Steroids and immunosuppressant drugs in myasthenia gravis

Abstract

In chronic autoimmune conditions such as myasthenia gravis (MG), immunosuppression--usually long-term--is often necessary. The mechanisms of action of immunosuppressant drugs in MG fall into three main categories: inhibition of the cell cycle (azathioprine, cyclophosphamide, methotrexate and mycophenolate mofetil), immunosuppression of T cells (steroids, ciclosporin and tacrolimus), and B-cell depletion (rituximab). Data on immunosuppressant drugs in MG derive mainly from clinical experience, observational studies and expert opinion. The main drawbacks of the randomized evidence are the small size of most drug trials, variations in study design, and a lack of head-to-head studies. It is therefore difficult to determine the relative efficacy of each immunosuppressant. Oral prednisolone, usually started at a low dose on an alternate-day regimen, and gradually increased, is the recommended first-choice short-term immunosuppressant. Long-term immunosuppression regimens vary between different countries and physicians. Azathioprine is often the first-choice drug for long-term immunosuppression, and it is usually started together with steroids to allow tapering of steroids to the lowest dose possible. Methotrexate, mycophenolate mofetil or tacrolimus should be considered in patients who are intolerant of or unresponsive to azathioprine. Ciclosporin and cyclophosphamide should only be considered as a last resort, as these drugs can cause serious adverse events. Data on rituximab use in MG are sparse, but the initial results are promising.

Independent long-term result of robotic thymectomy for myasthenia gravis, a single center experience

“…However, due to lack of randomized control trial, the usage of immunosuppressant varied and no uniform criterion of IM therapy was available for thymectomized MG patients (37). Thus, the IM therapy would probably impact on the results of surgical treatment for MG. To explore the independent long-term effect of robotic thymectomy, a period of sequential observation rather than immediate IM therapy was carried out after surgical procedure in our department.…”

Tacrolimus Monotherapy: A Promising Option for Ocular Myasthenia Gravis

“…The calcineurin inhibitor tacrolimus is the immunosuppressant agent used for organ transplantation and a variety of immune-mediated disorders including MG. Currently, tacrolimus is recommended only as a third-line therapy for long-term use in patients who are unresponsive to azathioprine, methotrexate, or mycophenolate mofetil [2]. To our knowledge, several preceding reports have documented the efficacy of tacroli-mus for MG when combined with corticosteroids [3,4,5], but we are not aware of -other studies that documented the efficacy of tacrolimus alone for MG.…”

Monoclonal antibodies in the therapy of multiple sclerosis

“…It is also used as a second line therapeutic in the treatment of rheumatoid arthritis. In clinical trials it is tested amongst others in ITP, autoimmune haemolytic anaemia, acquired haemophilia, thrombotic thrombocytopenic purpura, systemic lupus erythematodes (SLE) and myasthenia gravis [27, 70,71]. Rituximab depletes B cells from peripheral blood and the amount of B cells in CSF is typically decreased by 90 % under rituximab therapy [53].…”