An update on the use of immunoglobulins as treatment for myasthenia gravis

ABSTRACT

Introduction

Myasthenia gravis (MG) is an antibody mediated disease where pathogenic antibodies interact with the acetylcholine receptor or other proteins at the post-synaptic neuromuscular junction. There is growing evidence that immunoglobulin infusions are beneficial for clinical exacerbations and chronic refractory disease and may be an option for patients unresponsive to conventional immunosuppressive therapies.

Areas covered

We performed an extensive literature review, looking for evidence on the use of immunoglobulins for the treatment of MG, by conducting a search in MEDLINE (1946 to present), EMBASE (1947 to present) and Clinicaltrials.gov. We have included studies on the use of intravenous immunoglobulins (IVIG) and subcutaneous immunoglobulins (SCIG) for acute deterioration and chronic disease.

Expert opinion

The use of IVIG in MG provides an option for rapid improvement in critical deterioration, being preferred over more invasive and less available therapies such as plasmapheresis. For refractory MG, the addition of IVIG can improve a patient’s status and reduce the dosage of immunosuppressive medications. The alternative of SCIG is also effective and has advantages of infusion time flexibility, fewer side-effects, and patient independence. The safety and efficacy of both interventions, patient preferences and quality of life may direct therapeutic choices in the future.

KEYWORDS:

• Myasthenia gravis
• immunoglobulins
• subcutaneous
• intravenous
• IVIG
• SCIG
• treatment

Declaration of interest

M Alcantara is a clinical fellow, and her Fellowship is supported by UHN Foundation; C Barnett has received research funding from MGNet, NIH, US Department of Defense, Muscular Dystrophy Canada, Grifol and Octapharma. She has received honoraria from consulting services to Alexion, Sanofi, Argenx, CSL. She is the primary developer of the MGII and may receive royalties. H Katzberg has received personal fees for consulting and data safety monitoring board activities for Octapharma, Grifols, CSL Behring, UCB, Argenx, Takaeda, Alexion and clinical trial support from Takaeda. V Bril has been a consultant to Grifols, UCB, CSL, Octapharma, J&J, Takeda, Astra Zeneca/Alexion, Ionis, Roche, Sanofi, Powell Mansfield, Alnylam, Janssen, NovoNordisk and has received research support from Astra Zeneca/Alexion, Grifols, CSL, UCB, Argenx, Takeda, Octapharma, Akcea, Momenta [now J&J], Immunovant, Ionis, Vielo Bio [now Horizon]. 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.

Article highlights

• Myasthenia gravis is an autoimmune disease that frequently requires immunosuppressive or immunomodulating therapies.

• Intravenous immunoglobulins or plasmapheresis are effective in life-threatening manifestations and acute MG deterioration.

• There is increasing evidence that both intravenous and subcutaneous immunoglobulins are beneficial in chronic refractory disease, not fully responsive to common immunosuppressant medications.

• Availability, safety profile and patient preferences may direct future therapies.

Additional information

Funding

This paper was not funded.