What are the indications for inpatient care for myasthenia gravis?

Updated: Sep 20, 2018
  • Author: William D Goldenberg, MD; Chief Editor: Andrew K Chang, MD, MS  more...
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Answer

Patients who present to the ED with myasthenic or cholinergic crisis will often require admission to an intensive care unit [6] ; while patients with increasing muscle weakness of a less severe degree require admission to a monitored setting, because their course is unpredictable. [16] Patients with complications of the disease or treatment are admitted to a level of care corresponding to the nature and severity of the complication.

Patients with pneumonia should be admitted because they often are taking immunosuppressant medications and are at a high risk for aspiration pneumonia. [17]

Plasmapheresis has been found to be an effective short-term treatment of acute exacerbations of myasthenia gravis. Plasmapheresis removes circulating antibodies, including the autoimmune antibodies responsible for the disease. Clinical improvement takes several days to occur and lasts up to 3 weeks. [18] Because of the delayed onset of beneficial effects, plasmapheresis has limited utility in the ED setting, but often is used in the ICU setting. Some disagreement exists between various national societies on the amount of evidence supporting plasma exchange. The American Society for Apheresis considers therapeutic plasma exchange a first-line therapy for myasthenia gravis, whereas the American Academy of Neurology (AAN) states that the current evidence does not support or refute a benefit. [4, 19, 20]

Multiple observational and case series studies have shown a short-term benefit from plasma exchange, especially in myasthenic crisis. However, there is only 1 randomized clinical trial that showed no difference between the 2 treatment arms of plasma exchange versus intravenous immunoglobulin (IVIG). [21] Additionally the plasma exchange group had a higher mortality rate. [4]

Immunotherapy with intravenous gamma globulin appears to diminish the activity of the disease for unknown reasons. [22] The benefit begins within 2 weeks and may last for several months. Approximately 65% of patients with myasthenia gravis respond to intravenous gamma globulin. [23, 24] The AAN considers IVIG an effective therapy for moderate-to-severe cases of myasthenia gravis, as per their 2012 guidelines. [25]

Thymectomy is associated with clinical improvement in 85% of cases, and 35% of patients appear to have complete remission. [1] Patients past the age of puberty and younger than 50 years should have elective thymectomy as part of their treatment. [26]

The need for anticholinesterase medication fluctuates significantly in the postoperative period but overall is less than it was prior to thymectomy. [7]


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