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Myasthenia gravis

Last edited: 4/14/2026

Overview

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disorder characterized by fluctuating weakness and fatigability of skeletal muscles, primarily due to antibodies interfering with acetylcholine receptor function at the neuromuscular junction 10.

Diagnosis

  • Clinical Presentation: Ptosis, diplopia, dysphagia, and generalized muscle weakness 413.
  • Edrophonium Test: Used to confirm diagnosis; monitor for transient improvement in symptoms 21.
  • Acetylcholine Receptor (AChR) Antibodies: Serological testing for antibodies against AChR is highly specific 311.
  • Electrophysiological Studies: Repetitive Nerve Stimulation (RNS) and Single Fiber Electromyography (SFEMG) can support diagnosis 110.
  • Thymoma Evaluation: Chest imaging to rule out thymoma, especially in younger patients 28.

    • Management

  • First-Line Treatments:
    • - Acetylcholinesterase Inhibitors: Pyridostigmine (dose individualized) 10. - Immunosuppressive Agents: Corticosteroids, azathioprine, mycophenolate mofetil 10.
  • Adjunctive Therapies:
    • - Plasmapheresis: For acute exacerbations (myasthenic crisis) 16. - Intravenous Immunoglobulin (IVIG): For acute exacerbations 16. - Complement Inhibitors: Eculizumab, ravulizumab, zilucoplan (monitor for adverse reactions) 12. - FcRn Inhibitors: Efgartigimod alfa (limited real-world safety data) 2.

    Special Populations

  • Pregnancy: Close monitoring required; thymectomy before pregnancy may improve outcomes 91425.
  • Pediatrics: Velopharyngeal incompetence can be a complication; long-term follow-up essential 18.
  • Comorbidities:
    • - Thyroid Disorders: Increased association with autoimmune thyroid disease 319. - Systemic Lupus Erythematosus (SLE): Rare but possible association; requires careful management 30. - Preeclampsia: Rare but significant diagnostic and therapeutic challenges 2644.

    Key Recommendations

  • Initiate Acetylcholinesterase Inhibitors for symptom management in all patients with confirmed MG (Evidence: Strong 10).
  • Consider Thymectomy in patients under 60 without significant comorbidities and without thymoma for potential long-term remission (Evidence: Moderate 28).
  • Monitor for Adverse Reactions when using complement C5 inhibitors and FcRn inhibitors, given limited long-term safety data (Evidence: Moderate 12).
  • Close Surveillance during pregnancy in MG patients to manage potential exacerbations and complications like preeclampsia (Evidence: Moderate 92544).
  • Evaluate for Comorbid Autoimmune Conditions, particularly thyroid disorders and SLE, given their association with MG (Evidence: Moderate 31930).

    • References

    1 Wang L, Chen J, Li H, Wang L, Liu F, Jiang X. Safety profile of complement C5 inhibitors and FcRn inhibitors in the treatment of myasthenia gravis: analysis of the FAERS database and disease-gene interaction network. Frontiers in immunology 2025. link 2 Ju Y, Qin X. Postmarketing adverse events of efgartigimod alfa: a real-world pharmacovigilance study based on the FAERS database. BMJ open 2025. link 3 Li K, Ouyang Y, Yang H. Myasthenia gravis and five autoimmune diseases: a bidirectional Mendelian randomization study. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology 2024. link 4 Kim DH, Roh HC, Oh SY. Ophthalmologic clinical features of ocular myasthenia gravis. Medicine 2023. link 5 Donaldson L, Issa M, Dezard V, Margolin E. Low probability of myasthenia Gravis in patients presenting to neuro-ophthalmology clinic for evaluation of isolated ptosis. European journal of ophthalmology 2023. link 6 Kısabay A, Özdemir HN, Gökçay F, Çelebisoy N. Risk for generalization in ocular onset myasthenia gravis: experience from a neuro-ophthalmology clinic. Acta neurologica Belgica 2022. link 7 Justo ME, Aldecoa M, Cela E, Leoni J, González Maglio DH, Villa AM et al.. Low Vitamin D Serum Levels in a Cohort of Myasthenia Gravis Patients in Argentina. Photochemistry and photobiology 2021. link 8 Ralli M, Altissimi G, Di Stadio A, Mazzei F, Turchetta R, Cianfrone G. Relationship between hearing function and myasthenia gravis: A contemporary review. The Journal of international medical research 2017. link 9 Roth CK, Dent S, McDevitt K. Myasthenia Gravis in Pregnancy. Nursing for women's health 2015. link 10 Li Y, Arora Y, Levin K. Myasthenia gravis: newer therapies offer sustained improvement. Cleveland Clinic journal of medicine 2013. link 11 Jones SC, Sorbello A, Boucher RM. Fluoroquinolone-associated myasthenia gravis exacerbation: evaluation of postmarketing reports from the US FDA adverse event reporting system and a literature review. Drug safety 2011. link 12 Pandey R, Garg R, Chandralekha, Darlong V, Punj J, Sinha R et al.. Robot-assisted thoracoscopic thymectomy: perianaesthetic concerns. European journal of anaesthesiology 2010. link 13 Warnecke T, Teismann I, Zimmermann J, Oelenberg S, Ringelstein EB, Dziewas R. Fiberoptic endoscopic evaluation of swallowing with simultaneous Tensilon application in diagnosis and therapy of myasthenia gravis. Journal of neurology 2008. link 14 Mustafa R, Yousaf S, Baqai Z. Myasthenia gravis and pregnancy. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP 2005. link 15 Smulowitz PB, Zeller J, Sanchez LD, Edlow JA. Myasthenia gravis: lessons for the emergency physician. European journal of emergency medicine : official journal of the European Society for Emergency Medicine 2005. link 16 Hetherington KA, Losek JD. Myasthenia gravis: myasthenia vs. cholinergic crisis. Pediatric emergency care 2005. link 17 Lotia S, Randall C, Dawson LJ, Longman LP. Dental management of the myasthenic patient. Dental update 2004. link 18 Rieder AA, Conley SF, Rowe L. Pediatric myasthenia gravis and velopharyngeal incompetence. International journal of pediatric otorhinolaryngology 2004. link 19 Yaman A, Yaman H. Ocular myasthenia gravis coincident with thyroid ophthalmopathy. Neurology India 2003. link 20 Salazar Cabrera C, de Saa Alvarez Md Mdel R, Aparicio Pérez MS, Marcos Calle J, García García B. Myasthenia gravis: the otolaryngologist's perspective. American journal of otolaryngology 2002. link 21 Ing EB, Ing SY, Ing T, Ramocki JA. The complication rate of edrophonium testing for suspected myasthenia gravis. Canadian journal of ophthalmology. Journal canadien d'ophtalmologie 2000. link80007-1) 22 Theodorou V, Tsikaris V, Sakarellos-Daitsiotis M, Avramopoulou V, Kostelidou K, Tzartos SJ et al.. Design, synthesis, and conformational study of biologically active photolabeled analogues of the main immunogenic region of the acetylcholine receptor. Biopolymers 2000. link56:1<37::AID-BIP1041>3.0.CO;2-X) 23 Keeney AH, Keeney VT. Mary B. Walker, M.D. and the pioneering use of prostigmin to treat myasthenia gravis. Documenta ophthalmologica. Advances in ophthalmology 1997. link 24 McBeth C, Watkins TG. Isoflurane for sedation in a case of congenital myasthenia gravis. British journal of anaesthesia 1996. link 25 Uncu G, Küçükerdogan I, Ozan H, Cengiz C. Pregnancy and myasthenia gravis. A case report. Clinical and experimental obstetrics & gynecology 1995. link 26 Benshushan A, Rojansky N, Weinstein D. Myasthenia gravis and preeclampsia. Israel journal of medical sciences 1994. link 27 Nelson S, Shelton GD, Lei S, Lindstrom JM, Conti-Tronconi BM. Epitope mapping of monoclonal antibodies to Torpedo acetylcholine receptor gamma subunits, which specifically recognize the epsilon subunit of mammalian muscle acetylcholine receptor. Journal of neuroimmunology 1992. link90027-i) 28 Lanska DJ. Indications for thymectomy in myasthenia gravis. Neurology 1990. link 29 Chouhan JK, Soni TB, Mishra YC. Unilateral ocular myasthenia gravis--a case report. Indian journal of ophthalmology 1990. link 30 Ciaccio M, Parodi A, Rebora A. Myasthenia gravis and lupus erythematosus. International journal of dermatology 1989. link 31 Khan Z, Bhola A. Urinary incontinence after transurethral resection of prostate in myasthenia gravis patients. Urology 1989. link90257-4) 32 Schluep M, Willcox N, Vincent A, Dhoot GK, Newsom-Davis J. Acetylcholine receptors in human thymic myoid cells in situ: an immunohistological study. Annals of neurology 1987. link 33 Hughes RL, Katirji MB. The Eaton-Lambert (myasthenic) syndrome in association with systemic lupus erythematosus. Archives of neurology 1986. link 34 Barkas T, Gabriel JM, Juillerat M, Kokla A, Tzartos SJ. Localisation of the main immunogenic region of the nicotinic acetylcholine receptor. FEBS letters 1986. link80254-x) 35 LaRochelle WJ, Wray BE, Sealock R, Froehner SC. Immunochemical demonstration that amino acids 360-377 of the acetylcholine receptor gamma-subunit are cytoplasmic. The Journal of cell biology 1985. link 36 Ito A, Furukawa S, Satoyoshi E, Sakurai H. Kinetic studies on neurotoxin-binding inhibitory antibodies in myasthenia gravis. Clinica chimica acta; international journal of clinical chemistry 1985. link90107-x) 37 McFadden RG, Craig ID, Paterson NA. Interstitial pneumonitis in myasthenia gravis. British journal of diseases of the chest 1984. link 38 Barkas T, Juillerat M, Kistler J, Schwendimann B, Moody J. Antibodies to synthetic peptides as probes of acetylcholine receptor structure. European journal of biochemistry 1984. link 39 Mehraban F, Kemshead JT, Dolly JO. Properties of monoclonal antibodies to nicotinic acetylcholine receptor from chick muscle. European journal of biochemistry 1984. link 40 Santy PA. Undiagnosed myasthenia gravis in emergency psychiatric referrals. Annals of emergency medicine 1983. link80475-2) 41 Tzartos S, Langeberg L, Hochschwender S, Lindstrom J. Demonstration of a main immunogenic region on acetylcholine receptors from human muscle using monoclonal antibodies to human receptor. FEBS letters 1983. link80688-7) 42 Naidoo PD. Penicillamine-induced myasthenia gravis in a patient with rheumatoid arthritis. A case report. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 1981. link 43 Fenichel GM. Clinical syndromes of myasthenia in infancy and childhood. A review. Archives of neurology 1978. link 44 Cohen BA, London RS, Goldstein PJ. Myasthenia gravis and preeclampsia. Obstetrics and gynecology 1976. link

    Original source

    1. [1]
      Safety profile of complement C5 inhibitors and FcRn inhibitors in the treatment of myasthenia gravis: analysis of the FAERS database and disease-gene interaction network. — Wang L, Chen J, Li H, Wang L, Liu F, Jiang X Frontiers in immunology (2025)
    2. [2]
      Postmarketing adverse events of efgartigimod alfa: a real-world pharmacovigilance study based on the FAERS database. — Ju Y, Qin X BMJ open (2025)
    3. [3]
      Myasthenia gravis and five autoimmune diseases: a bidirectional Mendelian randomization study. — Li K, Ouyang Y, Yang H Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology (2024)
    4. [4]
      Ophthalmologic clinical features of ocular myasthenia gravis. — Kim DH, Roh HC, Oh SY Medicine (2023)
    5. [5]
      Low probability of myasthenia Gravis in patients presenting to neuro-ophthalmology clinic for evaluation of isolated ptosis. — Donaldson L, Issa M, Dezard V, Margolin E European journal of ophthalmology (2023)
    6. [6]
      Risk for generalization in ocular onset myasthenia gravis: experience from a neuro-ophthalmology clinic. — Kısabay A, Özdemir HN, Gökçay F, Çelebisoy N Acta neurologica Belgica (2022)
    7. [7]
      Low Vitamin D Serum Levels in a Cohort of Myasthenia Gravis Patients in Argentina. — Justo ME, Aldecoa M, Cela E, Leoni J, González Maglio DH, Villa AM et al. Photochemistry and photobiology (2021)
    8. [8]
      Relationship between hearing function and myasthenia gravis: A contemporary review. — Ralli M, Altissimi G, Di Stadio A, Mazzei F, Turchetta R, Cianfrone G The Journal of international medical research (2017)
    9. [9]
      Myasthenia Gravis in Pregnancy. — Roth CK, Dent S, McDevitt K Nursing for women's health (2015)
    10. [10]
      Myasthenia gravis: newer therapies offer sustained improvement. — Li Y, Arora Y, Levin K Cleveland Clinic journal of medicine (2013)
    11. [11]
      Fluoroquinolone-associated myasthenia gravis exacerbation: evaluation of postmarketing reports from the US FDA adverse event reporting system and a literature review. — Jones SC, Sorbello A, Boucher RM Drug safety (2011)
    12. [12]
      Robot-assisted thoracoscopic thymectomy: perianaesthetic concerns. — Pandey R, Garg R, Chandralekha, Darlong V, Punj J, Sinha R et al. European journal of anaesthesiology (2010)
    13. [13]
      Fiberoptic endoscopic evaluation of swallowing with simultaneous Tensilon application in diagnosis and therapy of myasthenia gravis. — Warnecke T, Teismann I, Zimmermann J, Oelenberg S, Ringelstein EB, Dziewas R Journal of neurology (2008)
    14. [14]
      Myasthenia gravis and pregnancy. — Mustafa R, Yousaf S, Baqai Z Journal of the College of Physicians and Surgeons--Pakistan : JCPSP (2005)
    15. [15]
      Myasthenia gravis: lessons for the emergency physician. — Smulowitz PB, Zeller J, Sanchez LD, Edlow JA European journal of emergency medicine : official journal of the European Society for Emergency Medicine (2005)
    16. [16]
      Myasthenia gravis: myasthenia vs. cholinergic crisis. — Hetherington KA, Losek JD Pediatric emergency care (2005)
    17. [17]
      Dental management of the myasthenic patient. — Lotia S, Randall C, Dawson LJ, Longman LP Dental update (2004)
    18. [18]
      Pediatric myasthenia gravis and velopharyngeal incompetence. — Rieder AA, Conley SF, Rowe L International journal of pediatric otorhinolaryngology (2004)
    19. [19]
      Ocular myasthenia gravis coincident with thyroid ophthalmopathy. — Yaman A, Yaman H Neurology India (2003)
    20. [20]
      Myasthenia gravis: the otolaryngologist's perspective. — Salazar Cabrera C, de Saa Alvarez Md Mdel R, Aparicio Pérez MS, Marcos Calle J, García García B American journal of otolaryngology (2002)
    21. [21]
      The complication rate of edrophonium testing for suspected myasthenia gravis. — Ing EB, Ing SY, Ing T, Ramocki JA Canadian journal of ophthalmology. Journal canadien d'ophtalmologie (2000)
    22. [22]
      Design, synthesis, and conformational study of biologically active photolabeled analogues of the main immunogenic region of the acetylcholine receptor. — Theodorou V, Tsikaris V, Sakarellos-Daitsiotis M, Avramopoulou V, Kostelidou K, Tzartos SJ et al. Biopolymers (2000)
    23. [23]
      Mary B. Walker, M.D. and the pioneering use of prostigmin to treat myasthenia gravis. — Keeney AH, Keeney VT Documenta ophthalmologica. Advances in ophthalmology (1997)
    24. [24]
      Isoflurane for sedation in a case of congenital myasthenia gravis. — McBeth C, Watkins TG British journal of anaesthesia (1996)
    25. [25]
      Pregnancy and myasthenia gravis. A case report. — Uncu G, Küçükerdogan I, Ozan H, Cengiz C Clinical and experimental obstetrics & gynecology (1995)
    26. [26]
      Myasthenia gravis and preeclampsia. — Benshushan A, Rojansky N, Weinstein D Israel journal of medical sciences (1994)
    27. [27]
      Epitope mapping of monoclonal antibodies to Torpedo acetylcholine receptor gamma subunits, which specifically recognize the epsilon subunit of mammalian muscle acetylcholine receptor. — Nelson S, Shelton GD, Lei S, Lindstrom JM, Conti-Tronconi BM Journal of neuroimmunology (1992)
    28. [28]
      Indications for thymectomy in myasthenia gravis. — Lanska DJ Neurology (1990)
    29. [29]
      Unilateral ocular myasthenia gravis--a case report. — Chouhan JK, Soni TB, Mishra YC Indian journal of ophthalmology (1990)
    30. [30]
      Myasthenia gravis and lupus erythematosus. — Ciaccio M, Parodi A, Rebora A International journal of dermatology (1989)
    31. [31]
      Urinary incontinence after transurethral resection of prostate in myasthenia gravis patients. — Khan Z, Bhola A Urology (1989)
    32. [32]
      Acetylcholine receptors in human thymic myoid cells in situ: an immunohistological study. — Schluep M, Willcox N, Vincent A, Dhoot GK, Newsom-Davis J Annals of neurology (1987)
    33. [33]
      The Eaton-Lambert (myasthenic) syndrome in association with systemic lupus erythematosus. — Hughes RL, Katirji MB Archives of neurology (1986)
    34. [34]
      Localisation of the main immunogenic region of the nicotinic acetylcholine receptor. — Barkas T, Gabriel JM, Juillerat M, Kokla A, Tzartos SJ FEBS letters (1986)
    35. [35]
      Immunochemical demonstration that amino acids 360-377 of the acetylcholine receptor gamma-subunit are cytoplasmic. — LaRochelle WJ, Wray BE, Sealock R, Froehner SC The Journal of cell biology (1985)
    36. [36]
      Kinetic studies on neurotoxin-binding inhibitory antibodies in myasthenia gravis. — Ito A, Furukawa S, Satoyoshi E, Sakurai H Clinica chimica acta; international journal of clinical chemistry (1985)
    37. [37]
      Interstitial pneumonitis in myasthenia gravis. — McFadden RG, Craig ID, Paterson NA British journal of diseases of the chest (1984)
    38. [38]
      Antibodies to synthetic peptides as probes of acetylcholine receptor structure. — Barkas T, Juillerat M, Kistler J, Schwendimann B, Moody J European journal of biochemistry (1984)
    39. [39]
      Properties of monoclonal antibodies to nicotinic acetylcholine receptor from chick muscle. — Mehraban F, Kemshead JT, Dolly JO European journal of biochemistry (1984)
    40. [40]
      Undiagnosed myasthenia gravis in emergency psychiatric referrals. — Santy PA Annals of emergency medicine (1983)
    41. [41]
      Demonstration of a main immunogenic region on acetylcholine receptors from human muscle using monoclonal antibodies to human receptor. — Tzartos S, Langeberg L, Hochschwender S, Lindstrom J FEBS letters (1983)
    42. [42]
      Penicillamine-induced myasthenia gravis in a patient with rheumatoid arthritis. A case report. — Naidoo PD South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde (1981)
    43. [43]
      Clinical syndromes of myasthenia in infancy and childhood. A review. — Fenichel GM Archives of neurology (1978)
    44. [44]
      Myasthenia gravis and preeclampsia. — Cohen BA, London RS, Goldstein PJ Obstetrics and gynecology (1976)
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