Editing Myasthenia gravis (section)

==Management==
Treatment is by medication and/or surgery. Medication consists mainly of acetylcholinesterase inhibitors to directly improve muscle function and [[immunosuppressant drug]]s to reduce the autoimmune process.<ref name="auto1" /><ref name="auto">{{Cite journal |vauthors=Mehndiratta MM, Pandey S, Kuntzer T |date=October 2014 |title=Acetylcholinesterase inhibitor treatment for myasthenia gravis |journal=The Cochrane Database of Systematic Reviews |volume=2014 |issue=10 |pages=CD006986 |doi=10.1002/14651858.CD006986.pub3 |pmc=7390275 |pmid=25310725}}</ref> [[Thymectomy]] is a surgical method to treat MG.<ref>{{Cite journal |vauthors=Gronseth GS, Barohn RJ |date=July 2000 |title=Practice parameter: thymectomy for autoimmune myasthenia gravis (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology |journal=Neurology |volume=55 |issue=1 |pages=7–15 |doi=10.1212/wnl.55.1.7 |pmid=10891896 |doi-access=free}}</ref><ref name="pmid39434135">{{cite journal |vauthors=Gu J, Qiao Y, Huang R, Cong S |title=Efficacy and safety of immunosuppressants and monoclonal antibodies in adults with myasthenia gravis: a systematic review and network meta-analysis |journal=J Transl Med |volume=22 |issue=1 |pages=955 |date=October 2024 |pmid=39434135 |pmc=11492773 |doi=10.1186/s12967-024-05751-1 |doi-access=free |url=}}</ref>

===Medication===
[[File:Neostigmine.svg|thumb|Neostigmine, chemical structure]]
[[File:Azathioprine.svg|thumb|Azathioprine, chemical structure]]
About 10% of people with generalized MG are considered [[Disease#Refractory disease|treatment-refractory]].<ref>{{Cite journal |vauthors=Suh J, Goldstein JM, Nowak RJ |date=June 2013 |title=Clinical characteristics of refractory myasthenia gravis patients |journal=The Yale Journal of Biology and Medicine |volume=86 |issue=2 |pages=255–60 |pmc=3670444 |pmid=23766745}}</ref> Autologous [[hematopoietic stem cell transplantation]] (HSCT) is sometimes used in severe, treatment-refractory MG. Available data provide preliminary evidence that HSCT can be an effective therapeutic option in carefully selected cases.<ref>{{Cite journal |vauthors=Burman J, Tolf A, Hägglund H, Askmark H |date=February 2018 |title=Autologous haematopoietic stem cell transplantation for neurological diseases |journal=Journal of Neurology, Neurosurgery, and Psychiatry |volume=89 |issue=2 |pages=147–155 |doi=10.1136/jnnp-2017-316271 |pmc=5800332 |pmid=28866625}}</ref>

[[Efgartigimod alfa]] (Vyvgart) was approved for medical use in the United States in December 2021.<ref name="FDA PR 20211217">{{citation-attribution|1={{Cite press release |title=FDA Approves New Treatment for Myasthenia Gravis |date=17 December 2021 |url=https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-myasthenia-gravis |access-date=21 December 2021 |url-status=live |archive-url=https://web.archive.org/web/20211220222022/https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-myasthenia-gravis |archive-date=20 December 2021 |website=U.S. [[Food and Drug Administration]] (FDA)}} }}</ref><ref>{{Cite press release |title=Argenx Announces U.S. Food and Drug Administration (FDA) Approval of Vyvgart (efgartigimod alfa-fcab) in Generalized Myasthenia Gravis |date=17 December 2021 |url=https://www.argenx.com/news/argenx-announces-us-food-and-drug-administration-fda-approval-vyvgarttm-efgartigimod-alfa-fcab |access-date=21 December 2021 |url-status=live |archive-url=https://web.archive.org/web/20211220195236/https://www.argenx.com/news/argenx-announces-us-food-and-drug-administration-fda-approval-vyvgarttm-efgartigimod-alfa-fcab |archive-date=20 December 2021 |website=Argenx}}</ref><ref>{{Cite press release |title=argenx Announces U.S. Food and Drug Administration (FDA) Approval of Vyvgart (efgartigimod alfa-fcab) in Generalized Myasthenia Gravis |date=17 December 2021 |publisher=Argenx |url=https://www.businesswire.com/news/home/20211217005641/en/argenx-Announces-U.S.-Food-and-Drug-Administration-FDA-Approval-of-VYVGART%E2%84%A2-efgartigimod-alfa-fcab-in-Generalized-Myasthenia-Gravis |via=Business Wire |access-date=21 December 2021 |url-status=live |archive-url=https://web.archive.org/web/20211219122355/https://www.businesswire.com/news/home/20211217005641/en/argenx-Announces-U.S.-Food-and-Drug-Administration-FDA-Approval-of-VYVGART%E2%84%A2-efgartigimod-alfa-fcab-in-Generalized-Myasthenia-Gravis |archive-date=19 December 2021}}</ref>

[[Efgartigimod alfa/hyaluronidase]] (Vyvgart Hytrulo) was approved for medical use in the United States in June 2023.<ref>{{Cite press release |title=Halozyme Announces argenx Receives FDA Approval for Vyvgart Hytrulo With Enhanze for Subcutaneous Use in Generalized Myasthenia Gravis |date=20 June 2023 |publisher=Halozyme Therapeutics |url=https://www.prnewswire.com/news-releases/halozyme-announces-argenx-receives-fda-approval-for-vyvgart-hytrulo-with-enhanze-for-subcutaneous-use-in-generalized-myasthenia-gravis-301855994.html |via=PR Newswire |access-date=24 June 2023 |url-status=live |archive-url=https://web.archive.org/web/20230624173634/https://www.prnewswire.com/news-releases/halozyme-announces-argenx-receives-fda-approval-for-vyvgart-hytrulo-with-enhanze-for-subcutaneous-use-in-generalized-myasthenia-gravis-301855994.html |archive-date=24 June 2023}}</ref><ref>{{Cite press release |title=Argenx Announces U.S. Food and Drug Administration Approval of Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) Injection for Subcutaneous Use in Generalized Myasthenia Gravis |date=20 June 2023 |url=https://www.argenx.com/news/argenx-announces-us-food-and-drug-administration-approval-vyvgart-hytrulo-efgartigimod-alfa |access-date=24 June 2023 |url-status=live |archive-url=https://web.archive.org/web/20230624190259/https://www.argenx.com/news/argenx-announces-us-food-and-drug-administration-approval-vyvgart-hytrulo-efgartigimod-alfa |archive-date=24 June 2023 |website=Argenx}}</ref>

[[Rozanolixizumab]] (Rystiggo) was approved for medical use in the United States in June 2023.<ref>{{Cite web |date=28 June 2023 |title=Novel Drug Approvals for 2023 |url=https://www.fda.gov/drugs/new-drugs-fda-cders-new-molecular-entities-and-new-therapeutic-biological-products/novel-drug-approvals-2023 |url-status=live |archive-url=https://web.archive.org/web/20230121035617/https://www.fda.gov/drugs/new-drugs-fda-cders-new-molecular-entities-and-new-therapeutic-biological-products/novel-drug-approvals-2023 |archive-date=21 January 2023 |access-date=28 June 2023 |website=U.S. [[Food and Drug Administration]] (FDA)}}</ref><ref>{{Cite press release |title=UCB announces U.S. FDA approval of Rystiggo (rozanolixizumab-noli) for the treatment of adults with generalized myasthenia gravis |date=27 June 2023 |publisher=UCB |url=https://www.prnewswire.com/news-releases/ucb-announces-us-fda-approval-of-rystiggo-rozanolixizumab-noli-for-the-treatment-of-adults-with-generalized-myasthenia-gravis-301864023.html |via=PR Newswire |access-date=28 June 2023 |url-status=live |archive-url=https://web.archive.org/web/20230628045311/https://www.prnewswire.com/news-releases/ucb-announces-us-fda-approval-of-rystiggo-rozanolixizumab-noli-for-the-treatment-of-adults-with-generalized-myasthenia-gravis-301864023.html |archive-date=28 June 2023}}</ref>

====Acetylcholinesterase inhibitors====
Acetylcholinesterase inhibitors can provide symptomatic benefit and may not fully remove a person's weakness from MG.<ref name="Mehndiratta_2014">{{Cite journal |vauthors=Mehndiratta MM, Pandey S, Kuntzer T |date=October 2014 |title=Acetylcholinesterase inhibitor treatment for myasthenia gravis |journal=The Cochrane Database of Systematic Reviews |volume=2014 |issue=10 |pages=CD006986 |doi=10.1002/14651858.CD006986.pub3 |pmc=7390275 |pmid=25310725}}</ref> While they might not fully remove all symptoms of MG, they still may allow a person the ability to perform normal daily activities.<ref name="Mehndiratta_2014" /> Usually, acetylcholinesterase inhibitors are started at a low dose and increased until the desired result is achieved. If taken 30 minutes before a meal, symptoms will be mild during eating, which is helpful for those who have difficulty swallowing due to their illness. Another medication used for MG, [[atropine]], can reduce the muscarinic side effects of acetylcholinesterase inhibitors.<ref>{{Cite web |date=2014 |title=Atropine – Myasthenia-gravis medicines and drugs |url=http://www.nhs.uk/medicine-guides/pages/MedicineOverview.aspx?condition=Myasthenia-gravis&medicine=Atropine |archive-url=https://web.archive.org/web/20150712212657/http://www.nhs.uk/medicine-guides/pages/MedicineOverview.aspx?condition=Myasthenia-gravis&medicine=Atropine |archive-date=12 July 2015 |access-date=2015-07-11 |publisher=NHS Choices}}</ref> [[Pyridostigmine]] is a relatively long-acting drug (when compared to other cholinergic agonists), with a half-life around four hours with relatively few side effects.<ref name=":1">{{Cite journal |vauthors=Kumar V, Kaminski HJ |date=February 2011 |title=Treatment of myasthenia gravis |journal=Current Neurology and Neuroscience Reports |volume=11 |issue=1 |pages=89–96 |doi=10.1007/s11910-010-0151-1 |pmid=20927659 |s2cid=41052495}}</ref> Generally, it is discontinued in those who are being mechanically ventilated, as it is known to increase the amount of salivary secretions.<ref name=":1" /> A few high-quality studies have directly compared cholinesterase inhibitors with other treatments (or placebo); their practical benefit may be so significant that conducting studies in which they would be withheld from some people would be difficult.<ref name="auto" />

====Immune suppressants====
The steroid [[prednisone]] might also be used to achieve a better result, but it can lead to the worsening of symptoms and takes weeks to achieve its maximal effectiveness.<ref name=":1" /> Research suggests that up to 15% of patients do not positively respond to immune suppressants.<ref>{{Cite journal |vauthors=Drachman DB, Adams RN, Hu R, Jones RJ, Brodsky RA |date=2008-06-01 |title=Rebooting the immune system with high-dose cyclophosphamide for treatment of refractory myasthenia gravis |journal=Annals of the New York Academy of Sciences |volume=1132 |issue=1 |pages=305–314 |bibcode=2008NYASA1132..305D |doi=10.1196/annals.1405.033 |pmc=3390145 |pmid=18567882}}</ref><ref>{{Cite journal |vauthors=Suh J, Goldstein JM, Nowak RJ |date=June 2013 |title=Clinical characteristics of refractory myasthenia gravis patients |journal=The Yale Journal of Biology and Medicine |volume=86 |issue=2 |pages=255–260 |pmc=3670444 |pmid=23766745}}</ref><ref name="auto1" /> Due to the myriad symptoms that steroid treatments can cause, it is not the preferred method of treatment.<ref name=":1" /> Other immune suppressing medications may also be used including [[rituximab]]<ref>{{Cite journal |vauthors=Tandan R, Hehir MK, Waheed W, Howard DB |date=August 2017 |title=Rituximab treatment of myasthenia gravis: A systematic review |journal=Muscle & Nerve |volume=56 |issue=2 |pages=185–196 |doi=10.1002/mus.25597 |pmid=28164324 |s2cid=19504332}}</ref> or [[azathioprine]].<ref name="NIH2016" />

[[Nipocalimab]] (Imaavy) was approved for medical use in the United States in April 2025.<ref>{{cite web | title=Novel Drug Approvals for 2025 | website=U.S. [[Food and Drug Administration]] (FDA) | date=1 May 2025 | url=https://www.fda.gov/drugs/novel-drug-approvals-fda/novel-drug-approvals-2025 | access-date=1 May 2025}}</ref><ref name="JandJ PR 20250430">{{cite press release | title=Johnson & Johnson receives FDA approval for Imaavy (nipocalimab-aahu), a new FcRn blocker offering long-lasting disease control in the broadest population of people living with generalized myasthenia gravis (gMG) | publisher=Johnson & Johnson | via=MultiVu | date=30 April 2025 | url=https://www.multivu.com/johnson-johnson/9331651-en-johnson-johnson-receives-fda-approval-imaavy-nipocalimab-aahu | access-date=1 May 2025}}</ref>

===Plasmapheresis and IVIG===
If the myasthenia is serious (myasthenic crisis), [[plasmapheresis]] can be used to remove the putative antibodies from the circulation. Also, [[intravenous immunoglobulin]]s (IVIGs) can be used to bind the circulating antibodies. Both of these treatments have relatively short-lived benefits, typically measured in weeks, and often are associated with high costs, which make them prohibitive; they are generally reserved for when MG requires hospitalization.<ref name=":1" /><ref name="Juel2004">{{Cite journal |vauthors=Juel VC |date=March 2004 |title=Myasthenia gravis: management of myasthenic crisis and perioperative care |journal=Seminars in Neurology |volume=24 |issue=1 |pages=75–81 |doi=10.1055/s-2004-829595 |pmid=15229794 |s2cid=260320936}}</ref>

===Surgery===
As [[thymoma]]s are seen in 10% of all people with the MG, they are often given a chest X-ray and CT scan to evaluate their need for surgical removal of their thymus glands and any cancerous tissue that may be present.<ref name="Rosen2014" /><ref name=":2" /> Even if surgery is performed to remove a thymoma, it generally does not lead to the remission of MG.<ref name=":1" /> Surgery in the case of MG involves the removal of the thymus, although in 2013, no clear benefit was indicated except in the presence of a thymoma.<ref name="Cea2013">{{Cite journal |vauthors=Cea G, Benatar M, Verdugo RJ, Salinas RA |date=October 2013 |title=Thymectomy for non-thymomatous myasthenia gravis |journal=The Cochrane Database of Systematic Reviews |issue=10 |pages=CD008111 |doi=10.1002/14651858.CD008111.pub2 |pmid=24122674|pmc=12083877 }}</ref> A 2016 randomized, controlled trial, however, found some benefits.<ref>{{Cite journal |display-authors=6 |vauthors=Wolfe GI, Kaminski HJ, Aban IB, Minisman G, Kuo HC, Marx A, Ströbel P, Mazia C, Oger J, Cea JG, Heckmann JM, Evoli A, Nix W, Ciafaloni E, Antonini G, Witoonpanich R, King JO, Beydoun SR, Chalk CH, Barboi AC, Amato AA, Shaibani AI, Katirji B, Lecky BR, Buckley C, Vincent A, Dias-Tosta E, Yoshikawa H, Waddington-Cruz M, Pulley MT, Rivner MH, Kostera-Pruszczyk A, Pascuzzi RM, Jackson CE, Garcia Ramos GS, Verschuuren JJ, Massey JM, Kissel JT, Werneck LC, Benatar M, Barohn RJ, Tandan R, Mozaffar T, Conwit R, Odenkirchen J, Sonett JR, Jaretzki A, Newsom-Davis J, Cutter GR |date=August 2016 |title=Randomized Trial of Thymectomy in Myasthenia Gravis |journal=The New England Journal of Medicine |volume=375 |issue=6 |pages=511–522 |doi=10.1056/NEJMoa1602489 |pmc=5189669 |pmid=27509100 |hdl=2318/1601939}}{{Erratum|doi=10.1056/NEJMx170003|pmid=28471717|http://retractionwatch.com/2017/06/20/big-corrections-usually-weaken-findings-recent-nejm-one-strengthened-author-says/ ''Retraction Watch''|checked=yes}}</ref>

===Physical measures===
People with MG should be educated regarding the fluctuating nature of their symptoms, including weakness and exercise-induced fatigue. Exercise participation should be encouraged with frequent rest.<ref name="Goldenberg" /> In people with generalized MG, some evidence indicates a partial home program including training in [[diaphragmatic breathing]], [[pursed-lip breathing]], and interval-based muscle therapy may improve respiratory muscle strength, chest wall mobility, respiratory pattern, and respiratory endurance.<ref>{{Cite journal |vauthors=Cup EH, Pieterse AJ, Ten Broek-Pastoor JM, Munneke M, van Engelen BG, Hendricks HT, van der Wilt GJ, Oostendorp RA |date=November 2007 |title=Exercise therapy and other types of physical therapy for patients with neuromuscular diseases: a systematic review |journal=Archives of Physical Medicine and Rehabilitation |volume=88 |issue=11 |pages=1452–1464 |doi=10.1016/j.apmr.2007.07.024 |pmid=17964887}}</ref>

===Medical imaging===
In people with myasthenia gravis, older forms of [[iodinated contrast]] used for medical imaging have caused an increased risk of exacerbation of the disease, but modern forms have no immediate increased risk.<ref name="MehriziPascuzzi2014">{{Cite journal |vauthors=Mehrizi M, Pascuzzi RM |date=September 2014 |title=Complications of radiologic contrast in patients with myasthenia gravis |journal=Muscle & Nerve |volume=50 |issue=3 |pages=443–4 |doi=10.1002/mus.24254 |pmid=24677227 |s2cid=206295540}}</ref>