Current pharmacotherapeutic options for myasthenia gravis

ABSTRACT

Introduction: Novel options for immune-based therapy in myasthenia gravis are improving the therapeutic outlook for patients. Multiple clinical trials on immunomodulation, complement inhibitors, and FcR inhibitors are providing evidence for novel immune-based therapies that promise to improve outcomes in myasthenia patients. These more focused immune treatments are reviewed in this paper.

Areas covered: This paper outlines classical treatment for myasthenia gravis and then reviews recent clinical trial evidence for novel immune therapies, particularly complement inhibitors and FcR inhibitors. Further, as immune therapies expand in other areas of medicine, such as oncology, iatrogenic myasthenia is being observed as a complication of some novel treatments.

Expert opinion: Exciting new options to help patients with myasthenia gravis are now available or in phase 3 trials based on promising phase 2 results. Manipulation of the immune system can also lead to iatrogenic MG. Although novel treatments can improve care for myasthenia gravis patients, future developments that prevent the production of specific abnormal auto-antibodies are desirable.

KEYWORDS:

• Myasthenia gravis
• treatment
• immune therapy
• eculizumab
• efgartigimod
• rozanolixizumab

Article highlights

• CMG syndromes vary in type of neuromuscular transmission impairment and symptomatic treatments need to be tailored to the specific CMG syndrome.

• Thymectomy leads to improved outcomes in MG for young-adults who are AChRAb positive, but not in those with onset age ≥50 years.

• Immunomodulation with IVIg improves MG by multiple mechanisms and MG patients can be successfully transitioned to SCIg.

• Corticosteroids remain a powerful positive treatment agent, particularly for ocular MG.

• Azathioprine, cyclosporine, tacrolimus, mycophenolate, methotrexate, and rituximab remain treatment options for MG although clinical trial evidence is contradictory.

• Stem cell therapy may be an option for the most severely affected patients.

• Novel treatments with complement inhibitors and anti-FcR antibodies promise to improve outcomes for patients with severe and difficult to treat MG.

• Manipulation of the immune system with agents such as check-point inhibitors can lead to iatrogenic MG that may be challenging to manage.

Declaration of interest

V Bril has acted as consultant for CSL, UCB Pharma, Grifols, Alexion, Argenx and Octapharma. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was self-funded.