Intravenous immunoglobulins may prevent prednisone-exacerbation in myasthenia gravis

Abstract

Corticosteroids may produce a paradoxical worsening of myasthenia gravis (MG) symptoms within the first weeks of treatment. We therefore wanted to assess the hypothesis that a prior infusion of intravenous immunoglobulin (IVIG) may have a protective effect. Our primary objectives were to show that the coadministration of immunoglobulins and glucocorticoids is safe and effective for controlling myasthenic symptoms, and to compare the exacerbation rate with this approach and historical practice without IVIG. We recruited 45 patients with generalized MG who required corticosteroids for the first time and we gave all IVIG before starting the full doses of prednisone. Monitoring was performed with validated scales, questionnaires, and blood tests over a 6-week period. Only 4.4% had severe adverse effects related to IVIG and 86.7% improved clinically. Notably, only 2.2% had a paradoxical symptom exacerbation in the first weeks of starting prednisone, which was statistically lower than the 42% reported in a historical series. We conclude that adjuvant therapy with IVIG when starting prednisone for the first time in patients with generalized MG is safe and effective. Given that the rate of paradoxical worsening was lower than that previously reported, the addition of IVIG may have a protective effect against such exacerbations.

Characteristics, treatment, and outcomes of Myasthenia Gravis in COVID-19 patients: A systematic review

“…This data suggests that other drugs such as intravenous immunoglobulin (IVIG) and plasma exchange ( PLEX), among others when used with prednisone may have a protective effect against aggravating MG in COVID-19 patients. Indeed, a recent report showed that adjuvant treatment with IVIG before starting treatment with prednisone significantly improved a paradoxical symptom exacerbation (2.2%) in the first weeks of starting prednisone, relative to the rates reported in a historical series (42.0%) [58] . However, we still cannot conclude that prednisone/corticosteroids is the reason of the unfavorable clinical outcomes due to the low number of patients in this study.…”

Immune Checkpoint Inhibitor–Induced Myocarditis with Myositis/Myasthenia Gravis Overlap Syndrome: A Systematic Review of Cases

“…All cases of IM3OS in our series were treated with high‐dose corticosteroids as per the current guidelines for immune‐related myocarditis [63]. In addition to the steroids, most patients with concurrent myocarditis and myasthenia gravis received upfront IVIG and plasmapheresis, given concerns regarding paradoxical exacerbation of myasthenia symptoms with steroids alone [28, 64]. However, some case reports employed IVIG and plasmapheresis even without myasthenia, highlighting the uncertainty in our understanding of the pathogenesis of myocarditis and myositis overlap syndromes.…”

Real world study on prevalence, treatment and economic burden of myasthenia gravis in Italy

“…An extensive use of corticosteroids during follow-up was also noticed. Although therapies proved to improve symptoms [ 27 ], their long-term use can result in several side effects, complications, and ultimately poorer QoL [ 18 , 28 ]. The chronic use of corticosteroids is also associated with increased mortality [ 29 ].…”