Effect of Sugammadex on Postoperative Myasthenic Crisis in Myasthenia Gravis Patients

Safety and efficacy of sugammadex in management of patients with myasthenia gravis undergoing general anesthesia: A systematic review

Objective

The objective of this study was to analyze available evidence on efficacy and safety of sugammadex in reversing neuromuscular blockades in patients with Myasthenia Gravis (MG), thereby providing a comprehensive understanding of its potential benefits and risks in this specific patient population.

Methods

We performed a systematic search for studies from PubMed, Embase, Web of Science, and Google Scholar. Sources were screened using Rayyan, following predefined inclusion and exclusion criteria focusing on English articles published from 2010 to 2024 on MG patients under general anesthesia. Data on patient characteristics and outcomes were extracted, and quality was appraised using the JBI Critical Appraisal Checklist.

Results

Out of 361 initial citations, 24 studies met inclusion criteria. Sugammadex demonstrated rapid and effective reversal of neuromuscular blockades, with ToF recovery times ranging from 79.7 s to 10 min, and short extubation times. The incidence of postoperative myasthenic crisis was low, and no mortalities were reported.

Conclusion

Sugammadex may serve as a reasonable option for the reversal of neuromuscular blockades in MG patients, indicating potential for rapid recovery and a relatively low incidence of serious complications. However, due to the limited number of studies and the nature of the evidence available, further large-scale and rigorous investigations are warranted to better establish its superiority over traditional reversal agents.

Neurologic disease in the obstetric patient

PURPOSE OF REVIEW

Neurologic disorders and complications during pregnancy are common, but guidelines and data are sparse. This review aims to give an overview of recent developments in neuroanesthesia and management of neuropathology during pregnancy, with the hope that these may fill the gaps in current guidelines and recommendations, as well as their implications for an anesthetic approach.

RECENT FINDINGS

Neuraxial and general anesthesia are safe in multiple sclerosis and myasthenia gravis, though neuromuscular blockade response is unpredictable and risk for exacerbation exists. Cerebral vascular pathology is common and carries a significant morbidity and mortality burden, but thrombolytic and endovascular therapies are often appropriate and safe. Instrumental vaginal delivery can minimize intracranial pressure shifts and is a viable option. Tumors and cerebral malformations require a complex multidisciplinary and anesthetic approach.

SUMMARY

While clinical trials remain sparse, larger population-based studies offer insight into the optimal approach to the parturient with neurologic disease.

Clinical characteristics of late-onset myasthenia gravis

Objective

Late-onset myasthenia gravis (LOMG) often has comorbidities, and its initial symptoms may be ignored or misdiagnosed as other diseases. There were few large surveys on LOMG. Our study aimed to summarize clinical characteristics of LOMG to improve the rate of correct MG diagnosis.

Methods

A retrospective cohort study included 240 LOMG patients with onset age ≥65 years old who were treated at PLA General Hospital from January 1, 2003 to January 1, 2023.

Results

The male to female ratio was 1:1.2 (P = 0.699). MGFA clinical classification: Class I 31.3%, Class IIa 12.9%, Class IIb 51.3%, Class IIIa 0.8%, Class IIIb 0.8%, Class IV 0.4%, Class V2.5%. The onset symptom was ptosis in 78.8% and diplopia was in 18.8%. Swallowing dysfunction in the stage of LOMG was in 41.7%. The incidence of thymoma in LOMG was 14.2%. 85.4% of patients antibodies against the muscle acetylcholine receptor (AChR) are detected. The overall incidence of supramaximal repetitive nerve stimulation (Jolly test) was 57.1%, among which the highest positive rate (50.7%) was in the facial nerve. Jolly test of Class IIb was tested in the highest positive rate and Class I was in the lowest one (χ2 = 7.023, P = 0.030).

Conclusion

There was no significant difference in the incidence of LOMG between males and females. The clinical manifestations were mainly Class I and Class II, and severe MG was rare. The most common onset symptom was ptosis. The incidence of LOMG with thymoma was low. Supramaximal repetitive nerve stimulation (Jolly test) of the facial nerve was the easiest to detect and Jolly test of Class IIb was tested in the highest positive rate and Class I was in the lowest one.

Comparison between Sugammadex and Neostigmine after Video-Assisted Thoracoscopic Surgery-Thymectomy in Patients with Myasthenia Gravis: A Single-Center Retrospective Exploratory Analysis

This single-center retrospective exploratory analysis evaluated the effects of sugammadex compared with neostigmine on postoperative recovery in patients with myasthenia gravis (MG) who underwent video-assisted thoracoscopic surgery (VATS)-thymectomy. This retrospective study included 180 patients with MG, aged >18 years, who received sugammadex (sugammadex group, n = 83) or neostigmine-glycopyrrolate (neostigmine group, n = 88) after VATS-thymectomy between November 2007 and December 2020. Inverse probability of treatment weighting (IPTW) adjustment was performed to balance the baseline characteristics between the two groups. The primary outcome was the length of postoperative hospital stay, and the secondary outcomes were the incidence of postoperative mortality and complications, as well as the postoperative extubation and reintubation rates, in the operating room after VATS-thymectomy; the outcomes were compared between the two groups. After IPTW adjustment, the sugammadex group showed a significantly shorter median postoperative hospital stay than the neostigmine group (4 (2, 4) vs. 5 (3, 6) days, respectively; p = 0.003). There were no significant differences between the two groups in the incidences of postoperative complications (including postoperative myasthenic crisis, nerve palsy, atelectasis, and pleural effusion). Patients with MG following VATS-thymectomy who received sugammadex showed a significantly shorter postoperative hospital stay than those who received neostigmine.

The economic burden of individuals living with generalized myasthenia gravis and facing social determinants of health challenges

Objective

Better understanding the impact of social determinants of health (SDOH) barriers from the patient perspective is crucial to improve holistic patient support in generalized myasthenia gravis (gMG), a rare autoimmune disorder with high disease and treatment burden. The objective of this study was to identify economic challenges experienced by individuals living with gMG and SDOH barriers to better address current unmet needs.

Methods

Adults (18-75 years) living with gMG and experiencing SDOH barriers in the United States were recruited to a mixed-methods study including qualitative interviews and a web-based quantitative survey. Quotas were implemented to include a balanced spread of baseline demographic categories including insurance type, living environment, and employment status among the study sample. Direct and indirect economic challenges were identified by degree of concern.

Results

The survey was completed by 38 individuals living with gMG, the majority of whom were enrolled in public insurance and not employed. The most commonly reported major economic concerns were managing funds for emergency care (66%), loss of income (61%), and non-medical expenses (58%), highlighting the diversity of economic challenges. Individuals who were using public insurance plans, living in non-urban environments, and unemployed experienced pronounced challenges around managing non-medical costs and accessing government assistance.

Conclusion

Both direct and indirect costs were emphasized as major concerns among individuals living with gMG and SDOH barriers. Increasing access to relevant, personalized, and holistic resources, including care management, should be prioritized to improve disease management and outcomes for individuals living with gMG.

Myasthenic crisis

Myasthenic crisis (MC) is a life-threatening manifestation of myasthenia gravis (MG) defined by respiratory insufficiency that requires the use of invasive or non-invasive ventilation. This is often the result of respiratory muscle weakness but can also be due to bulbar weakness with upper airway collapse. MC occurs in approximately 15%-20% of patients with MG usually within the first 2 to 3 y of the disease course. Many crises have a specific trigger with respiratory infections being most common; however, no specific trigger is found in 30%-40% of patients. MG patients with a history of MC, severe disease, oropharyngeal weakness, muscle-specific kinase (MuSK) antibodies and thymoma appear to be at higher risk. Most episodes of MC do not occur suddenly, providing a window of opportunity for prevention. Immediate treatment is directed toward airway management and removing any identified triggers. Plasmapheresis is preferred over intravenous immune globulin as the treatments of choice for MC. The majority of patients are able to be weaned from mechanical ventilation within 1 mo and the outcomes of MC are generally favorable. The mortality rate in United States cohorts is less than 5% and mortality in MC seems to be driven by age and other medical co-morbidities. MC does not appear to affect long-term prognosis as many patients are able to eventually achieve good MG control.

The comparison of caesarean section bleeding between volatile and total intravenous anaesthesia in a Japanese nationwide database

BACKGROUND

Volatile anaesthesia may increase blood loss because of the uterine-relaxing effect of the volatile anaesthetics during caesarean section under general anaesthesia.

OBJECTIVE

This study compared the bleeding risk during caesarean section between volatile anaesthesia and total intravenous anaesthesia (TIVA) using a nationwide inpatient database in Japan.

DESIGN

Observational study.

SETTING

Nationwide inpatient database in Japan from April 2012 to March 2020.

PATIENTS

Women who underwent caesarean section under general anaesthesia.

MAIN OUTCOME MEASURES

Volume of blood loss.

RESULTS

We identified 26 585 women, including 19 320 in the volatile anaesthesia group (mean age = 32.9 ± 5.5 years) and 7265 in the TIVA group (mean age = 32.8 ± 5.5 years). The mean blood loss was 1113 ± 909 and 1136 ± 944 ml and the proportion of blood transfusion was 14.7 and 16.0% in the volatile and TIVA groups, respectively. With conventional regression analyses, volatile anaesthesia was associated with a slightly lower risk of bleeding: the adjusted mean difference for blood loss (95% CI) was -56.1 (-81.4 to -30.7). However, in the instrumental variable analysis, volatile anaesthesia was associated with a higher risk of bleeding: adjusted mean difference for blood loss (95% CI) was 154.3 (112.4 to 196.3) ml.

CONCLUSION

This large observational study with instrumental variable analyses suggested an increased bleeding risk associated with volatile anaesthesia, and the results were not identical to those in the conventional regression analyses.

European Neuromuscular Centre consensus statement on anaesthesia in patients with neuromuscular disorders

BACKGROUND AND PURPOSE

Patients with neuromuscular conditions are at increased risk of suffering perioperative complications related to anaesthesia. There is currently little specific anaesthetic guidance concerning these patients. Here, we present the European Neuromuscular Centre (ENMC) consensus statement on anaesthesia in patients with neuromuscular disorders as formulated during the 259th ENMC Workshop on Anaesthesia in Neuromuscular Disorders.

METHODS

International experts in the field of (paediatric) anaesthesia, neurology, and genetics were invited to participate in the ENMC workshop. A literature search was conducted in PubMed and Embase, the main findings of which were disseminated to the participants and presented during the workshop. Depending on specific expertise, participants presented the existing evidence and their expert opinion concerning anaesthetic management in six specific groups of myopathies and neuromuscular junction disorders. The consensus statement was prepared according to the AGREE II (Appraisal of Guidelines for Research & Evaluation) reporting checklist. The level of evidence has been adapted according to the SIGN (Scottish Intercollegiate Guidelines Network) grading system. The final consensus statement was subjected to a modified Delphi process.

RESULTS

A set of general recommendations valid for the anaesthetic management of patients with neuromuscular disorders in general have been formulated. Specific recommendations were formulated for (i) neuromuscular junction disorders, (ii) muscle channelopathies (nondystrophic myotonia and periodic paralysis), (iii) myotonic dystrophy (types 1 and 2), (iv) muscular dystrophies, (v) congenital myopathies and congenital dystrophies, and (vi) mitochondrial and metabolic myopathies.

CONCLUSIONS

This ENMC consensus statement summarizes the most important considerations for planning and performing anaesthesia in patients with neuromuscular disorders.

Safety of sugammadex for myasthaenia gravis patients undergoing general anaesthesia: a retrospective database study

Background

Using neuromuscular blocking drugs (NMBDs) for patients with myasthaenia gravis remains a challenge in perioperative management. Sugammadex has enabled the safe use of NMBDs. We investigated whether the adverse outcomes, and the treatment used for myasthaenic crises and tracheotomy, are affected by NMBD use in patients with myasthaenia gravis under general anaesthesia.

Methods

Patients with myasthaenia gravis who underwent general anaesthesia were retrieved from the Diagnostic Procedure Combination/Per-Diem Payment systems in Japan between 1 January 2010 and 30 November 2020. This database did not contain information on the severity of myasthaenia gravis (Osserman classification). Patients who received rocuronium and sugammadex were compared with those who did not receive NMBDs after propensity-score matching. We excluded patients who underwent emergency or cardiac surgery or tracheal intubation before anaesthesia. The primary outcome was receipt of postoperative treatment used for myasthaenic crises.

Results

Among 2304 surgical patients with comorbid myasthaenia gravis, propensity-score matching identified 788 patients administered rocuronium and sugammadex and 449 not administered NMBDs. On comparing the treatment used for myasthaenic crises, we found no significant difference between the two groups (6.2% vs 5.3%; hazard ratio, 1.14; 95% confidence interval, 0.70-1.85).

Conclusions

Use of rocuronium and sugammadex in patients with myasthaenia gravis did not significantly affect the receipt of postoperative treatment used for myasthaenic crises compared with no use of NMBDs. As well as the severity of myasthaenia gravis was not fully adjusted, it is unclear whether intraoperative administration of rocuronium with the use of sugammadex postoperatively is acceptable and further investigations are needed.

Successful Neuromuscular Blockade Reversal Using Sugammadex and Neostigmine Failed to Prevent Myasthenic Crisis After Emergency Surgery: A Case Report

Recent literature suggests that the use of sugammadex for the reversal of neuromuscular blocking agents (NMBAs) reduces the risk of postoperative myasthenic crisis (MC) in patients with myasthenia gravis (MG), particularly after thymectomy, but studies are lacking on emergency surgeries. We achieved successful intraoperative reversal of neuromuscular blockade (NMB) using a combination of sugammadex and neostigmine (with glycopyrrolate). However, MC was not avoided and reintubation was required on postoperative day 1.

A 65-year-old male with a longstanding history of MG presented to the emergency department with complaints of abdominal pain, diarrhea, vomiting, chills, and fatigue for three days. A computed tomography (CT) scan of the abdomen showed acute appendicitis, for which he underwent a laparoscopic appendectomy on hospital day 1. The patient received successful general anesthesia with a rapid sequence induction using a smaller than average dose of rocuronium, given his history of MG. At the conclusion of the case, sugammadex followed by neostigmine/glycopyrrolate and a subsequent dose of sugammadex were given, with reversal of NMB. The patient was successfully extubated but required reintubation on postoperative day 1 for hypercapnic respiratory failure.

Our case report on this patient with MG yields two topics that have not been extensively examined. First, dual therapy with sugammadex and neostigmine/glycopyrrolate may provide significant clinical benefit over individual therapy for NMBA reversal, given that their mechanisms of action are different and particularly when sugammadex is given prior to neostigmine/glycopyrrolate. Second, anesthesia literature is lacking on MG patients undergoing emergency surgeries. While sugammadex has been promising in medically optimized non-emergent surgeries, we discuss here a case where sugammadex failed to prevent MC in the emergency surgery setting and a look into what may provide patients with the best chance for avoiding postoperative MC.

Effects of Plasma Exchange Combined with Immunoglobulin Therapy on Consciousness, Immune Function, and Prognosis in Patients with Myasthenia Gravis Crisis: A Prospective Randomized Test

Background

Myasthenia gravis (MG) is an acquired autoimmune disease. The main clinical features of MG are skeletal muscle fatigue and pathological fatigue, which worsen at night or after fatigue, such as dyspnea, dysphagia, and systemic weakness. Plasma exchange (PE) is often used in patients with acute exacerbation of MG. Intravenous immunoglobulin (IVIG) is a collection of immunoglobulins from thousands of donors. IVIG can replace a variety of immunosuppressants or PE. However, the effect of PE or IVIG on patients' consciousness, immune function, and prognosis is not clear.

Objective

A prospective randomized test of the effects of PE combined with immunoglobulin on consciousness, immune function, and prognosis in patients with myasthenia gravis crisis (MGC).

Methods

Sixty patients with MGC treated from February 2019 to April 2021 were enrolled in our hospital. The cases who received PE were set as the PE group, and those who received PE combined with immunoglobulin were set as the PE+immunoglobulin group. The efficacy, clinical score, state of consciousness, immune function, acetylcholine receptor antibody (AChR-Ab), lymphocyte (LYM), albumin (ALB) levels, and the incidence of adverse reactions were compared.

Results

The improvement rate was 100.005% in the treatment group and 83.33% in the PE group. After treatment, the clinical score of the PE+immunoglobulin group was lower than that of the PE group, and the clinical relative score of the PE+immunoglobulin group was higher than that of the PE group (P < 0.05). The number of conscious people in the PE+immunoglobulin group was more than that in the PE group (P < 0.05). Immunoglobulin A, immunoglobulin M, immunoglobulin G, and immunoglobulin G in the PE+immunoglobulin group were higher than those in the PE group (P < 0.05). The levels of AChR-Ab and ALB in the PE+immunoglobulin group were higher than those in the PE group, while the level of LYM in the PE+immunoglobulin group was lower than that in the PE group. The incidence of skin system, gastrointestinal system, nervous system, and systemic damage in the PE+immunoglobulin group was lower than that in the PE group (P < 0.05).

Conclusion

The treatment of MGC with PE combined with immunoglobulin can not only effectively enhance the consciousness and immune function of patients but also effectively promote the prognosis, and the safety of treatment can be guaranteed.

Mapping the current evidence on the anesthetic management of adult patients with neuromuscular disorders-a scoping review

PURPOSE

Patients with neuromuscular disorders (NMDs) are at increased risk of perioperative complications. The objective of this scoping review was to examine emerging evidence from published studies, case reports, and review articles on anesthetic management of patients with NMDs, following the methodological frame for scoping reviews.

SOURCES

We searched PubMed and EMBASE for articles published between 1 January 2000 and 14 July 2021.

PRINCIPAL FINDINGS

Three prospective and 21 retrospective studies on altered pharmacokinetics and pharmacodynamics of neuromuscular blocking agents (NMBA) in NMD patients were included. Furthermore, 168 case reports/series reporting 212 anesthetics in 197 patients were included. These studies showed that preanesthetic neuromuscular monitoring can be used for precise NMBA dosing in myasthenia gravis patients. Sugammadex was associated with fewer postoperative myasthenic crises. Perioperative complications were not associated with specific anesthetic agents. Case reports/series showed that in 32% (67/212) of anesthetics, at least one complication was reported. Unexpected intensive care unit admission was a frequently reported complication. Patients with a complicated disease course may have had a higher use of succinylcholine (unadjusted relative risk, 0.13; 95% confidence interval [CI], 0.20 to 0.86) and volatile anesthetics (adjusted odds ratio [OR], 0.38; 95% CI, 0.20 to 0.73; P = 0.004).

CONCLUSION

Evidence on the anesthetic management and perioperative complications of patients with NMDs is mainly based on small retrospective studies and case reports. Further clinical trials or large retrospective studies are required to investigate the choice of safe anesthetic agents. Main areas of interest are the potential benefits of neuromuscular monitoring and sugammadex and the risks possibly associated with volatile anesthetics and succinylcholine.

Causes of symptom dissatisfaction in patients with generalized myasthenia gravis

BACKGROUND

Patient-centered assessments have attracted increasing attention in the last decade in clinics and research. The purpose of this study was to examine the association between patients' satisfaction with symptoms and several disease-specific and generic outcome measures in 100 patients with generalized myasthenia gravis (gMG).

METHODS

In this cross-sectional study, patients with gMG followed at the Copenhagen Neuromuscular Center from October 2019 to June 2020 participated in one test. The patients completed commonly used MG-specific outcome measures and generic questionnaires for depression (Major Depression Inventory), comorbidities (Charlson Comorbidity Index), fatigue (Multidimensional Fatigue Inventory), overall health state (EQ-5D-3L), and satisfaction with MG treatment. The analyses were anchored in the Patient Acceptable Symptom State (PASS).

RESULTS

N = 190 patients were screened for the study, and 100 patients were included. One-third of the patients reported dissatisfaction (negative PASS status) with the current symptom state. Increasing MG symptoms, fatigue, depression, low MG-related quality of life, and shorter disease duration were associated with negative PASS status. Age, sex, BMI, MG treatment, and comorbidity did not influence PASS status.

CONCLUSIONS

This study shows that dissatisfaction with the current symptom level is high in patients with gMG and that dissatisfaction is associated with disease severity, disease length, depression, fatigue, and lower MG-related quality of life. The results emphasize the importance of a patient-centered approach to MG treatment to optimize patient satisfaction. The PASS question was useful in this study to investigate the causes of symptom dissatisfaction in gMG.

Sugammadex, the Guardian of Deep Muscle Relaxation During Conventional and Robot-Assisted Laparoscopic Surgery: A Narrative Review

High intra-abdominal pressure induced by artificial pneumoperitoneum can obviously impair respiratory and circulatory functions and has a negative effect on the prognosis of patients undergoing conventional and robot-assisted laparoscopic surgery. The application of deep neuromuscular blockade during the operation is reported to lower the intra-abdominal pressure and improve patients’ outcome. However, concern lies in the risks of postoperative residual muscular paralysis with the use of deep neuromuscular blockade. Sugammadex, a specific antagonist for aminosteroids muscle relaxants, can effectively and rapidly reverse rocuronium and vecuronium induced neuromuscular blockade of different depths. Thus, sugammadex allows the ability to safeguard the application of deep neuromuscular blockade in laparoscopic operations and helps to alleviate the adverse complications associated with pneumoperitoneum. Here, we review the application of deep neuromuscular blockade in different laparoscopic surgeries and discuss the benefits and possible risks of sugammadex administration in the reversal of deep neuromuscular blockade in these operations.

Rocuronium reversed with sugammadex for thymectomy in myasthenia gravis: A retrospective analysis of complications from Japan

BACKGROUND

Postoperative respiratory failure is a serious problem in the anaesthetic management of patients with myasthenia gravis who undergo thymectomy. Although the classical recommendation is to avoid neuromuscular blockers, there is no strong evidence to support it.

OBJECTIVES

To evaluate the postoperative outcomes in patients with myasthenia gravis after thymectomy when anaesthetic management included rocuronium reversed with sugammadex.

DESIGN

A retrospective cohort study.

SETTING

Nationwide acute in-patient care database.

PATIENTS

A total of 1143 patients with myasthenia gravis who underwent thymectomy were included. Data were collected from the medical insurance claims data of acute care in-patient hospitals.

MAIN OUTCOME MEASURES

The postoperative complications when rocuronium reversed with sugammadex was compared against no muscle relaxant use using propensity score matching. The primary outcomes were the rates of in-hospital mortality, plasma exchange following thymectomy and the use of immunoglobulins. The secondary outcomes were the length of stay in the high dependency/ICUs, the total length of hospital stay and the duration and type of respiratory support following thymectomy.

RESULTS

There were no significant differences between the propensity score matched groups in terms of plasma exchange [relative risk, 0.96; 95% confidence interval (CI), 0.64 to 1.43] and use of immunoglobulins (relative risk, 1.09; 95% CI, 0.60 to 1.97). The length of hospital stay was significantly shorter in patients in whom rocuronium and sugammadex were used: 29.0 vs. 35.4 days, P = 0.035.

CONCLUSIONS

Anaesthetic management with rocuronium reversed by sugammadex was not associated with increased risk of respiratory complications. These findings could help in the anaesthetic management of patients with myasthenia gravis.

Drugs That Induce or Cause Deterioration of Myasthenia Gravis: An Update

Myasthenia gravis (MG) is an autoimmune neuromuscular disorder which is characterized by presence of antibodies against acetylcholine receptors (AChRs) or other proteins of the postsynaptic membrane resulting in damage to postsynaptic membrane, decreased number of AChRs or blocking of the receptors by autoantibodies. A number of drugs such as immune checkpoint inhibitors, penicillamine, tyrosine kinase inhibitors and interferons may induce de novo MG by altering the immune homeostasis mechanisms which prevent emergence of autoimmune diseases such as MG. Other drugs, especially certain antibiotics, antiarrhythmics, anesthetics and neuromuscular blockers, have deleterious effects on neuromuscular transmission, resulting in increased weakness in MG or MG-like symptoms in patients who do not have MG, with the latter usually being under medical circumstances such as kidney failure. This review summarizes the drugs which can cause de novo MG, MG exacerbation or MG-like symptoms in nonmyasthenic patients.

Administration of Sugammadex Intraoperatively in a Patient With a Congenital Myasthenic Syndrome: A Case Report

Congenital myasthenic syndromes are a group of genetic neuromuscular disorders caused by mutations that impair synaptic transmission at the neuromuscular junction. Developing an anesthetic plan for patients with this diagnosis is difficult, as they are at risk for prolonged neuromuscular blockade. Sugammadex is an alternative to neostigmine for neuromuscular blockade reversal that does not produce muscarinic side effects, yet there is a little literature assessing sugammadex in congenital myasthenic syndromes. We present the case of a 6-year-old boy with a congenital myasthenic syndrome who received sugammadex without complication. This case provides support for clinicians to consider sugammadex in these patients.

Economic Costs of Myasthenia Gravis: A Systematic Review

OBJECTIVES

The objective of our study was to conduct a systematic literature review of economic costs (henceforth costs) associated with myasthenia gravis (MG).

METHODS

We searched MEDLINE (through PubMed), CINAHL, Embase, PsycINFO, and Web of Science for studies reporting costs of MG published from inception up until March 18, 2020, without language restrictions. Two reviewers independently screened records for eligibility, extracted the data, and assessed included studies for risk of bias using the Newcastle-Ottawa Scale. Costs were inflated and converted to 2018 United States dollars ($).

RESULTS

The search identified 16 articles for data extraction and synthesis. Estimates of costs of MG were found for samples from eight countries spanning four continents (Europe, North America, South America, and Asia). Across studies, the mean per-patient annual direct medical cost of illness was estimated at between $760 and $28,780, and cost per hospitalization between $2550 and $164,730. The indirect cost of illness was estimated at $80 and $3550. Costs varied considerably by patient characteristics, and drivers of the direct medical cost of illness included intravenous immunoglobulin and plasma exchange, myasthenic crisis, mechanical ventilatory support, and hospitalizations.

CONCLUSIONS

We show that the current body of literature of costs of MG is sparse, limited to a few geographical settings and resource categories, mostly dated, and subject to non-trivial variability, both within and between countries. Our synthesis will help researchers and decision-makers identify gaps in the local health economic context of MG and inform future cost studies and economic evaluations in this patient population.

Use of sugammadex in patients with neuromuscular disorders: a systematic review of case reports

Background

Sugammadex is a modified gamma-cyclodextrin that acts by selectively encapsulating free amino-steroidal neuromuscular relaxants. Several case reports have been published on the use of sugammadex in patients with neuromuscular disorders that include neuromuscular junction diseases, myopathies, neuropathies, and motor neurone disorders. The primary aim of this review is to systematically review the evidence on the use of sugammadex in patients with this heterogeneous group of diseases and provide recommendations for clinical practice.

Methods

A systematic electronic search of Medline, Embase and CINAHL databases was done until June 2019, to identify case reports describing the use of sugammadex in adult surgical patients with neuromuscular disorders.

Results

Of the 578 records identified through database searches, 43 articles were finally included for the systematic review. Of these, 17 reports were on patients with myopathy, 15 reports on myasthenia gravis, 9 reports on motor neuron diseases and 2 reports on neuropathies.

Conclusions

Majority of the articles reviewed report successful use of sugammadex to reverse steroidal muscle relaxants, especially rocuronium, in patients with neuromuscular diseases. However, with sugammadex, unpredictability in response and uncertainty regarding optimum dose still remain issues. Quantitative neuromuscular monitoring to ensure complete reversal and adequate postoperative monitoring is strongly recommended in these patients, despite the use of sugammadex.