Articles / Clinical Conversations: Myasthenia Gravis – A Practical Approach for GPs | Part two
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Neurologist; Inner West Neurology and Concord Hospital, NSW
This is part two of this series.
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Practice points
• The acetylcholine (ACH) receptor antibody is the most common antibody found.
• MuSK” stands for “muscle-specific kinase” antibody and it targets the postsynaptic neuromuscular junction.
• In patients with generalised clinical myasthenia, approximately 85% of them have ACH receptor antibodies and about 5% to 10% of them have MuSK antibodies.
• If there are pure ocular symptoms, half the patients have ACH receptor antibodies but MuSK antibodies are very rare.
• If antibodies have returned positive and a patient is waiting for a clinic appointment, a CT chest is something easily ordered prior to the patient being referred.
• If the patient is starting to aspirate or has a high respiratory rate, shortness of breath, head drop or swallowing difficulties they should be referred to Emergency.
• Pyridostigmine (Mestinon®) works almost immediately but it is limited in its maximal benefit. Patients take it fifteen to thirty minutes before any activity and may self-titrate the dose.
• Plasma exchange that directly removes the pathological antibodies, and intravenous immunoglobulins are prescribed via the blood bank. Both are expensive and short-acting.
• Long-acting oral treatments include corticosteroids, azathioprine, methotrexate, mycophenolate, and the infusions, such as rituximab and cyclophosphamide, but the latter are chemotherapy drugs.
• Acute, high dose steroids can severely exacerbate myasthenia gravis symptoms and cause them to go into cholinergic crisis requiring intubation.
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Neurologist; Inner West Neurology and Concord Hospital, NSW
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