Management of Insomnia and Anxiety in Myasthenia Gravis

Abstract

Myasthenia gravis is a neuroimmunological disorder leading to skeletal muscle weakness. Common symptoms of the disease, such as anxiety, depression, and insomnia, can cause significant distress in patients. Unfortunately, selecting an appropriate medication for treatment of psychiatric comorbidities can prove to be challenging for providers given the unique pharmacologic constraints that myasthenia gravis presents. The authors present the following clinical vignette and accompanying discussion in an attempt to highlight the special considerations that must be taken into account when treating anxiety and insomnia in patients with myasthenia gravis, as well as to provide an overview of available medication options through the lens of existing constraints.

Treatment of insomnia in myasthenia gravis—A prospective study on non-benzodiazepine hypnotics in the treatment of myasthenia gravis patients with insomnia

“…Psychiatric co-morbidity is common in patients with myasthenia gravis. It is unclear whether MG combined with insomnia is primary insomnia or co-morbid insomnia, and the exact relationship between MG and psychiatric co-morbidity is an area for further research ( 4 ). The relationship between MG and psychiatric co-morbidity needs further research.…”

“…It is generally recommended that patients with MG should not take benzodiazepine and non-benzodiazepine hypnotics ( 4 ). Molenaar and Van Kempen ( 5 ) used the rat model of MG to study the effect of diazepam on muscle weakness.…”

“…They found that diazepam does not aggravate muscle weakness caused by neuromuscular blockade. There was a case report ( 4 ) that patients with stable MG were treated with benzodiazepines for 11 years without aggravation. In clinical settings, the application of non-benzodiazepine hypnotics in MG patients with insomnia under stable disease control could improve the quality of life while not causing muscle weakness or respiratory disturbances.…”

Depression: A Contributing Factor to the Clinical Course in Myasthenia Gravis Patients

“…Notably, insomnia and mood fluctuations, spanning from irritability to varying degrees of depression, are widespread but often poorly documented adverse effects affecting nearly all patients. The underreported nature of these challenges underscores the need for heightened awareness and comprehensive documentation to better address the array of difficulties encountered by those with MG.40, [54,55].…”

“…An additional factor to consider is the potential interactions between different medications, for example, those possessing anticholinergic qualities like antihistamines, tricyclic antidepressants, and trazodone. This medication has the potential to reduce the cholinergic effects of pyridostigmine [54].…”