Myastenia gravis

Management escalation pathway

  • Steroids indicated (oral or i.v.)
  • Pyridostigmine initial dose 30 mg
  • Neurological consult If no improvement, or worsening, plasmapheresis or IVIG may be considered
  • Avoid certain medications, that may precipitate cholinergic crisis (e.g. ciprofloxacin, beta blockers, amikacin, benzodiazepines and above all curares during general anesthesia)’)

Assessment and Investigations

  • Check for ocular muscle and proximal muscle fatigability AChr and MuSK antibodies
  • Bedsides tests, e.g. Tensilon test or ice pack test with neurological input
  • Repetitive nerve stimulation and single fibre EMG
  • Exclude myocarditis with cardiac enzymes (and cardiac MRI in case of doubt) (cave pseudo myasthenic myositis)


ACPA: Anti Citrullinated Antibody
ANF: Anti Nuclear Factor
C3/C4: Complement Factor 3 or 4
CK: Creatine Kinase
CK MB: Creatine Kinase Muscle
ECG: ElectroCardioGram
EMG: ElectroMyoGram
ICPi: Immune Checkpoint Blockade Inhibition
IVIg: IntraVeneous Immunoglobulins
MRI: Magnetic Resonance Imaging
PD: Per Day
PO: Per Os
Pro-BNP: Pro-Brain Natriuretic Peptide
RF: Rheuma Factor
ULN: Upper Limit of Normal