International Consensus Guidance for Management of Myasthenia Gravis: 2020 Update

Efficacy of multi-cycle Efgartigimod in achieving minimal symptom expression in myasthenia gravis: A comparative multi-center study

OBJECTIVES

Efgartigimod has been approved as an effective and safe treatment for myasthenia gravis (MG). However, real-world experience on multi-cycle efgartigimod treatment and its comparison with Standard of Care (SoC) remain limited. This study aimed to evaluate minimal symptom expression (MSE) as the treatment goal and compared the proportion and time to achieving it between two groups.

METHODS

Patients receiving multi-cycle efgartigimod and contemporaneous counterparts treated with SoC were included. The rate of MSE achievement were compared using Kaplan-Meier analysis and Cox regression. Subgroup analysis focused on efgartigimod group, observing involved muscles and oral medication for further insights.

RESULTS

A total of 76 and 124 MG patients were enrolled in the efgartigimod and SoC groups, respectively. Efgartigimod group demonstrated a higher rate (73.3 % vs. 22.6 %, p < 0.001) and shorter time [0.7 (0.5, 3.1) vs. 3.3 (3, 6.1), months, p < 0.001] to achieving MSE compared to SoC group. Kaplan-Meier analysis revealed efgartigimod group had a higher MSE probability with a median time of 2.27 (95 %CI, 0.70, 4.39) months. MG Patients had a 9.69 fold (95 %CI, 5.54, 16.92) greater chance of achieving MSE compared to SoC group, remaining significant at 9.44 fold (95 %CI, 5.36, 16.60) after adjusting for ADL scores. After treatment, respiratory and bulbar symptoms improved significantly, with average scores from 0.57 ± 0.87 to zero, and 2.62 ± 2.56 to 0.37 ± 0.96. Additionally, the daily dosage of corticosteroid dropped from 20(10, 25) mg to 10(10,20) mg, with only 7 (9.2 %) patients requiring over 20 mg/day.

CONCLUSION

Multi-cycle efgartigimod treatment achieves early MSE more effectively than SoC, serving as a fast-acting therapy for MG.

Autoimmune neuro-ophthalmic disorders: pathophysiologic mechanisms and targeted biologic therapies

INTRODUCTION

Autoimmune neuro-ophthalmic disorders encompass a diverse array of conditions, including thyroid eye disease (TED), myasthenia gravis (MG), optic neuropathy due to giant cell arteritis (GCA), and optic neuritis related to multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). While traditional treatments have shown efficacy in managing symptoms, the rapid emergence of biologic therapies has brought forth new avenues for targeted intervention, revolutionizing treatment approaches for these conditions.

AREAS COVERED

This review highlights the pathophysiologic pathways and FDA-approved biologic therapies utilized in the management of autoimmune neuro-ophthalmic disorders. We explore multiple therapeutic approaches for autoimmune neuro-ophthalmic disorders, including IGF-1 R antagonism, IL-6 inhibition, complement inhibition, FcRn targeting, B-cell depletion and T-cell modulation. Literature from clinical trials, observational studies, and meta-analyses through 2024 was evaluated to assess efficacy, safety, and long-term outcomes.

EXPERT OPINION

Biologic therapies represent a significant advancement in autoimmune neuro-ophthalmic disorders, offering targeted approaches with improved efficacy and safety profiles compared to traditional treatments. Ongoing developments in biomarker identification and delivery systems suggest an increasingly personalized approach to treatment. Future advances will likely focus on optimizing patient selection, reducing costs, improving accessibility, and developing novel therapeutic targets.

Health care costs and resource utilization among patients with myasthenia gravis in the United States

BACKGROUND

Myasthenia gravis (MG) is a rare neuromuscular disorder with an estimated prevalence of 37 per 100,000 individuals in the United States. Despite patients with MG using a wide range of health care services, there is a lack of information regarding health care costs and health care resource utilization (HCRU).

OBJECTIVE

To gain insight into the health care cost and HCRU associated with an MG diagnosis from the US payer perspective.

METHODS

Patients with MG, defined by at least 2 claims for MG diagnoses, were identified from a commercial and Medicare claims database between 2016 and 2021. Controls who were never diagnosed with MG were matched at a 10:1 ratio with each patient with MG based on baseline demographic and clinical characteristics. The primary outcomes were 1-year total health care costs associated with MG diagnosis, and the secondary outcomes were 1-year HCRU associated with MG diagnosis. Difference-in-difference estimates from a multivariable linear regression model were used to report adjusted health care costs and HCRU.

RESULTS

The final analytic cohort included 3,700 patients with MG and 37,000 controls. On average, patients were aged 54 years, with 60% being female. The difference-in-difference estimates of the total health care cost for MG diagnosis in commercial and Medicare patients were $25,799 and $4,927, respectively (P < 0.01). MG diagnosis had significant impacts on HCRU across all health care settings.

CONCLUSIONS

We quantified a significant increase in health care costs and HCRU in the first year following diagnosis of MG compared with the matched cohort. Future studies can further investigate long-term health care costs associated with patients with MG.

High-Dose Steroids, Treatment Escalation, and Healthcare Burden in Myasthenia Gravis: A US Claims-Based Cohort Study

INTRODUCTION

Myasthenia gravis (MG) is a rare neuromuscular autoimmune disease, characterized by chronic, fluctuating muscle weakness and fatigability. Despite established therapies, many patients have inadequately controlled MG. We describe treatment escalation patterns and outcomes for patients with MG between 2010 and 2018.

METHODS

We conducted a retrospective cohort analysis of medical and pharmacy claims data. Patients aged ≥ 18 years at MG diagnosis were included from two US Merative™ MarketScan® databases. MG treatment escalation was defined as an increase of the administered prednisolone-equivalent corticosteroid dose, use of add-on treatments, or treatment switches.

RESULTS

The cohort included 4925 adults with newly diagnosed MG (1102 aged 18-49 and 3823 aged ≥ 50 at first MG diagnosis) from January 1, 2010 to December 31, 2018. Median follow-up was 30.0 months (18-49 group) and 27.5 months (≥ 50 group). Overall, 71.5% (3521/4925) of patients had ≥ 1 MG treatment escalation; escalation with high-dose corticosteroids was the most common type (64.8% [18-49 group] and 58.5% [≥ 50 group]). In the first year post-diagnosis, median (range) maximal daily prednisolone-equivalent corticosteroid dose was 40.0 (20.0-75.0) mg/day (18-49 group) and 40.0 (20.0-70.0) mg/day (≥ 50 group). Treatment breaks and de-escalation led to rescue treatment or treatment re-escalation in most patients. Exacerbations occurred in 26.3% (n = 290; 18-49 group) and 21.6% (n = 825; ≥ 50 group). Healthcare resource utilization (HCRU) and costs were highest in Year 1, with mean MG-related costs per patient between $24,982 (≥ 50 group) and $33,023 (18-49 group).

CONCLUSION

The study findings highlight that MG is inadequately controlled in a substantial proportion of patients despite conventional treatment and high reliance on corticosteroids. Earlier treatment with targeted therapies and improved safety profiles may reduce patient burden, HCRU, and costs.

Predicting worsening risk in MGFA class I, II and III myasthenia gravis patients: development and validation of a predictive nomogram

BACKGROUND

Myasthenia gravis (MG), a neuromuscular junction autoimmune disorder, causes skeletal muscle weakness. MG worsening frequently occurs during the disease course, severely impairing quality of life and elevating myasthenic crisis risk. Existing predictive models remain scarce. This study developed a predictive model for MG worsening to facilitate early risk stratification and personalized care.

RESEARCH DESIGN & METHODS

Retrospective analysis included 437 the Myasthenia Gravis Foundation of America (MGFA) class I - III myasthenia gravis patients from December 2019 to September 2024. Sociodemographic, clinical variables and worsening status were analyzed. Predictors were identified via univariate analysis, the Least Absolute Shrinkage and Selection Operator (LASSO) regression, and multivariate logistic regression. Model performance was assessed using receiver operating characteristic (ROC) analysis, calibration curves, and decision curve analysis.

RESULTS

Patients were randomized into training (n = 305) and validation (n = 132) cohorts. Worsening rates were comparable (26.52% vs. 31.15%, p = 0.331). Six predictors emerged: age, MGFA classification, thymectomy history, chills, fatigue, and emotional disturbances (ED). The nomogram demonstrated strong discrimination (AUC: 0.82 training, 0.83 validation) and calibration (Hosmer-Lemeshow p > 0.05). Decision curve analysis confirmed clinical utility at 10-70% probability thresholds.

CONCLUSION

This nomogram integrates accessible clinical variables to stratify MG worsening risk, enabling early intervention. Validation through multicenter prospective studies is warranted to optimize generalizability.

The real-world impact of corticosteroid-associated adverse events in myasthenia gravis: A patient-reported survey analysis

BACKGROUND

Corticosteroids are crucial for managing acute exacerbation symptoms and preventing relapses in myasthenia gravis (MG) patients.

METHODS

Between April 15-30, 2024, 2368 online self - report questionnaires were distributed. Eventually, 444 MG patients who had received corticosteroid therapy completed the survey.

RESULTS

Self-reported adverse events (AEs) were observed in 97.5 % of the respondents. Among them, 72.5 % (322 patients) reported experiencing more than four AEs. The quality of life (QOL) of patients with MG was significantly impacted, with average MG-QOL scores of 18.07 ± 12.03. Patients with a cumulative dosage exceeding 20 g experienced the highest incidence of various AEs compared to those with lower cumulative dosages (5-20 g and less than 5 g). Additionally, a longer duration of corticosteroid exposure was associated with a higher reported incidence of AEs. Cox risk regression modeling revealed that a longer disease course, a history of myasthenic crisis, and the average daily dose of steroids (exceeding 5 mg/d), were independent predictors of corticosteroid-associated AEs. The study revealed in a single MG center, the awareness of these AEs was low among Chinese patients.

CONCLUSION

This study systematically assessed the incidence and risk factors of corticosteroid-related AEs in Chinese MG patients. The study found that the occurrence of AEs was associated with the cumulative dosage and duration of corticosteroid use. Additionally, long disease duration, a history of myasthenic crises, and an average daily dosage exceeding 5 mg/d are identified as risk factors for corticosteroid-related AEs in patients with MG.

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.

Efficacy and safety of FcRn inhibitors in patients with Myasthenia gravis: An updated systematic review and meta‑analysis

BACKGROUND

Myasthenia gravis (MG) is a chronic, complex autoimmune disorder characterized by the production of autoantibodies that destroy neuromuscular junctions. Blocking the neonatal Fc receptors (FcRn) enhances IgG catabolism, offering a novel therapeutic approach.

METHODS

PubMed, Embase, and the Cochrane Library were searched up to February 2025, for RCTs evaluating FcRn inhibitors in MG. A random effects model to calculate pooled risk ratios (RR) and mean differences with 95 % confidence intervals (CI).

RESULTS

873 patients from 8 randomized control trials (RCTs) were analyzed. Compared to placebo, FcRn inhibitors significantly reduced Myasthenia Gravis Activities of Daily Living (MG-ADL) scores (MD of -1.45 [95 % CI, -1.91 to -0.99]; P < 0.00001), Quantitative Myasthenia Gravis( QMG) scores (MD = -2.33 [95 % CI, -3.57 to -1.09]; P = 0.0002), and Myasthenia Gravis Composite (MGC) scores (MD = -2.96 [95 % CI, -4.29 to -1.63]; P < 0.0001). The FcRn inhibitors improved MG-ADL responder rates (RR = 1.60 [95 % CI, 1.27-2.02]; P < 0.0001), and Myasthenia Gravis Quality of Life (MGQoL15r) scores (MD = -2.18 [95 % CI, -3.35 to -1.00]; P = 0.0003). Serious adverse events were lower with the FcRn inhibitors (32/519) than the placebo (39/397). Subgroup analysis revealed that Rozanolixizumab and Nipocalimab improved MG-ADL scores, but had inferior responder rates. Additionally, Rozanolixizumab significantly improved MGC scores but had more adverse events.

CONCLUSION

FcRn inhibitors demonstrated good efficacy and safety in MG, with efgartigimod and nipocalimab showing strong efficacy without added risk. Further research is required to evaluate long-term outcomes and optimize treatment.

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.

Real-World Experience with FcRn Inhibitors Efgartigimod and Rozanolixizumab in Myasthenia Gravis: Administration in Multiple Cycles and Transition from Intravenous to Subcutaneous Formulation

INTRODUCTION

The neonatal Fc receptor (FcRn) inhibitors efgartigimod and rozanolixizumab have not long been introduced for treating generalized myasthenia gravis (MG); hence, real-world evidence for their administration in multiple cycles and switching from intravenous to subcutaneous formulation remains insufficient.

METHODS

We retrospectively assessed 17 consecutive patients with generalized MG and diverse backgrounds who were treated with FcRn inhibitors.

RESULTS

All patients initially received an intravenous efgartigimod formulation. Of 17 patients, 10 (59%) were considered responders, defined as a persistent improvement of at least two points for a minimum of four consecutive weeks in the MG activities of daily living score during the first treatment cycle. Four of the non-responders in the first cycle demonstrated an improvement in fulfilling the criteria for responders in the second cycle. One of these patients, who had thymoma metastatic lesions, experienced a significant worsening of MG symptoms during the first treatment cycle. Five patients switched from intravenous to subcutaneous formulations, which was successful in all patients. The efficacy of the subcutaneous formulations was similar to that of the intravenous formulation, even in patients who switched from efgartigimod to rozanolixizumab. The drugs were well tolerated without any drug-related serious adverse events irrespective of the formulation type.

CONCLUSION

FcRn inhibitors were effective and safe in patients with generalized MG, but their efficacy may depend on the disease activity during treatment. The transition from the intravenous formulation to more convenient subcutaneous formulations was successful, indicating the likely growth of future demand for subcutaneous formulations.

The role of complement in the immunopathogenesis of acetylcholine receptor antibody-positive generalized myasthenia gravis: bystander or key player?

The complement system is a key component of the innate immune system. In antiacetylcholine receptor (AChR) antibody-positive (Ab+) generalized myasthenia gravis (MG), complement activation has long been considered a principal driver of pathology. Understanding the role of complement in AChR-Ab+ generalized MG has gained increasing importance in recent years, as anticomplement drugs have been approved for clinical use or are undergoing phase II/III clinical trials. This review aims to discuss recent and previous findings on the role of complement in AChR-Ab+ MG pathology, including its interaction with pathogenic antibodies and mechanisms beyond the classical pathway activation.

Complement inhibitor therapy in thymoma-associated myasthenia gravis: a real-world experience

Introduction

Thymoma-associated myasthenia gravis (TAMG) accounts for 15-20% of all myasthenia gravis (MG) cases and is typically characterized by severe clinical manifestations and suboptimal response to conventional therapies. However, TAMG patients are underrepresented in clinical trials, leaving gaps in evidence for optimal treatment strategies. This study assessed the efficacy of complement inhibitors (CI) in TAMG population.

Methods

We retrospectively reviewed 23 TAMG patients who received CI, with a minimum follow-up of six months. Additionally, we randomly included 22 MG patients without thymoma, treated with CI, in the control group. Clinical outcomes were measured using Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores at baseline, three, and six months.

Results

Among the 23 TAMG patients, 21 initiated CI after thymectomy, with a median interval of eight years (IQR:2.5-15) post-surgery. Two patients achieved sufficient stabilization on CI to undergo thymectomy thereafter. The most frequent thymoma histological subtype was WHO type B2, detected in 43.5% of cases. Median MG-ADL score decreased from 11 (IQR:8-15) to 3 (IQR:2-5) and 4 (IQR:1-5) at three and six months, respectively (both p<0.001). Median QMG score decreased from 16 (IQR:14-22) to 10 (IQR: 5-11) at three and six months (both p<0.001). Prednisone dosage was tapered in 20 patients. No significant differences were observed between TAMG and MG patients without thymoma in MG-ADL, QMG and steroid reduction.

Conclusion

CI demonstrated significant improvements in MG-ADL and QMG scores, along with a steroid-sparing effect, suggesting its potential as an effective treatment for this challenging subpopulation.

Efgartigimod Followed by Telitacicept in Adult Generalized Myasthenia Gravis: A Retrospective Case Series

Background

The emergence of biologics for the treatment of generalized myasthenia gravis (gMG) has increased therapeutic options, but evidence on their flexible use remains limited.

Purpose

This study retrospectively analyzed gMG patients treated with efgartigimod followed by telitacicept.

Methods

A retrospective analysis was conducted on gMG patients treated with efgartigimod followed by telitacicept. Outcomes included changes in Quantitative Myasthenia Gravis (QMG) and Myasthenia Gravis-Activities of Daily Living (MG-ADL) scores from baseline to weeks 13 and 28, Minimal Manifestation Status (MMS), corticosteroid-sparing potential, safety, and serological markers.

Results

Among seven patients included for efficacy evaluation, the baseline QMG and MG-ADL scores were 12.4±4.3 and 7.1±3.6, respectively. These scores decreased by 8.4±3.9 and 5.7±4.2 at week 13 and further decreased by 8.7±3.2 and 6.8±3.4 by week 28 (both P < 0.001). Six patients (86%) achieved Minimal Manifestation Status (MMS), with a median time to achieve MMS being 9 weeks. The average prednisone dosage was significantly reduced from 51.43±14.64 mg at baseline to 5.71±1.89 mg by week 28 (P < 0.05). Common adverse events included mild injection site reactions (n=2) and upper respiratory infections (n=2), with no serious events reported. IgM and IgA levels significantly declined by week 17 (P < 0.05), while BAFF levels increased significantly following telitacicept treatment by week 21 (P < 0.05).

Conclusion

This regimen demonstrated favorable efficacy and safety, suggesting its potential as an effective option for gMG management.

A Phase 3 Trial of Inebilizumab in Generalized Myasthenia Gravis

BACKGROUND

Autoimmune generalized myasthenia gravis is a disease that manifests with fluctuating muscle weakness. Inebilizumab is a monoclonal antibody that depletes CD19+ B cells, which are central to disease pathogenesis.

METHODS

In this phase 3, double-blind, randomized, placebo-controlled trial, we enrolled participants with myasthenia gravis who had anti-acetylcholine receptor antibodies or anti-muscle-specific kinase antibodies. Participants were randomly assigned, in a 1:1 ratio, to receive intravenous inebilizumab (300 mg administered on days 1 and 15 for all, and additionally on day 183 for participants who were acetylcholine receptor antibody-positive) or matching placebo for 52 weeks (in participants who were acetylcholine receptor antibody-positive) or 26 weeks (in those who were muscle-specific kinase antibody-positive). Glucocorticoid therapy was tapered, starting at week 4, to a target of 5 mg per day by week 24. The primary end point was the change from baseline in the score on the Myasthenia Gravis Activities of Daily Living scale (MG-ADL; scores range from 0 to 24, with higher scores indicating greater disease activity) at week 26 in the combined acetylcholine receptor antibody-positive and muscle-specific kinase antibody-positive trial populations. A key secondary end point was the change from baseline in the score on the Quantitative Myasthenia Gravis scale (QMG; scores range from 0 to 39, with higher scores indicating greater disease activity) at week 26 in the combined population. Safety was assessed.

RESULTS

A total of 238 participants underwent randomization (119 per group). Participants who received inebilizumab had a greater reduction in the MG-ADL score than those who received placebo (least-squares mean change, -4.2 vs. -2.2; adjusted difference, -1.9; 95% confidence interval [CI], -2.9 to -1.0; P<0.001) at week 26. Participants who received inebilizumab had a greater reduction in the QMG score than those who received placebo (least-squares mean change, -4.8 vs. -2.3; adjusted difference, -2.5; 95% CI, -3.8 to -1.2; P<0.001). The most common adverse events with inebilizumab were headache, cough, nasopharyngitis, infusion-related reactions, and urinary tract infections. Inebilizumab was not associated with a higher incidence of serious adverse events.

CONCLUSIONS

In participants with acetylcholine receptor antibody-positive or muscle-specific kinase antibody-positive generalized myasthenia gravis, inebilizumab improved function and reduced disease severity. (Funded by Amgen; MINT ClinicalTrial.gov number, NCT04524273.).

The Role of Exosomes in Central Immune Tolerance and Myasthenia Gravis

BACKGROUND

Immune homeostasis plays a crucial role in immunology andis dependent on both central and peripheral tolerance. Centraltolerance and peripheral tolerance occur in the thymus and thesecondary lymphoid tissues, respectively. Tolerance breakdown andimmune regulation defects can lead to autoimmune disorders. In thisreview article, we aimed to describe the role of exosomes inregulating central tolerance and provide a summary of their effectson the pathogenesis, diagnosis, and therapeutic potential inmyasthenia gravis (MG).

METHODS

Articles for this review wereidentified using the PubMed database.

RESULTS

As the primarylymphoid organ, the thymus is responsible for building an immunecompetent, yet self-tolerant of T-cell population. Thymic statesinclude thymoma, thymic hyperplasia, and thymic atrophy, which canexert a significant influence on the central immune tolerance andrepresent specific characteristics of MG. Previous studies have foundthat exosomes derived from human thymic epithelial cells carryantigen-presenting molecules and a wide range of tissue restrictedantigens, which may indicate a vital role of thymic exosomes in MG.Besides, exosomal miRNAs and lncRNAs may also play a critical role inthe pathophysiology of MG.

CONCLUSION

This review provides thetherapeutic and diagnostic potential of exosomes in MG patients.

Evidence-based guidelines for the pharmacological treatment of migraine

We here present evidence-based guidelines for the pharmacological treatment of migraine. These guidelines, created by the Italian Society for the Study of Headache and the International Headache Society, aim to offer clear, actionable recommendations to healthcare professionals. They incorporate evidence-based recommendations from randomized controlled trials and expert-based opinions. The guidelines follow the Grading of Recommendations, Assessment, Development and Evaluation approach for assessing the quality of evidence. The guideline development involved a systematic review of literature across multiple databases, adherence to Cochrane review methods, and a structured framework for data extraction and interpretation. Although the guidelines provide a robust foundation for migraine treatment, they also highlight gaps in current research, such as the paucity of head-to-head drug comparisons and the need for long-term outcome studies. These guidelines serve as a resource to standardize migraine treatment and promote high-quality care across different healthcare settings.

Factors associated with increased severity of generalized myasthenia gravis among patients in the United States and Europe

Among individuals with generalized myasthenia gravis (gMG), risk factors for increased severity over time are unknown. This study examined the association between demographic and clinical variables and patient progression to a more severe MG Foundation of America (MGFA) classification. Data were drawn from the Adelphi Real World myasthenia gravis Disease Specific Programme™, a cross-sectional survey capturing retrospective data from patients' medical histories. Among 421 individuals, 16% experienced increased gMG severity (progression to higher MGFA class between diagnosis and the time of the survey, 1-7 years later) and for 84%, gMG was stable/improved (MGFA class the same/lower). Logistic elastic net regression determined that increased severity was associated with the occurrence of prior misdiagnosis. Bivariate analyses indicated significant associations between increased severity and longer time between symptom onset and (a) the first consultation with a healthcare practitioner and (b) MG diagnosis. Increased severity was also associated with older age and presence of specific symptoms at diagnosis. gMG stability/improvement was associated with employment status and general fatigue at diagnosis. There is a need for prompt and accurate diagnosis and improved treatment options with the potential to increase the likelihood of stability/improvement for gMG patients.

Efficacy and Safety of Efgartigimod for Patients With Myasthenia Gravis in a Real-World Cohort of 77 Patients

AIMS

Efgartigimod, a first-in-class neonatal Fc receptor antagonist, is approved for generalized myasthenia gravis (gMG). Its safety and efficacy across MG subtypes remain unclear.

METHODS

This single-center real-world study (September 2023-July 2024) analyzed patients from an MG registry study in China. The primary efficacy outcome is the mean MG-ADL score changes from baseline at weeks 4, 8, and 12, analyzed via generalized estimating equations. Safety was assessed by adverse events.

RESULTS

Among 77 patients (mean age 56.1 ± 15.2 years; 59.7% male), 76 completed at least one treatment cycle (20 completed 2 cycles; 1 completed 3 cycles). After efgartigimod treatment, MG-ADL scores decreased significantly by week 4 (mean difference -6.4, 95% CI -7.2 to -5.6, p < 0.001), sustaining through week 12 (-6.9, -7.8 to -6.1, p < 0.001). After the second cycle, MG-ADL scores at week 12 trended lower than the first cycle (mean difference: -0.8, 95% CI: -2.0 to -0.5, p = 0.061). Efficacy was consistent across MGFA classes and thymoma status. In refractory patients, efgartigimod reduced MG-ADL scores (p < 0.001). Adverse events occurred in 3.9% (3/77).

CONCLUSION

Efgartigimod safely improved MG-ADL scores and reduced steroid use across MG subtypes, with sustained efficacy through multiple treatment cycles. These findings support its potential when conventional therapies fail.

Effect of the Administration of Cautionary Drugs on the Risk of Worsening Myasthenia Gravis: A Retrospective Matched Case-Control Study

PURPOSE

Although some medications trigger the worsening of myasthenia gravis (MG), their clinical influence on patients with MG has not been significantly evaluated. We aimed to investigate whether the risk of clinical worsening of MG increases after administering cautionary drugs in patients with MG.

MATERIALS AND METHODS

This retrospective case-control study was based on the medical records of patients diagnosed with MG between 2007 and 2020. We analyzed the risk of MG worsening in patients exposed to cautionary drugs during the risk period, defined as 6 months from the first exposure to cautionary drugs. The risk of MG worsening in the exposed patients was compared to that in the non-exposed patients, who were individually matched in a 1:1 ratio with exposed cases for sex, age, thymoma, and autoantibodies.

RESULTS

Of the 2002 patients diagnosed with MG, 552 (27.6%) were exposed to cautionary drugs. Neuromuscular blocking agents (320 patients) and beta blockers (66123 person-days) were the most frequently prescribed medications. After exact matching, 220 exposed and 220 non-exposed patients were enrolled. The incidence rate of clinical worsening during the risk period was significantly higher in the exposed patients than in the non-exposed patients (odds ratio=4.09; 95% confidence interval, 1.88-8.90; p<0.001). Clinical worsening was observed in 31 (14.1%) of the exposed patients and in 8 (3.6%) of the non-exposed patients.

CONCLUSION

The administration of cautionary drugs increased the risk of clinical worsening in patients with MG. Clinicians should be aware of this risk when cautionary drugs need to be administered.

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.

Cost Trends of New-To-Market Neurologic Medications: An Insurance Claims Database Analysis

BACKGROUND AND OBJECTIVES

Costs for neurologic medications have increased considerably in recent years. Since 2014, more than 30 neurologic medications have been approved by the US Food and Drug Administration (FDA) for neurologic conditions. This study aims to characterize recent trends in annual costs and aggregate spending from 2012 to 2021 for new-to-market (NTM) medications for 9 neurologic conditions.

METHODS

We used the Merative MarketScan commercial and Medicare supplemental databases to observe patients seen by a neurologist with neurologic diseases with newly FDA-approved medications from 2014 to 2021: amyotrophic lateral sclerosis (ALS), transthyretin amyloidosis (ATTR), Duchenne muscular dystrophy (DMD), Huntington disease (HD), myasthenia gravis (MG), migraine, orthostatic hypotension (OH), tardive dyskinesia (TD), and spinal muscular atrophy (SMA). Patients were included if they had ≥1 disease-related prescription medication fill from 2012 to 2021. NTM (medications approved from 2014 to 2021) and older evidence-based guideline-supported medications were observed annually. Outcomes examined were annual and aggregate out-of-pocket (OOP) and total medication costs.

RESULTS

We identified 2,687 unique individuals with ALS, 38 with ATTR, 69 with DMD, 884 with HD, 9,984 with MG, 441,099 with migraine, 4,723 with OH, 1,266 with TD, and 17 with SMA. The youngest population was DMD (mean = 25 years [SD = 7]), and the oldest was TD (mean = 66 years [SD = 14]). For DMD, the population was 99% male and for migraine, the population was 84% female, and the other conditions had more relatively even sex divides. Collectively, migraine medications had the largest increase in aggregate costs (1993%) and had a substantial increase in OOP costs on average by 234% ($86-$288). Eculizumab for MG was an extreme outlier, with OOP costs increasing by 4,099% ($413-$17,359) and aggregate OOP costs by 7,005% ($5,375-$381,894). OOP costs of edaravone ($304-$5,707) and deutetrabenazine ($670-$7,170) sharply increased by 1,775% and 971%, respectively.

DISCUSSION

NTM medications for neurologic conditions have substantial and increasing individual and societal costs, which was not observed for older generic medications. These data suggest a need for policies to limit the financial burden of NTM medications on patients with neurologic conditions.

Efgartigimod for induction and maintenance therapy in muscle-specific kinase myasthenia gravis

Background

The efficacy of efgartigimod in treating myasthenia gravis (MG) patients with muscle-specific kinase (MuSK) antibodies has not been demonstrated in the clinical trial, existing case reports, or observational studies.

Objectives

To evaluate the efficacy and safety of efgartigimod combined with immunotherapies such as tacrolimus or B-cell depleting agents, as maintenance treatment for MuSK-MG patients.

Design

This retrospective study included 14 MuSK-MG patients treated with efgartigimod at three tertiary hospitals from 2023 to 2024.

Methods

Data on the activities of daily living (ADL) scores, Quantitative Myasthenia Gravis scores, and the time reaching minimal symptom expression (MSE) were collected. The combined use of steroids, immunosuppressants, and rescue therapies, as well as the adverse event incidence, were also recorded.

Results

The mean age at first efgartigimod treatment was 55 ± 18 years old with a median follow-up time of 28 weeks. From baseline to week 4, MG-ADL scores decreased significantly from 10.1 ± 4.0 to 2.2 ± 3.1 (n = 14, p = 0.001). The majority of patients (92.9%) maintains a reduction of at least 2 points for more than 8 weeks. The median time to achieve MSE was 4 weeks, with 71.4% (10/14) of patients reaching MSE by week 12. In patients receiving CD20 B cell depleting therapy or tacrolimus as maintenance, the time-weighted average dosage of prednisone was 16 mg while that in those with prednisone alone was 37 mg. Of all the 14 patients, one developed an upper respiratory tract infection 4 weeks after rituximab (RTX), and one was infected with herpes zoster virus 13 weeks after RTX.

Conclusion

A single-cycle efgartigimod as an induction therapy, combined with immunotherapies such as tacrolimus or B cell depleting agents, as maintenance treatment, could benefit MuSK-MG patients.

Efficacy and safety of different dosages of rituximab for myasthenia gravis: a single-arm meta-analysis

BACKGROUND

Rituximab (RTX) is one of the treatment options for refractory myasthenia gravis (MG), yet the optimal dosing schedule remains undetermined. Our study aims to explore this issue and offer a valuable reference for clinical dosing.

METHODS

This is a single-arm meta-analysis. Studies in adults with myasthenia gravis published before 31 December 2023 were searched in PubMed, Web of Science, and other databases. Two primary effectiveness outcomes were analyzed: (1) Proportion of patients achieving minimal manifestation status (MMS) or better, (2) Change in Quantitative MG Score (QMGs) after RTX treatment. Safety outcomes included the incidence and description of serious adverse events (SAEs) and adverse events (AEs). Forest plots were generated to provide an overview and detailed combined effects. Publication bias was evaluated using funnel plots and the Egger test. Conventional dose refers to an RTX regimen similar to that used for the treatment of B-cell lymphoma: 375 mg/m2 per week for 4 weeks or 1000 mg for Weeks 1 and 3. Dosing regimens below the conventional dose in a treatment cycle are defined as low dose.

RESULTS

A total of 1037 MG patients received RTX treatment. Overall, 59.0% (95% CI: 48.2-69.8%, n = 599) of patients achieved MMS or better, with a mean decrease in QMGs of 6.81 (95% CI, -9.27 to -4.35, n = 222). The low-dose group showed a higher proportion of patients achieving MMS or better (76.6% vs 51.6%) and a more significant decrease in QMGs from baseline (-9.04 vs -3.62) compared to the conventional dose group (P < 0.01). Differences in the incidence of SAEs and AEs between the two groups were not significant (P > 0.05). Univariate meta-regression analyses showed that the dose administered was significantly associated with the proportion of MMS or better and the change in QMGs, whereas the proportion of Musk patients was not significantly associated with any of the outcomes. Stepwise logistic regression analyses showed that non-refractory MG, mild disease severity (MGFA classification), and low-dose were significant predictors for achieving an MMS or better prognosis, whereas for achieving improvement or better, only low dose was an independent predictor.

CONCLUSION

RTX can improve clinical symptoms, reduce QMGs in MG patients and the use of oral glucocorticoids and other immunosuppressants. The efficacy of low-dose RTX in treating MG patients is more effective than conventional-dose RTX and demonstrates a better safety profile. Mild disease severity, non-refractory MG, low dose, and MuSK-MG over AChR-MG predict better efficacy. Large randomized controlled trials are necessary to evaluate the efficacy and safety of RTX in MG patients and its various subtypes.

Survival and autoimmune risks post-thymectomy

Background and objectives

Recent studies have raised concerns about thymectomy's deleterious effects. However, this conclusion was not exclusive to patients with myasthenia gravis (MG). The objective of this study was to test this hypothesis in thymectomy patients, regardless of their MG status.

Methods

We conducted a retrospective case-control study to analyze clinical and radiological data from 1 January 2010 to 30 November 2023. Patients were divided into four groups: MG with (MG-Thy) or without thymectomy (MG-NO-Thy); thoracoscopic surgery without thymectomy (Surgery-NO-Thy) and Non-MG with thymectomy (Non-MG-Thy).

Results

We identified a total of 456 patients (n=41, MG-Thy; n= 278, MG-NO-Thy; n=65, Non-MG-Thy; and n=72, Surgery-NO-Thy). The median ages were as follows: MG-Thy, 45.6 years (range: 22-79); MG-NO-Thy, 65 years (13-93); Non-MG-Thy, 59.8 (19-85) years; and Surgery-NO-Thy, 59.8 years (range: 19-85) (p<0.001). The median follow-up times were 5.5 years in MG-Tym, 3 in MG-NO-Thy, 3.9 in Non-MG-Thy, and 4.7 years in Surgery-NO-Thy. A thymic mass was detected with chest computed tomography (CT) in 56% (23/41) of the MG-Thy cohort and in all the Non-MG-Thy cohort. Thymic pathology in the MG-Thy group showed normal/fat atrophic thymus in 31.7% (13/41), hyperplasia in 26.8% (11/41), thymic cyst in 2.4% (1/41), and malignant in 39% (16/41). Thymic pathology in the non-MG group showed hyperplasia, fat, or normal thymus in 16.9% (11/65); thymic cyst in 18.5% (12/65); malignant thymoma in 60% (39/65); and others in 4.6% (3/65). The death rate was the lowest in the MG-Thy group, compared to the non-MG groups and the MG-No-Thy group. Specifically, death occurred in zero cases in the MG-Thy group, while it occurred in 13.8% (9/65) of the thymectomized non-MG group and in 35.6% (99/278) of the MG-without thymectomy group. Excluding late-onset MG patients (LOMG), the death incidence was 14.4% (15/104). The prevalence of autoimmune diseases before thymectomy was 14.6% (6/41) in the MG-Thy group versus 12.3% (8/65) in the Non-MG-Thy group, with three new cases post thymectomy in non-MG group. Post thymectomy cancer incidence was zero in the MG-Thy group, versus 16.2% (45/278) in the MG-NO-Thy group.

Conclusion

The benefits of thymectomy outweigh potential risks for patients with MG or patients with thymic malignancies. Incidental thymectomy should be avoided. This call for reevaluation of thymectomy especially for non-neoplastic causes.

Toward European harmonization of national myasthenia gravis registries: modified Delphi procedure-based expert consensus on collectable data

BACKGROUND

Myasthenia gravis (MG) is a rare autoimmune disorder. Several new treatment concepts have emerged in recent years, but access to these treatments varies due to differing national reimbursement regulations, leading to disparities across Europe. This highlights the need for high-quality data collection by stakeholders to establish MG registries. A European MG registry could help bridge the treatment access gap across different countries, offering critical data to support regulatory decisions, foster international collaborations, and enhance clinical and epidemiological research. Several national MG registries already exist or are in development. To avoid duplication and ensure harmonization in data collection, a modified Delphi procedure was implemented to identify essential data elements for inclusion in national registries.

RESULTS

Following a literature review, consultations with patient associations and pharmaceutical companies, and input from multiple European MG experts, 100 data elements were identified. Of these, 62 reached consensus for inclusion and classification, while only 1 item was agreed for exclusion. 30 items failed to reach the ≥ 80% agreement threshold and were excluded. Among the 62 accepted items, 21 were classified as mandatory data elements, 32 optional, and 9 items pertained to the informed consent form.

CONCLUSIONS

Through a modified Delphi procedure, consensus was successfully achieved. This consensus-based approach represents a crucial step toward harmonizing MG registries across Europe. The resulting dataset will facilitate the sharing of knowledge and enhance European collaborations. Furthermore, the harmonized data may assist in regulatory or reimbursement decisions regarding novel therapies, as well as address treatment access disparities between European countries.

App- and Wearable-Based Remote Monitoring for Patients With Myasthenia Gravis and Its Specialists: Feasibility and Usability Study

Background

Myasthenia gravis (MG) is rare, chronic autoimmune disorder of the neuromuscular junction that requires specialized care and often lifelong treatment, facing challenges due to its rarity and the limited availability of specialists. Telemedical solutions in specialized centers hold considerable promise in bridging this gap by increasing access to this care to a broader patient population in a timely manner. However, there is no research regarding interventional remote care solutions in the field of MG to date.

Objective

This study aimed to assess the feasibility and usability among patients with MG and specialists of a telemedicine platform, tailored to patients with MG and designed to facilitate remote monitoring, treated in a specialized center.

Methods

The telemedicine platform consisted of an app for patients and a web-based portal for physicians. Over a period of 3 months, 30 patients continuously monitored their vital parameters through external devices, including a digital spirometer and a wearable (activity tracker). Furthermore, patients completed 7 different patient-reported outcome measures (PROMs) through the app at predefined intervals. Specialists could review this monitoring data and adjust therapy as necessary. In addition, communication between patients and physicians was facilitated through a chat module. Feasibility was evaluated by total adherence rates for completing PROMs within the app, alongside the collection of spirometry and wearable data. Furthermore, user satisfaction was assessed among both patients with MG and physicians at the end of study.

Results

Total adherence rates ranged from 74.3% (1830/2464) to 97.9% (327/334) across all data types, with the highest adherence observed for PROMs (1139/1179, 96.6%), followed by spirometry (293/334, 87.7%) and wearables (1830/2261, 80.9%). Notably, patients wore the wearable longer than required by protocol and conducted a higher number of spirometry measurements during the study than required per protocol (median 20 h/d [IQR 15-24] vs 14 h/d and median 49 [IQR 15-59] measurements vs 11 measurements, respectively). Technical issues and discomfort with wearables were factors affecting lower adherence in some patients. The System Usability Scale yielded a median score of 85 indicating "excellent usability." In addition, results from a more detailed user evaluation questionnaire showed high levels of user satisfaction among both patients and health care professionals across diverse categories, including their experience of the care program, communication, and evaluation of the program.

Conclusions

Remote monitoring of patients with MG through the telemedical platform demonstrated good feasibility and acceptability, as evidenced by above-average adherence rates and user satisfaction for both patients and physicians. The majority of patients wanted to continue using the app. These findings highlight the potential for user-friendly digital tools to enhance care for patients with MG, although addressing technical challenges and ensuring patient comfort with wearables are essential for optimal implementation. Further research involving larger cohorts and longer study duration is warranted to validate these findings.

Long-term safety of cyclical rozanolixizumab in patients with generalized myasthenia gravis: Results from the Phase 3 MycarinG study and an open-label extension

BACKGROUND

Generalized myasthenia gravis (gMG) is a rare, chronic, fluctuating and heterogeneous autoimmune disease requiring lifelong treatment. The Phase 3 MycarinG study demonstrated the efficacy and safety of one 6-week cycle of weekly rozanolixizumab in adult patients with gMG. Open-label extension studies demonstrated consistent symptom improvement over additional treatment cycles.

OBJECTIVE

To present findings from pooled analyses on the long-term safety of repeated cycles of rozanolixizumab.

METHODS

Data from the Phase 3 randomized MycarinG study (NCT03971422) and the ongoing open-label extension study MG0007 (NCT04650854) were pooled to assess safety outcomes during cyclical treatment, including incidence of any treatment-emergent adverse events (TEAEs), severe TEAEs, serious TEAEs and TEAEs leading to discontinuations. Additional analyses were performed for TEAEs, including headache, infections, and hypersensitivity reactions.

RESULTS

At data cutoff (July 8, 2022), a total of 188 patients in MycarinG and MG0007 had received ≥1 treatment cycle with rozanolixizumab; total time in studies was 174.71 patient-years. Overall, 169/188 (89.9%) patients experienced any TEAE: 89/188 (47.3%) experienced any headache (including migraine, migraine with aura); 85/188 (45.2%) experienced an infection; 25/188 (13.3%) experienced a hypersensitivity reaction. One patient experienced an event of aseptic meningitis. The majority of AEs were mild-to-moderate in intensity, and incidence did not increase with repeated cyclic treatment. A total of 50/188 (26.6%) patients experienced severe TEAEs, the most common of which were MG worsening in 4/133 (3.0%) and 7/131 (5.3%) patients in the rozanolixizumab 7 mg/kg and rozanolixizumab 10 mg/kg groups, respectively, MG crisis in 0 and 4/131 (3.1%) patients, and headache in 1/133 (0.8%) and 7/131 (5.3%) patients.

CONCLUSIONS

These pooled results, representing 174.71 patient-years in the studies, demonstrate that treatment with rozanolixizumab in patients with gMG was well tolerated, and TEAEs were consistent and did not increase in incidence over repeated cycles in this patient population.

Development and Application of a Cell-Based Assay for Detecting Anti-Agrin Antibodies Associated With Myasthenia Gravis

BACKGROUND AND PURPOSE

Anti-agrin antibodies (agrin Abs) have recently been identified in patients with myasthenia gravis (MG), sometimes in conjunction with antibodies (Abs) to the acetylcholine receptor (AChR), muscle-specific tyrosine kinase (MuSK), or low-density lipoprotein receptor-related protein 4. This study aimed to develop an in-house cell-based assay (CBA) for detecting agrin Abs, and to test its application to serum samples collected from individuals diagnosed with MG.

METHODS

Agrin complementary DNA as cloned into a pCMV6-AC-GFP vector, which was subsequently transfected into human embryonic kidney 293T (HEK293T) cells. Transfected HEK293T cells were incubated with patient serum and antihuman immunoglobulin G Ab conjugated with a red fluorescent dye. Agrin Ab levels were measured using the CBA in 389 serum samples: 340 from patients with MG, 36 from patients with other neuromuscular diseases, and 13 from healthy controls. The presence of agrin Ab was determined based on the fluorescence intensity and colocalization using fluorescence microscopy.

RESULTS

The expression levels of agrin mRNA and protein in transfected HEK293T cells were confirmed using the reverse-transcription polymerase chain reaction and Western blotting, respectively. Agrin expression in cells was further confirmed by immunocytochemistry. Two (0.6%) of the 340 patients with MG tested positive for agrin Ab: 1 of 191 AChR-positive patients and 1 of 54 MuSK-positive patients.

CONCLUSIONS

We have developed and validated a novel CBA for detecting agrin Abs. This CBA was successfully applied to detect agrin Abs in serum samples obtained from individuals with MG.

Myasthenic Gravis Crisis in an 85-Year-Old Male Requiring Emergent Intubation and Plasmapheresis

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disorder caused by autoantibodies targeting acetylcholine receptors at the neuromuscular junction, leading to impaired synaptic transmission and muscle weakness. Myasthenic crisis (MC) is a life-threatening complication characterized by severe respiratory muscle weakness, often necessitating emergent airway management and intensive care. Common triggers for MC include infections, stress, medication changes, and underlying malignancies. Standard management includes ventilatory support, immunomodulatory therapies such as plasmapheresis or intravenous immunoglobulin (IVIG), and corticosteroids. We present the case of an 85-year-old male with a history of ocular MG on pyridostigmine, Parkinson's disease on carbidopa/levodopa, and colorectal adenocarcinoma on active chemoradiation. He presented to the emergency department with three days of worsening facial weakness, dysphagia, dysarthria, and respiratory distress. Examination revealed significant bulbar weakness, inability to clear secretions, and hypoxia despite noninvasive ventilatory support. His negative inspiratory force (NIF) deteriorated from -12 to -10, prompting emergent intubation for airway protection. Given his ongoing respiratory failure, he underwent plasmapheresis with subsequent clinical improvement. He remained intubated for four days, completed six sessions of plasmapheresis, and was transitioned to rehabilitation upon discharge. This case highlights the unpredictable nature of MC, emphasizing the need for early recognition and timely intervention in the emergency setting. It highlights the importance of multidisciplinary management, including neurology and critical care, and the role of plasmapheresis as a rapid and effective therapeutic option for severe MG exacerbations.

International Consensus Guidance for the Management of Glucocorticoid Related Complications in Neuromuscular Disease

INTRODUCTION/AIMS

Glucocorticoid (GC)-related adverse reactions and risks are commonly seen during the treatment of immune-mediated and inflammatory neuromuscular disorders. There is wide variation in the management of associated complications. The aim of this study is to develop international consensus guidance on the management of GC-related complications in neuromuscular disorders.

METHODS

Through the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM), an international task force of 15 experts was convened to develop clinical guidance for the management of GC-related complications in neuromuscular patients. The RAND/UCLA appropriateness method (RAM) was used to develop consensus guidance statements. Initial guidance statements were crafted after a thorough literature review and were modified after anonymous panel input, with up to three rounds of voting via email to achieve consensus.

RESULTS

Statements were developed and achieved consensus for general care, monitoring of patients while on GC, osteoporosis prevention, vaccinations, infection screening, and Pneumocystis jiroveci pneumonia prophylaxis. A multidisciplinary approach to the management of GC-related complications was emphasized.

DISCUSSION

These formal consensus statements provide guidance to clinicians who use GC in the treatment of neuromuscular diseases regarding prevention and management of the more common associated adverse events and risks that arise with long and short-term GC use and serve as a springboard for investigation and updates.

Initial Management of Neuromuscular Emergencies

Neuromuscular emergencies can be anxiety provoking for neurologist and nonneurologist alike. This review will discuss common causes of neuromuscular respiratory failure and how to treat them. An algorithmic approach to neuromuscular neurology will be employed to help the nonneurologist be more comfortable with acute neuromuscular emergencies.

Can Non-Thymomatous Late-Onset Myasthenia Gravis Benefit From Thymectomy? A Systematic Review and Meta-Analysis

BACKGROUND

Thymectomy is beneficial for treating early-onset acetylcholine receptor antibody-positive myasthenia gravis (MG); however, its effects on late-onset MG (LOMG) remain less well understood. Given the increasing incidence of MG among the population 50 years old and above, addressing the question of whether thymectomy is effective for this age group is critically important. This study aimed to assess the present evidence for the efficacy of thymectomy in LOMG and identify potential characteristics that may predict the treatment response.

METHODS

Four electronic databases were searched from their inception to September 10, 2024. Six studies with both thymectomy and medical therapies in LOMG patients, along with another 14 studies with only a surgical group, were enrolled in the meta-analysis. The primary outcome was the response (remission and minimal manifestations status) to thymectomy in LOMG.

RESULTS

In LOMG, response in the surgical group was greater than in the medical therapies alone group (OR = 1.42 [0.86-2.35], p = 0.169), but not significantly. However, subgroup analysis showed that when the age of MG onset was ≥ 45 years old or the age at thymectomy was ≥ 50 years old, thymectomy appeared better than medical therapies alone (OR = 1.92 [1.06-3.48], p = 0.031). Across all 20 studies, 34% (24%-44%) of LOMG patients improved with thymectomy. A higher response was observed in patients with a preoperative duration of less than 3 years from diagnosis [39% (16%-65%), p < 0.001, q < 0.001].

CONCLUSION

Thymectomy may be a potentially effective treatment for LOMG, particularly in patients who undergo the procedure soon after diagnosis. A randomized controlled study for LOMG patients is needed.

Composition and function of AChR chimeric autoantibody receptor T cells for antigen-specific B cell depletion in myasthenia gravis

In acetylcholine receptor (AChR)-seropositive myasthenia gravis (MG), anti-AChR autoantibodies impair neuromuscular transmission and cause severe muscle weakness. MG therapies broadly suppress immune function, risking infections. We designed a chimeric autoantibody receptor (CAAR) expressing the 210-amino acid extracellular domain of the AChR α subunit (A210) linked to CD137-CD3ζ cytoplasmic domains to direct T cell cytotoxicity against anti-AChRα B cells. A210-CAART incorporating a CD8α transmembrane domain (TMD8α) showed functional but unstable surface expression, partially restored by inhibiting lysosomal degradation. A210-CAART with a CD28 TMD showed sustained surface expression, independent of TMD dimerization motifs. In a mouse xenograft model, A210.TMD8α-CAART demonstrated early control of anti-AChR B cell outgrowth but subsequent rebound and loss of surface CAAR expression, whereas A210.TMD28-CAART induced sustained surface CAAR expression and target cell elimination. This study demonstrates the importance of the CD28 TMD for CAAR stability and in vivo function, laying the groundwork for future development of precision cellular immunotherapy for AChR-MG.

Pathogenesis and detection methods of anti-acetylcholine receptor antibodies in myasthenia gravis

Myasthenia gravis (MG), which affects the endplate region of the postsynaptic neuromuscular junction, is the best-understood autoimmune disease. MG is driven by anti-acetylcholine receptor (AChR) or muscle-specific receptor tyrosine kinase, and 65% of MG patients have anti-AChR-positive generalized MG. Experimental autoimmune MG is a useful model to investigate the pathogenic mechanisms of anti-AChR antibodies and to evaluate the efficacy of new immunotherapies. Since long-term drug treatment is usually necessary for MG patients, the selection of immunotherapy must be chosen based on an understanding of the pathophysiology, including the roles of the thymus, T cells, B cells, autoantibodies, and neuromuscular junction. The main pathogenic mechanism of MG is the activation of the complement system caused by the attack of anti-AChR antibodies. Molecular technology using the neonatal Fc receptor (FcRn) is currently being applied to the development of new MG therapies. Many biological drugs targeting B cells, interleukin-6, FcRn and complement show promise as potential therapeutics for anti-AChR-positive generalized MG. With regard to anti-AChR antibody detection, the overall agreement rate between radioimmunoassay and enzyme linked immunosorbent assay is 91%, with positive agreement of 87% and negative agreement of 99%.

Fast-acting treatment of myasthenic crisis with efgartigimod from the perspective of the neonatal intensive care unit

BACKGROUND

Myasthenic crisis (MC) refers to rapid deterioration of myasthenia gravis (MG), affecting lung and bulbar muscles and causing breathing difficulties. Currently, efgartigimod has shown good therapeutic effects in patients with generalized myasthenia gravis (GMG). This retrospective real-world study explored the effectiveness of efgartigimod in patients with MC.

METHOD

Reviewing the clinical data of five patients (including four patients with refractory MC) with MC who received efgartigimod at the First Affiliated Hospital of Sun Yat-sen University, all of these patients were admitted from September 2023 to December 2023.

RESULTS

Each patient received 20 mg/kg of efgartigimod on the first and fifth day. After discharge, all patients showed a clinically meaningful decrease in Myasthenia Gravis Activities of Daily Living (MG-ADL) scale (a decrease of ≥ 2 points) and an improvement in their lung function. Additionally, all patients had a decrease in IgG levels (58.59 ± 18.48% after one cycle of efgartigimod). We also explored the ICU stay and mechanical ventilation (MV) duration for these five patients, and found no significant improvement compared to a large sample data. In terms of safety, four patients experienced adverse events (AEs), all of which were mild. At the last follow-up, four patients achieved the minimal symptom expression (MSE) status (an MG-ADL score of 0 or 1) after 6.25 ± 3.30 weeks. Only one patient experienced a worsening of symptoms in the second week after discharge, but she also achieved the MSE status after receiving a second cycle of efgartigimod treatment.

CONCLUSIONS

Given the conclusion that intravenous efgartigimod is a non-invasive fast-acting treatment with fewer AEs, this may provide NICU workers with another option for managing patients with MC.

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.

Therapeutic development towards T follicular helper cells as a molecular target in myasthenia gravis disease

This review intends to gather literature to provide a comprehensive understanding of the molecular mechanisms and role of T follicular helper cells (Tfh) in the interaction with germinal centers (GCs) in Myasthenia Gravis (MG) disease regarding new developments focusing on Tfh as a therapeutic target and its key regulator B cell lymphoma 6 (Bcl6). Tfh cells are CD4+ T cells specialized in providing signals for the activation and maturation of B cells plus the formation and maintenance of GCs; the role of Bcl6 stands as the key transcriptional factor for the survival of GCs and promotion of Tfh generation. Previous studies have demonstrated gene therapy to be beneficial by achieving re-establishment of "immune homeostasis" and amelioration of the proinflammatory process.

Efficacy and Safety of Zilucoplan in Amyotrophic Lateral Sclerosis: A Randomized Clinical Trial

Importance

The etiology of amyotrophic lateral sclerosis (ALS), a fatal neurodegenerative disease, is unknown. However, neuroinflammation and complement activation may play a role in disease progression.

Objective

To determine the effects of zilucoplan, an inhibitor of complement C5, in individuals with ALS.

Design, Setting, and Participants

Zilucoplan was tested as regimen A of the HEALEY ALS Platform Trial, a phase 2 to 3 multicenter, randomized, double-blind, placebo-controlled perpetual platform clinical trial with sharing of trial infrastructure and placebo data across multiple regimens. Regimen A was conducted from August 17, 2020, to May 4, 2022. A total of 162 participants were randomized to receive zilucoplan (122 [75.3%]) or regimen-specific placebo (40 [24.7%]). An additional 124 concurrently randomized participants were randomized to receive placebo in other regimens.

Interventions

Eligible participants were randomized in a 3:1 ratio to receive zilucoplan or matching placebo within strata of edaravone and/or riluzole use for a planned duration of 24 weeks. Active drug (zilucoplan, 0.3 mg/kg) and placebo were provided for daily subcutaneous dosing.

Main Outcomes and Measures

The primary end point was change in disease severity from baseline through 24 weeks as measured by the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) total score and survival, analyzed using a bayesian shared-parameter model and reported as disease rate ratio (DRR; <1 indicating treatment benefit). The study included prespecified rules for early stopping for futility. Outcome analyses were performed in the full analysis set comparing the zilucoplan group with the total shared placebo group (n = 164).

Results

Among the 162 participants who were randomized (mean [SD] age, 59.6 [11.3]; 99 [61.1%] male), 115 (71.0%) completed the trial. The estimated DRR common to ALSFRS-R and survival was 1.08 (95% credible interval, 0.87-1.31; posterior probability of superiority, 0.24). The trial was stopped early for futility. No unexpected treatment-related risks were identified.

Conclusions and Relevance

In this randomized clinical trial of zilucoplan in ALS, treatment did not alter disease progression. The adaptive platform design of the HEALEY ALS Platform Trial made it possible to test a new investigational product with efficient use of time and resources.

Trial Registration

ClinicalTrials.gov Identifier: NCT04297683.

Burden of Myasthenia Gravis in the Czech Republic: Analysis of the Nationwide Patient Registry

INTRODUCTION

The main goal of this study was to describe the Czech population of patients with MG in terms of demographics, disease characteristics, management approaches, and treatment trends.

METHODS

We selected all patients, both incident and prevalent, who were enrolled in the Czech MyReg registry between August 24, 2015 and November 19, 2021. For the descriptive analysis, all patients enrolled in the registry, regardless of their date of diagnosis or date of enrolment, were included. We analyzed the following disease-related endpoints: myasthenia gravis composite (MGC) score, forced vital capacity (FVC), and Myasthenia Gravis Foundation of America (MGFA) clinical classification.

RESULTS

The incidence showed a consistent increasing trend from 0.62 to 3.13. The mean MGC score was 5.0 (median 4.0, 95% CI 4.7, 5.3) representing mild form of MG. The difference in FVC from the predicted value in patients during and without myasthenic crisis was 58.93% (95% CI 37.27, 80.59) and 75.93% (95% CI 74.87, 77.00), respectively. We identified 70 patients (5.0%) with refractory MG, of whom 58.6% were female. The MGFA classifications in those with refractory vs. non-refractory disease was as follows: IIa 21.8% vs 23.2%, IIb 45.3% vs 33.6%, and IIIb 14.1% vs 4.6%, respectively.

CONCLUSION

Our analysis shows that the incidence of MG is increasing in the Czech Republic and that patients with refractory disease, of whom up to 58% are female, have a higher burden of disease than non-refractory patients.

Thyroid eye disease and ocular myasthenia gravis

PURPOSE OF REVIEW

An overview of two ocular diseases, which significantly impact quality of life: thyroid eye disease (TED) and ocular myasthenia gravis (OMG). Additionally, we describe the clinical challenge when they occur simultaneously. We will describe the pathophysiology of both conditions, the currently available diagnostic tools, and the therapies available.

RECENT FINDINGS

Recent literature has described newer diagnostic modalities, predictors of disease severity and co-occurrence of TED and OMG, and novel therapies. There is also critical analysis of current therapeutics and risk factors.

SUMMARY

The findings from this review suggest a need for heightened clinical awareness and early detection strategies for TED and OMG due to their overlapping clinical presentation. Emerging therapies and diagnostic techniques should be integrated into practice. Further research is warranted to explore the long-term safety and efficacy of novel treatments and the potential genetic links between these conditions.

Distal muscle weakness as the main onset symptom in thymoma-associated myasthenia gravis: a case report and literature review

Myasthenia gravis (MG) is an autoimmune disorder within the spectrum of neuromuscular rare diseases, characterized by fluctuating muscle weakness. This report presents a case of a middle-aged woman with a chronic onset of asymmetric upper limb weakness accompanied by difficulty in finger extension, without ptosis or fluctuation for 4 years. The patient was finally diagnosed with MG by a significant decrement of Compound Muscle Action Potential in repetitive nerve stimuli, positive anti-acetylcholine receptor antibodies as well as the presence of a mass located in the anterior mediastinum. With subsequent immunotherapies for one month, the patient exhibited marked enhancement in muscle strength, followed by an uneventful thymectomy. After two months, the patient's symptoms were fully alleviated, as evidenced by the reduction in Quantitative MG Score from 9 to 4 points, Myasthenia Gravis Composite Score from 6 to 1 points, Myasthenia Gravis Activities of Daily Living Score from 4 to 1 points, and Myasthenia Gravis Quality of Life-15 score from 14 to 8 points respectively. This case highlights the importance of differentiating autoimmune disorders from hereditary neuromuscular diseases and initiating timely treatment.

Application of efgartigimod in Chinese patients with myasthenia gravis: a single-center real-world prospective study

Background

China has a large number of myasthenia gravis (MG) patients, creating an urgent need for rapid and tolerable treatment options. As the first-approved Fc receptor antagonist, efgartigimod has bright prospects for treating MG. However, real-world evidence on its application within the Chinese MG population are limited.

Objective

This study aims to evaluate the rapid efficacy and safety of efgartigimod in Chinese MG population.

Design

This single-center prospective study enrolled Chinese MG patients aged 18 and older who were treated with efgartigimod, classified as Myasthenia Gravis Foundation of America I-IV, with a baseline Myasthenia Gravis Activities of Daily Living (MG-ADL) score of at least 4.

Methods

Patients received efgartigimod at a dose of 10 mg/kg infused once weekly for 4 weeks. During the treatment, the corticosteroids dosage could be adjusted as appropriate or the non-steroidal immunosuppressive therapies (NSISTs) added. Prior to each infusion, patients' MG-ADL scores, IgG levels, and routine laboratory tests were evaluated, while also recording the prednisone tapering and any adverse events occurring during the treatment.

Results

Twenty five Chinese MG patients were enrolled between November 2023 and June 2024, including 3 with ocular MG (OMG) and 22 with generalized MG (GMG). During the 8-week follow-up, in GMG patients, whether positive for acetylcholine receptor (AChR) or muscle-specific tyrosine kinase (MuSK) antibodies, the overall efficacy was significant. Within one treatment cycle, 18 (82%) patients showed a reduction of at least 2 points in MG-ADL scores and sustained for at least 4 weeks, and 6 (27%) attained minimal symptom expression (MSE) and sustained for at least 4 weeks. Only 1 patient experienced exacerbation. Among OMG patients, 1 achieved MSE within the treatment cycle, while 2 showed minor improvements. Patients who added tacrolimus concurrently with efgartigimod did not achieve better improvement in MG-ADL scores compared to others. The average reduction in prednisone dosage was 27.4%. Only one patient experienced transient vomiting and diarrhea, with no serious adverse reactions reported.

Conclusion

This study confirmed the short-term efficacy and safety of efgartigimod in Chinese MG patients. However, in clinical practice, careful consideration is needed regarding its application in OMG and whether to add NSISTs regimen during the treatment. Efgartigimod could potentially serve as an alternative to long-term corticosteroids therapy.

Mitochondrial dysfunction in myasthenia gravis: Exploring directions for future immunotherapy? A review

Myasthenia gravis (MG) is an acquired autoimmune disease characterized by impaired transmission at the neuromuscular junction, primarily manifesting as fluctuating muscle weakness, fatigability, and partial paralysis. Due to its long disease course, treatment resistance, and frequent relapses, it places a significant burden on patients and their families. In recent years, advances in molecular biology have provided growing evidence that mitochondrial dysfunction impairs muscle function and affects immune cell proliferation and differentiation in patients. Mitochondria, as the cell's energy source, play a critical role in various pathological processes in MG, including oxidative stress, dynamic abnormalities, mitophagy, and mitochondrial metabolism. The role of mitochondrial dysfunction in the pathogenesis of MG has garnered increasing attention. This manuscript primarily explores mitochondrial function and abnormal morphological changes in MG, as well as mitochondrial quality control, metabolic reprogramming, and their potential mechanisms in the pathological changes of the disease. It also reviews the current status of drug therapies aimed at improving mitochondrial function. The goal is to provide novel perspectives and strategies for future mitochondrial-targeted therapies in MG.

Short-term and long-term prognoses in AChR-Ab positive very-late-onset myasthenia gravis patients

Background

Very-late-onset myasthenia gravis (VLOMG) refers to myasthenia gravis (MG) with onset at age 65 or older. Current research on VLOMG prognosis remains limited, especially regarding factors influencing outcomes.

Objectives

To identify the clinical factors that affect the short- and long-term prognosis of MG patients with an onset age ⩾65 years.

Design

This was a single-center, retrospective cohort study of AChR-ab positive VLOMG patients, classified into two subgroups based on age of onset: sub-very-late-onset MG (S-VLOMG, onset age ⩾65 and <75 years), and super-late-onset MG (SLOMG, onset age ⩾75 years).

Methods

A total of 93 patients were included, including 75 in the S-VLOMG group and 18 in the SLOMG group. Clinical, therapeutic, and prognosis data were reviewed, and the Cox regression model was used to identify factors influencing short- and long-term prognosis.

Results

Patient characteristics were well balanced between the groups. Overall, 49.5% of patients achieved minimal symptom expression (MSE) within 6 months and 86% within 24 months. There was no significant difference between the groups in the proportion achieving MSE at 6 months (p = 0.635) or 24 months (p = 0.714). The median time to achieve MSE was also comparable between the S-VLOMG and SLOMG groups (199.0 days vs 280.5 days, p = 0.463). Low baseline MG-ADL score and steroid therapy were associated with better short-term prognosis (p = 0.007 and p = 0.002, respectively). For long-term prognosis, baseline bulbar and limb involvement, time to treatment initiation, and use of immunosuppressants were significant factors (p = 0.025, p = 0.004, p = 0.025, and p < 0.0001, respectively). There were no significant differences in side effects or drug withdrawal rates between two groups.

Conclusion

This study demonstrated that AChR-ab positive VLOMG patients have a favorable prognosis and responded well to medication, with age and comorbidities showing no significant impact.

Report on the 6th Ottawa International Conference on Neuromuscular Disease & Biology - September 7-9, 2023, Ottawa, Canada

The 6th Ottawa International Conference in Neuromuscular Disease and Biology was held on September 7-9, 2023 in Ottawa, Canada. The goal of the conference was to assemble international experts in fundamental science, translational medicine and clinical neuromuscular disease research. Speakers provided attendees with updates on a wide range of topics related to neuromuscular disease and biology, including methods to identify novel diseases, recent developments in muscle, motor neuron and stem cell biology, expanded disease pathogenesis of known diseases, and exciting advances in therapy development. A summary of the major topics and results presented by these speakers is provided.

Refractory myasthenia gravis treated with autologous hematopoietic stem cell transplantation

OBJECTIVES

Patients with refractory myasthenia gravis (MG) have few treatment options. Autologous hematopoietic stem cell transplantation (HSCT) has been used to treat immune diseases; however, its use in the treatment of MG is not broadly considered. Our objective is to report on the efficacy and safety of HSCT in refractory MG.

METHODS

Twenty-one patients who underwent HSCT for MG were retrospectively reviewed. All patients had severe MG refractory to multiple therapies. Stem cells were mobilized with cyclophosphamide and granulocyte colony-stimulating factor. The grafts were depleted of immune cells by selecting CD34+ cells. HSCT conditioning consisted of high-dose cytoreductive therapy and anti-thymocyte globulin. The primary efficacy outcome was achieving clinically stable remission or minimal manifestations without treatment and remaining as such until most recent follow-up.

RESULTS

The median time from MG diagnosis to HSCT was 4.0 years. The primary outcome was reached in 16 of 18 evaluable patients (89%) at a median of 1.7 years and maintained with a median follow-up of 6.7 years (range 1.0-21.9 years). Three patients were not evaluable for the primary outcome: one due to confounding illness and two died within 12 months of transplant. The transplant-related mortality at 100 days was 9.5%. Two late deaths occurred, with uncertain relation to the HSCT.

INTERPRETATION

After HSCT for refractory MG, most patients achieved sustained disease remission. However, HSCT-related mortality in medically complex MG patients may be high. Prospective studies investigating the efficacy and safety of HSCT in the treatment of refractory MG are warranted.

Disease burden, healthcare resource utilisation, and treatment patterns in patients with newly diagnosed myasthenia gravis in England: A retrospective cohort study

BACKGROUND

Myasthenia gravis (MG), a chronic and unpredictable autoimmune disease, is associated with multiple comorbidities and high disease burden.

OBJECTIVE

To assess the disease burden, healthcare resource utilisation (HCRU), and treatment patterns of patients with newly diagnosed MG in England.

METHODS

Data from Clinical Practice Research Datalink GP practices linked to the Hospital Episode Statistics database were used. Eligible patients had ≥1 diagnostic code for MG, with the first MG diagnostic code recorded between 01 January 2010 and 31 December 2019. Non-MG controls were selected if they had no recorded MG diagnosis and ≥12 months of data. Controls were matched for age, sex and GP practice in a maximum ratio of 5:1.

RESULTS

Mean follow-up duration was 2.8 and 3.1 years for the MG and non-MG cohorts, respectively. In the MG cohort, 56% of patients were male, with a mean age of 67 years at baseline. Incidence rates of all comorbidities assessed during follow-up were higher in the MG cohort than in controls. Almost two-thirds of MG patients experienced ≥1 myasthenic exacerbation during follow-up; incidence rates (95% confidence interval) of MG exacerbations and crises were 50.0 (44.7-55.9) and 1.3 (0.8-2.0) per 100 person-years, respectively. Visits to non-neurology specialists and outpatient clinics were the most common instances of HCRU overall, each being more frequent in the MG cohort than for controls. In the first year of follow-up, acetylcholinesterase inhibitors (AChEIs) and corticosteroids were used by 56.0% and 50.2% of MG patients, respectively; the use of AChEIs declined thereafter.

CONCLUSIONS

Despite treatment, there is a high disease burden for patients with newly diagnosed MG in England, with high rates of MG exacerbation and HCRU use. Thus, there is a need for targeted treatments with sustained efficacy and improved safety to adequately manage MG symptoms and reduce MG-related disease burden.

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.

A new pragmatic classification system for thymoma-associated myasthenia gravis: a retrospective cohort study

The management and outcomes of patients with thymoma-associated myasthenia gravis (TAMG) are heterogeneous. Here, the authors propose a novel classification system based on Masaoka stage and Myasthenia Gravis Foundation of America (MGFA) classification, aiming to guide surgical decisions and perioperative management for these patients. Considering both oncological and neurological factors, this novel TAMG classification provides valuable information on outcome stratification and clinical decision-making for TAMG.

Frequency of upper respiratory tract infections in patients with myasthenia gravis compared to the general population

INTRODUCTION

Patients with myasthenia gravis (MG) undergoing immunomodulating therapies are at an increased risk of serious infections. However, the risk of developing self-limited infections, particularly upper respiratory tract infections (URTI), remains unclear. This study aimed to determine the frequency of URTI among patients with MG compared to the general population and to identify potential predisposing factors.

METHODS

A monthly questionnaire was administered to patients with MG and a control group over a period of 6 months. The questionnaire assessed the presence of URTI symptoms within the previous month. Statistical analysis was conducted using a chi-square or Fischer exact test, as appropriate.

RESULTS

The study included 161 participants (50 MG patients and 111 control subjects). The frequency of URTI was comparable between the MG group (70 %) and controls (82 %) (p = 0.09). Among patients with MG, a higher proportion of patients who received rituximab developed URTI (93 %) than those who did not (61 %), P = 0.04.

CONCLUSION

The frequency of URTI was similar in patients with MG compared to the general population. Due to the small sample size and several other limitations, further research is warranted to validate these findings and explore associations between rituximab and URTI.