 ± 4.7 (baseline: 11.7 ± 6.0), and the corticosteroid dose reduced to 23.2 ± 26.5 mg (baseline: 41.8 ± 63.9 mg). Two patients with TAMA showed significant improvement in skin lesions and thrombocytopenia. Two TEAEs were recorded including COVID-19 and herpes labialis infection. Four patients (18.2%) died of respiratory or circulatory failure owing to thymoma metastasis.

Conclusion

This real-world study demonstrates the efficacy of eculizumab in achieving symptom control and corticosteroid reduction for TAMG. It may also be a therapeutic option for refractory TAMG and TAMA.

Trial registration

NCT04535843.

First line treatment with subcutaneous efgartigimod in impending myasthenic crisis: a case report

In acetylcholine receptor (AChR) antibody-positive generalized myasthenia gravis (gMG), neonatal Fc-receptor (FcRn) inhibition has broadened the therapeutic spectrum. Myasthenic crisis (MC), heralded by an impending myasthenic crisis (iMC), is a critical condition requiring treatments with rapid onset and sustained efficacy. Currently treatments used for iMC, including intravenous immunoglobulins and plasma exchange/immunoadsorption, have limitations, such as delayed onset of action and potential side effects. So far, there is limited data on the use of FcRn inhibitors in the management of impending or manifest MC (mMC). Here, we present a case of AChR antibody-positive gMG with iMC, where subcutaneous administration of the FcRn inhibitor efgartigimod resulted in rapid clinical remission. Within 24 h of administration, the patient exhibited significant improvement in respiratory and bulbar muscle function, preventing progression to manifest MC and the need for mechanical ventilation. This rapid response was accompanied by a marked reduction in AChR antibody level by 89.8% within 4 weeks. This case supports the potential of efgartigimod as a fast-acting and effective treatment option for managing iMC, offering an alternative to existing therapies.

Complement inhibition in seropositive generalized myasthenia gravis as rescue therapy in impending and effective treatment in frequently recurring impending myasthenic crisis-a case series

In seropositive myasthenia gravis (MG), complement inhibition has been shown to be an effective and a fast-acting therapeutic option. Myasthenic crisis (MC), usually preceded by impending MC, is a life-threatening complication requiring highly effective treatments with rapid onset of action. Currently used treatment options of MC are limited, consisting mainly of symptomatic and immune therapies, that is, intravenous immunoglobulins and plasma exchange/immunoadsorption. So far, there is only very limited data on complement inhibitors in impending or manifest MC or termination of frequently recurring impending crises. Here, we report three cases of acetylcholine receptor antibody positive MG, two with impending and one case suffering from high-frequency impending MC, where complement inhibition with eculizumab or ravulizumab resulted in a rapid and sustained remission. Meningococcal vaccination, mandatory when using complement inhibitors, did not result in symptom-worsening or manifest MC.

A clinical perspective on muscle specific kinase antibody positive myasthenia gravis

The discovery of autoantibodies directed against muscle-specific kinase (MuSK) in "seronegative" myasthenia gravis (MG) patients marked a milestone in MG research. In healthy muscle, MuSK regulates a phosphorylation pathway, which is essential for the development and maintenance of acetylcholine receptor (AChR) clusters at the neuromuscular junction. Autoantibodies directed against MuSK are predominantly of the IgG4 subclass, but there is increasing evidence that IgG1-3 could also contribute to the pathology underlying MuSK-MG. MuSK-IgG4 are monovalent and block the binding site for LRP4 on MuSK, thereby inhibiting the downstream phosphorylation pathway and compromising the formation of AChR clusters. Clinically, MuSK-MG is commonly associated with the predominant involvement of bulbar, facial, shoulder and neck muscles. Cholinesterase inhibitors should be avoided in MuSK-MG due to the risk of clinical impairment and cholinergic crisis. Corticosteroids and other non-steroidal immunosuppressants are less effective with the need for higher doses and prolonged treatment. Rituximab, by contrast, has been shown to be particularly effective and is now often used early in the disease course. Its use is associated with a significant improvement in the clinical outcome of MuSK-MG patients over time. This review aims to describe the pathophysiology underlying MuSK-MG and provide a comprehensive overview of the clinical features and therapeutic options.

Towards personalized management of myasthenia gravis phenotypes: From the role of multi-omics to the emerging biomarkers and therapeutic targets

Predicting the onset, progression, and outcome of rare and chronic neurological diseases, i.e. neuromuscular diseases, is an important goal for both clinicians and researchers and should guide clinical decision-making and personalized treatment plans. A prime example is myasthenia gravis (MG), an antibody-mediated disease that affects multiple components of the postsynaptic membrane, impairing neuromuscular transmission and producing fatigable muscle weakness. MG is characterized by several clinical phenotypes, defined by a broad spectrum of factors, which have contributed to the current lack of consensus on the optimal management and treatments of this disease and its related phenotypes (subtypes). This represents a crucial challenge in MG and encourages a revolutionary change in diagnostic, prognostic and therapeutic guidelines. Emerging factors, such as demographic, clinical and pathophysiological factors, must also be considered. Consequently, the different MG phenotypes are characterized by precise biological signatures, which could represent appropriate biomarkers and targets. Here we describe and discuss these new concepts, highlighting that, thanks to multi-omics technologies, the identification of emerging diagnostic/prognostic biomarkers, such as miRNAs, and the subsequent development of new diagnostic/therapeutic algorithms could be facilitated. The latter, in turn, could facilitate the management of different MG phenotypes also in a personalized manner. Limitations and advantages are also reported.

Anti-CD19 CAR-T cells are effective in severe idiopathic Lambert-Eaton myasthenic syndrome

Lambert-Eaton myasthenic syndrome (LEMS) is an autoantibody-mediated disease of the neuromuscular junction characterized by muscular weakness. Autoantibodies to presynaptic P/Q-type voltage-gated calcium channels (VGCCs) induce defective neuromuscular function. In severe cases, current immunosuppressive and immunomodulatory treatment strategies are often insufficient. First reports show beneficial effects of anti-CD19 chimeric antigen receptor (CAR)-T cell therapy in patients with autoantibody-mediated myasthenia gravis. We report a patient with isolated idiopathic LEMS treated with autologous anti-CD19-CAR-T cells. In this patient, CAR-T infusion leads to expansion of predominantly CD4+ CAR-T cells with a terminally differentiated effector memory cells re-expressing CD45RA (TEMRA)-like phenotype indicating cytotoxic capabilities and subsequent B cell depletion. VGCC antibody titers decrease, resulting in a clinical improvement of LEMS symptoms, e.g., 8-fold increase in walking distance. The patient does not show relevant side effects except for cytokine release syndrome grade 2 and intermittent neutropenia suggesting that anti-CD19 CAR-T cell therapy may be a treatment option in patients with LEMS.

Optimal time for the addition of non-corticosteroid immunosuppressants in myasthenia gravis: a single-center retrospective study in China

Introduction

Patients with myasthenia gravis (MG) display strong treatment heterogeneity. Recent studies have indicated that low-dose steroids or immunosuppressants are effective. However, factors affecting the add-on of non-corticosteroid immunosuppressants to corticosteroids remain unknown.

Method

Consecutive patients with MG were retrospectively reviewed from May 15, 2015, to December 29, 2020. We included one group of patients with steroid treatment alone and another group who transitioned to non-steroid immunosuppressant therapy. Clinical features of the included patients were analyzed. Univariate and multivariate Cox regression models were used to identify potential influential factors.

Results

A total of 107 patients with MG were analyzed, including 66 receiving corticosteroid treatment alone and 41 who subsequently also received non-corticosteroid immunosuppressant therapy. Eight potential factors were primarily selected in univariate analysis (Ps < 0.1). Achieving minimal symptom expression (MSE) within 6 months (HR: 4.424, 95%CI: 2.102-11.865), body mass index (BMI) (HR: 0.385, 95% CI: 0.186-0.797), quantitative MG (QMG) bulbar muscle score (HR: 1.553, 95% CI: 1.140-2.118), disease duration (HR: 0.987, 95% CI: 0.977-0.997) and relapse (HR: 2.638, 95% CI: 1.031-6.750) were finally identified as potential influencing factors.

Discussion

We found multifactorial clinical factors were highly associated with the add-on of non-steroid immunosuppressants after steroid treatment in patients with MG. Achieving MSE within 6 months, BMI, QMG bulbar muscle score at baseline before steroid treatment, disease duration, and disease relapse may represent crucial influencing factors, which should be considered to improve the long-term prognosis for patients with MG in future studies and practice.

Complement system activation: bridging physiology, pathophysiology, and therapy

The complement system is a set of over 50 proteins that constitutes an essential part of the innate immune system. Complement system activation involves an organized proteolytic cascade. Overactivation of complement system activation is the main pathogenic mechanism of several diseases and contributes to the manifestations of many other conditions. This review describes the normal complement system and the role for complement dysregulation in critical illnesses, notably sepsis and acute respiratory distress syndrome. Complement activation is involved in the immune system response to pathogens but, when excessive, can contribute to tissue damage, runaway inflammation, and capillary leakage syndrome. Complement overactivation may play a key role in severe forms of coronavirus disease 2019 (COVID-19). Two diseases whose manifestations are mainly caused by complement overactivation, namely, atypical hemolytic and uremic syndrome (aHUS) and myasthenia gravis, are discussed. A diagnostic algorithm for aHUS is provided. Early complement-inhibiting therapy has been proven effective. When renal transplantation is required, complement-inhibiting drugs can be used prophylactically to prevent aHUS recurrence. Similarly, acetylcholine-receptor autoantibody-positive generalized myasthenia gravis involves complement system overactivation and responds to complement inhibition. The two main complement inhibitors used in to date routine are eculizumab and ravulizumab. The main adverse event is Neisseria infection, which is rare and preventable, but can be fatal. The complement system is crucial to health but, when overactivated, can cause or contribute to disease. Effective complement inhibitors are now available, although additional data are required to determine optimal regimens. Further research is also needed to better understand the complement system, develop advanced diagnostic tools, and identify markers that allow the personalization of treatment strategies.

Efgartigimod: A Review in Generalised Myasthenia Gravis

Efgartigimod (Vyvgart®; Vyvgart® Hytrulo) is a neonatal fragment crystallizable receptor (FcRn) antagonist indicated for the treatment of generalised myasthenia gravis (gMG) in adults who are acetylcholine receptor (AChR) antibody positive (Ab+). Efgartigimod is approved for both intravenous (IV) and subcutaneous (SC) use. In a pivotal phase III trial, IV efgartigimod was associated with significant and clinically meaningful improvements in myasthenia gravis symptoms and reductions in disease burden. The beneficial effects of IV efgartigimod were reproducible, durable and maintained over the long term. IV efgartigimod also improved health-related quality of life (HRQOL). In another phase III trial, SC efgartigimod PH20 was noninferior to IV efgartigimod in reducing total immunoglobulin G levels. Clinical improvement with SC efgartigimod PH20 was consistent with that of IV efgartigimod and was reproducible over the long term. Efgartigimod was generally well tolerated; the most common adverse events were headache and infections (with IV efgartigimod) and injection-site reactions (with SC efgartigimod PH20). Although further long-term data are required, IV and SC formulations of efgartigimod provide effective, generally well-tolerated and flexible treatment options for adults with AChR Ab+ gMG.

New treatment strategies in Myasthenia gravis

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disorder characterized by muscle weakness and fatigue. The disease is primarily caused by antibodies targeting acetylcholine receptors (AChR) and muscle-specific kinase (MuSK) proteins at the neuromuscular junction. Traditional treatments for MG, such as acetylcholinesterase inhibitors, corticosteroids, and immunosuppressants, have shown efficacy but are often associated with significant long-term side effects and variable patient response rates. Notably, approximately 15% of patients exhibit inadequate responses to these standard therapies. Recent advancements in molecular therapies, including monoclonal antibodies, B cell-depleting agents, complement inhibitors, Fc receptor antagonists, and chimeric antigen receptor (CAR) T cell-based therapies, have introduced promising alternatives for MG treatment. These novel therapeutic approaches offer potential improvements in targeting specific immune pathways involved in MG pathogenesis. This review highlights the progress and challenges in developing and implementing these molecular therapies. It discusses their mechanisms, efficacy, and the potential for personalized medicine in managing MG. The integration of new molecular therapies into clinical practice could significantly transform the treatment landscape of MG, offering more effective and tailored therapeutic options for patients who do not respond adequately to traditional treatments. These innovations underscore the importance of ongoing research and clinical trials to optimize therapeutic strategies and improve the quality of life for individuals with MG.

Efgartigimod treatment for generalized myasthenia gravis: a single-center case series of 16 patients

Background

Efgartigimod was approved in Japan in January 2022 for the treatment of generalized myasthenia gravis (gMG), regardless of antibody status. This case series describes a real-world experience in Japan of efgartigimod treatment for gMG patients with diverse backgrounds.

Methods

We retrospectively analyzed the medical records of 16 Japanese patients (11 females and five males, mean age 40.4 years) with gMG who received efgartigimod at the Kumamoto University Hospital between August 2022 and September 2023. The outcomes were Quantitative Myasthenia Gravis (QMG) responders (≥ 3 point reduction), IgG levels, and change in prednisolone dose, in the first cycle of efgartigimod.

Results

Fifteen patients completed one cycle of efgartigimod. Of the 14 patients for whom QMG scores were obtained, 10 patients were QMG responders. Four of the five patients with Myasthenia Gravis Foundation of America class V were QMG responders. Improvement in QMG after efgartigimod treatment was observed in one patient with myasthenic crisis and in one refractory patient who had unsuccessful eculizumab treatment. The mean reductions from baseline in IgG levels at weeks 1, 2, 3, and follow-up were 38.3, 56.1, 63.1, and 43.9%, respectively. A decrease in prednisolone dose was observed in seven patients. The most common adverse events were headache (three patients) and diarrhea (two patients). One patient discontinued efgartigimod treatment due to a treatment-related adverse event of rash.

Conclusion

Improvements in the outcomes of patients with gMG, including patients with severe gMG, myasthenic crisis, and refractory to anti-complementary therapy, were observed after the first cycle of efgartigimod treatment. Our real-world experience in Japan suggests the future possibilities for the treatment with efgartigimod for gMG with diverse backgrounds.

Rectal cancer with solitary hepatic metastasis and Lambert-Eaton myasthenic syndrome

Lambert-Eaton myasthenic syndrome (LEMS) is a rare autoimmune neuromuscular disease mediated by antibodies to voltage-gated calcium channels (VGCCs) at the neuromuscular junction. LEMS often presents as a paraneoplastic disease. Between 40% to 62% of patients diagnosed with LEMS are confirmed to have small cell lung cancer (SCLC). There are few concerned reports on Gastrointestinal carcinomas. This article reports the treatment process of a young woman with rectal cancer and liver metastasis who associated with LEMS to summarize relevant clinical experience and reduce the rate of clinical misdiagnosis.

Auto-immuno-deficiency syndromes

Autoimmune diseases constitute a broad, heterogenous group with many diverse and often overlapping symptoms. Even so, they are traditionally classified as either systemic, rheumatic diseases or organ-directed diseases. Several theories exist about autoimmune diseases, including defective self-recognition, altered self, molecular mimicry, bystander activation and epitope spreading. While there is no consensus about these theories, it is generally accepted that genetic, pre-disposing factors in combination with environmental factors can result in autoimmune disease. The relative contribution of genetic and environmental factors varies between diseases, as does the significance of individual contributing factors within related diseases. Among the genetic factors, molecules involved in antigen (Ag) recognition, processing, and presentation stand out (e.g., MHC I and II) together with molecules involved in immune signaling and regulation of cellular interactions (i.e., immuno-phenotypes). Also, various immuno-deficiencies have been linked to development of autoimmune diseases. Among the environmental factors, infections (e.g., viruses) have attracted most attention, but factors modulating the immune system have also been the subject of much research (e.g., sunlight and vitamin D). Multiple sclerosis currently stands out due to a very strong and proven association with Epstein-Barr virus infection, notably in cases of late infection and in cases of EBV-associated mononucleosis. Thus, a common picture is emerging that both systemic and organ-directed autoimmune diseases may appropriately be described as auto-immuno-deficiency syndromes (AIdeSs), a concept that emphasizes and integrates existing knowledge on the role of immuno-deficiencies and chronic infections with development of overlapping disease syndromes with variable frequencies of autoantibodies and/or autoreactive T cells. This review integrates and exemplifies current knowledge on the interplay of genetically determined immuno-phenotypes and chronic infections in the development of AIdeSs.

Recommendations for the management of myasthenia gravis in Belgium

International guidelines on the treatment of myasthenia gravis (MG) have been published but are not tailored to the Belgian situation. This publication presents recommendations from a group of Belgian MG experts for the practical management of MG in Belgium. It includes recommendations for treatment of adult patients with generalized myasthenia gravis (gMG) or ocular myasthenia gravis (oMG). Depending on the MG-related antibody a treatment sequence is suggested with therapies that can be added on if the treatment goal is not achieved. Selection of treatments was based on the level of evidence of efficacy, registration and reimbursement status in Belgium, common daily practice and the personal views and experiences of the authors. The paper reflects the situation in February 2024. In addition to the treatment considerations, other relevant aspects in the management of MG are addressed, including comorbidities, drugs aggravating disease symptoms, pregnancy, and vaccination. As many new treatments might potentially come to market, a realistic future perspective on the impact of these treatments on clinical practice is given. In conclusion, these recommendations intend to be a guide for neurologists treating patients with MG in Belgium.

Efgartigimod for generalized myasthenia gravis: A multicenter real-world cohort study in China

OBJECTIVE

Efgartigimod, a neonatal Fc receptor antagonist, facilitates antibody degradation including pathogenic IgGs. The ADAPT study demonstrated the tolerability and efficacy of efgartigimod in the treatment of generalized myasthenia gravis (gMG). However, very limited evidence is available for the Chinese population, and it remains inconclusive about which kind of patients are selected to preferentially receive efgartigimod in real-world settings.

METHODS

This multicenter cohort study included gMG patients treated at 14 neuromuscular reference centers in China. The Myasthenia Gravis Activities of Daily Living (MG-ADL) score, immunosuppressants, and the incidence of treatment-emergent adverse events (TEAEs) were prospectively collected.

RESULTS

Of the 1640 gMG admitted between September and December 2023, 61 (3.7%) received efgartigimod for at least one treatment cycle. Among them, 56 cases (92%) were anti-AChR antibody-positive, 4 were anti-MuSK antibody-positive, and 1 was seronegative. Thymoma-associated myasthenia gravis accounted for most cases (44%, 27 out of 61). The principal causes of efgartigimod initiation included MG acute exacerbation (MGAE) (48%, 29 out of 61) and myasthenic crisis (MC) (15%, 9 out of 61). Clinically meaningful improvement was rapidly achieved in 97% (58 out of 61) of patients at 1.3 ± 0.7 weeks. By week 12, the MG-ADL score reduced to 3.8 ± 4.1 (baseline:10.5 ± 5.2) for all participants, while it reduced to 4.0 ± 4.7 for MGAE and 3.8 ± 4.2 for MC, respectively. All but one TMG patient required no additional rescue therapies after efgartigimod initiation. 11.5% (7 out of 61) reported ≥1 TEAEs.

INTERPRETATION

This multicenter cohort study demonstrated the efficacy of efgartigimod in rapid control of gMG. Patients with MGAE or MC would benefit from efgartigimod treatment.

Thymoma-Related Chest Pain and Dyspnea in a Middle-Aged Caucasian Female With Myasthenia Gravis and Good's Syndrome: A Case Report

Thymomas are rare tumors originating from thymic tissue, often associated with various paraneoplastic syndromes that can pose significant clinical management challenges. Myasthenia gravis, one of the most common paraneoplastic syndromes linked to thymomas, is characterized by autoantibodies targeting the neuromuscular junction, leading to muscle weakness exacerbated by repetitive use. Good's syndrome, an adult-onset immunodeficiency associated with thymomas, results in hypogammaglobulinemia and susceptibility to opportunistic infections, which can be life-threatening. We present the case of a 57-year-old Caucasian female with no prior medical history, who presented with a three-month history of progressive chest pain, dyspnea, and muscle weakness. A computed tomography (CT) scan of the chest revealed an anterior mediastinal soft tissue mass. Upon admission, a diagnostic workup, including serum anti-acetylcholine receptor antibodies and electromyography, confirmed the diagnosis of myasthenia gravis. Immune studies revealed hypogammaglobulinemia, consistent with Good's syndrome. The patient underwent complete surgical resection of the thymoma and received intravenous immunoglobulin (IVIG) therapy. This case report highlights the rarity and clinical significance of concurrent myasthenia gravis and Good's syndrome as paraneoplastic manifestations secondary to thymoma. Given the incidence of thymoma-associated paraneoplastic syndromes, early recognition and intervention are crucial for optimal outcomes. Future research may further elucidate the mechanisms underlying these associations, guiding improved management strategies.

The safety and efficacy profile of eculizumab in myasthenic crisis: a prospective small case series

Eculizumab has improved recovery from ventilatory support in myasthenic crisis (MC) cases. However, the safety and efficacy profiles from prospective studies are still lacking. This study aimed to explore eculizumab's safety and efficacy in a prospective case series of patients with refractory MC. We followed a series of anti-acetylcholine receptor (AChR) antibody-positive myasthenia gravis (MG) patients who received eculizumab as an add-on therapy for 12 weeks during MC to facilitate the weaning process and reduced disease activity. Serum anti-AChR antibodies and peripheral immune molecules associated with the complement pathway were evaluated before and after eculizumab administration. Compared to the baseline Myasthenia Gravis Foundation of America (MGFA)-quantitative MG test (QMG) scores (22.25 ± 4.92) and MG-activities of daily living (MG-ADL; 18.25 ± 2.5) scores at crisis, improvements were observed from 4 weeks (14.5 ± 10.47 and 7.5 ± 7.59, respectively) through 12 weeks (7.5 ± 5.74 and 2.25 ± 3.86, respectively) post-treatment. Muscle strength consistently improved across ocular, bulbar, respiratory, and limb/gross domain groups. One patient died of cardiac failure at 16 weeks. Three cases remained in remission at 24 weeks, with a mean QMG score of 2.67 ± 2.89 and ADL score of 0.33 ± 0.58. No significant side effects were reported. Serum CH50 and soluble C5b-9 levels significantly declined, while there were no significant changes in serum anti-AChR antibody levels, C1q, C5a levels, or peripheral lymphocyte proportions. Eculizumab was well tolerated and showed efficacy in this case series. Large prospective cohort studies with extended follow-up periods are needed to further explore the safety and efficacy profile in real-world practice.

Case report: Rapid clinical improvement in acute exacerbation of MuSK-MG with efgartigimod

Myasthenia gravis with positive MuSK antibody often involves the bulbar muscles and is usually refractory to acetylcholinesterase inhibitors. For MuSK-MG patients who experience acute exacerbations and do not respond to conventional treatments, there is an urgent need to find more suitable treatment options. With the advent of biologic agents, efgartigimod has shown promising results in the treatment of MG. We report a 65-year-old MuSK-MG patient who presented with impaired eye movements initially, and the symptoms rapidly worsened within a week, affecting the limbs and neck muscles, and had difficulties in chewing and swallowing. Lymphoplasmapheresis did not achieve satisfactory results, but after a cycle of efgartigimod treatment, the patient's symptoms gradually improved and remained in a good clinical state for several months.

Case report: A highly active refractory myasthenia gravis with treatment of telitacicept combined with efgartigimod

There is always a lack of effective treatment for highly active refractory generalized myasthenia gravis (GMG). Recently, telitacicept combined with efgartigimod significantly reduces circulating B cells, plasma cells, and immunoglobulin G, which brings promising therapeutic strategies. We report a case of a 37-year-old female patient with refractory GMG, whose condition got significant improvement and control with this latest treatment after multiple unsuccessful therapies of immunosuppressants. The new combination deserves further attention in the therapeutic application of myasthenia gravis.

Efficacy of ravulizumab in patients with generalized myasthenia gravis by time from diagnosis: A post hoc subgroup analysis of the CHAMPION MG study

INTRODUCTION/AIMS

The CHAMPION MG study demonstrated that ravulizumab significantly improved Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) total scores versus placebo in adults with acetylcholine receptor antibody-positive generalized myasthenia gravis (AChR+ gMG). This post hoc analysis aimed to assess these outcomes by time from MG diagnosis.

METHODS

Changes from baseline to week 26 in MG-ADL and QMG total scores were analyzed by time from MG diagnosis to study entry (≤2 vs. >2 years). Within each subgroup, least-squares (LS) mean changes for ravulizumab and placebo were compared using mixed models for repeated measures.

RESULTS

In ravulizumab-treated patients, differences in LS mean (standard error of the mean) changes from baseline to week 26 were not statistically significant in the ≤2-years subgroup versus the >2-years subgroup for MG-ADL (-4.3 [0.70] vs. -2.9 [0.37]; p = .0511) or QMG (-4.3 [0.94] vs. -2.5 [0.50]; p = .0822) scores. No clear trends were observed in the placebo group. LS mean changes from baseline were significantly greater for ravulizumab versus placebo in both the ≤2 and >2 years from diagnosis subgroups for MG-ADL and QMG scores (all p < .05). The difference in treatment effect between the ≤2-years and >2-years subgroups was not statistically significant. No clinically meaningful between-subgroup differences in treatment-emergent adverse events were observed in ravulizumab-treated patients.

DISCUSSION

Ravulizumab treatment improved clinical outcomes for patients with AChR+ gMG regardless of time from diagnosis. A numerical trend was observed favoring greater treatment effect with earlier versus later treatment after diagnosis. Further studies are required for confirmation.

Treatment strategies and treatment-related adverse events in MG according to the age of onset

Introduction

Early-onset (EOMG) and late-onset (LOMG) are distinct groups of MG patients. It is unclear if treatment strategies and treatment-related adverse events may differ according to the age of MG onset.

Methods

This single-center retrospective study includes all MG patients followed at a tertiary center since 2007. We reviewed the electronic clinical records.

Results

In total, 212 patients were identified, 142 (67.0%) females, with a median disease duration of 10 years. The median age of symptom onset was 42.0 (26.0-64.5) years, with 130 (61.3%) EOMG cases and 82 (38.7%) LOMG. EOMG were more frequently female, had longer disease duration and often more generalized MG (p < 0.001). Comorbidities were significantly more frequent in LOMG (67.1%) compared to EOMG (53.1%) (p = 0.002). Steroid-related adverse effects motivating the switch to steroid-sparing agents (82.0%) were different between groups, with hypertension, hypercholesterolemia, diabetes mellitus and malignancies being more common in LOMG. At the same time, osteoporosis and dyspepsia were more frequent in EOMG (p < 0.001). The most common first-line choice was azathioprine (45.8%), and rituximab was used in 4 patients (1.9%).

Conclusion

Our study shows that treatment modalities are similar between EOMG and LOMG, while steroid-related adverse events appear to be distinct.

[Experience of using eculizumab in refractory myasthenia gravis]

Myasthenia gravis (MG) is a chronic autoimmune disease mediated by autoreactive T- and B-cells and manifested by progressive pathological muscle weakness and fatigue. Traditional immunomodulatory treatment does not always lead to the clinical picture significant improvement, despite adequate dosage and duration of use. Refractory myasthenia gravis requires new therapeutic approaches development and implementation. The range of target innovative agents in refractory MG includes monoclonal antibodies, which act directly on individual components of the complement system. Based on the results of randomized controlled trials, data on the effectiveness and safety of eculizumab, which inhibits the C5 component of the complement system, is presented. We present our own clinical experience of using eculizumab in a young woman with refractory generalized AChR-positive MG with a rapid decrease in the severity of symptoms to a minimum level and restoration of ability to work, and the absence of adverse events during therapy.