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Myasthenia Gravis Medical Archive Questions

Below are Dr. Hafer-Macko’s answers to Myasthenia Gravis Medical questions
received through the Ask the Expert feature.

This content is provided for informational purposes only, and is not intended
to be a substitute for individual medical advice in diagnosing or treating a
health problem. Please consult with your physician about your specific health
care concerns.

Now displaying records 1 to 15 of 57.

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Q : 1

I have generalized Myasthenia Gravis (all three blood markers are present). I have been controlling the symptoms for over two years using Mestinon only. The last neurologist I saw was the first to tell me that failure to eliminate the autoimmunity will ultimately cause permanent muscle damage. Is that your experience? He wants me to consider Imuran as a first step. My thymus is fine and I'm 64.

You need to discuss your myasthenia gravis (MG) management with your physician. There are many therapies available to treat the MG. The Mestinon is a good medication that treats the symptoms of weakness and fatigue. It sounds like it works for you and you are tolerating it. It does nothing to treat the auto-immune disease process. Steroids and steroid sparing drugs, such as Azathioprine or Imuran work to blunt the immune process. Thymectomy is another treatment option, but you have no thymus or suggestion of a thymoma. Our other treatment strategies that we use for MG emergencies is IVIG and plasmapheresis (blood filtering) work quickly. You would not need these treatment options. For more information on the treatment options, check the Myasthenia Gravis Foundation of America website, or check with your local VA support group.

Q : 2

Are recruiting for the Myasthenia Gravis clinical trials? Do you need to live in the Baltimore area? I was dignosed in 2005, and have been stable about 4 years. I would like information about the trial.

The trial is being conducted in Baltimore, it is a supervised exercise program. Please call my clinical office and ask for Gregg. Please forward your contact information if you are interested in future study contact. You can also go to the Myasthenia Gravis Foundation of America website. We have done a podcast and plan to a PT session.

Q : 3

I have been diagnosed with MG. I am taking pyridostigmine for drooping lids. I have started using steroids It seems as though the steroids are helping the double vision. Is there something else I can use in place of steroids?

There are a number of treatment choices for myasthenia gravis. The first line of treatment is pyridostigmine. We also use immunosuppressive agents. Steroids and steroids sparing agets. The choice of agents depends of the severity of the symptoms. You need to discuss the risks and benefits of each medication used with your primary care and neurologist. A great source of information on myastheia gravis and your medictaions is the Myasthenia Gravis Foudation of America. The National Annual Meeting of the MGFA will be held in Miami May 8-10, 2013, this is another great opportunity to learn more about your myasthenia gravis.

Q : 4

Will myasthenia gravis prevent me from driving a commercial vehicle? I have been tested and confirmed to have this. I have suffered all summer and fall with this andI need answers.

The myasthenia gravis can cause ptosis (drooping eyelids) and diplopia (double vision). These symptoms can worsen with repeated use, driving long distances. You should take proper rests to avoid eye fatigue. Sun glare can also fatigue the eyes. You should where good polarized lens in the sun. Double vision will impair your vision. The heat will also make the MG worse. Other MG symptoms include fatigue, trouble chewing, swallowing, speaking, and shortness of breath. It also cause neck, arm, and leg weakness. There are treatments for myasthenia gravis once you are diagnosed. A wonderful source for information of myasthenia gravis is the Myasthenia Gravis Foundation of America website. We are available for consultations in myatshenia gravis, call 410-328-3100.

Q : 5

Is there a connection between Coumadin and MG? Shortly after my dad was told to stop taking Coumadin, MG took over.

There should not be a connection between the coumadin and the MG. However, coumadin and many medications share the same enzyme system in the liver to process and clear the medications. It is common to have to adjust the coumadin dose for an adequate INR (bleeding time) whenever new medications are added.

Q : 6

Does your clinic have lots of experience with Rituximab and Prednisone as treatment for MUSK+ MG patients? If so, have there been hurdles with securing insurance coverage as treatment for MG solely?

I have been using Rituxamab as one of my therapeutic (drug) strategies on my refractory (patients who are less responsive to the FDA approved therapies) MG patients, especially the MUSK+ MG patients. The insurance companies support this type of therapy for patients who are still very symptomatic despite aggressive traditional medical care, with a letter supporting the rational for their use. Prednisone is one of the usual therapies for myasthenia gravis.

Q : 7

I was recently diagnosed with MG. My doctor has ordered at CT of the chest with contrast, but I read that iodine could worsen the symptoms. Is that true?

The iodine that they use for CT scan has the potential to make the MG worse. Unfortunately, we get a much better look at the chest and thymus with the contrast. I generally let the radiology team know about the MG. They should watch you more closely due to the MG.

Q : 8

Can children have MG?

Myasthenia gravis can definitely effect children. There are different forms of myasthenia gravis in children. They may have congenital forms (inherited forms that affect genes that cause problems at the nerve muscle junction) or auto-immune (immune attack on the nerve muscle junction). The first step in treatment is to confirm that your daughter has myasthenia gravis (MG) and what form to ensure she receives the correct treatment.

Q : 9

If muscle weakness worsens with prolonged exercise for patients with MG, how can they increase muscle strength?

There are two ways of making a stronger muscular response. The first is to activate additional motor units. The second is to increase the rate of neuromuscular activity at the neuromuscular junction.

Q : 10

Can a 68-year-old MG patient take Viagra? I am also taking Imuran.

In a randomized study in American Journal of cardiology in 2005, 132 patients were treated with either Viagra (sildenafil) or placebo (a sugar pill). Sixty percent of patients who received Vigara and 48 percent of patients who received a placebo developed side effects on the medication. Side effects included transient (brief) headache, facial flushing, colds, and asthenia (fatigue and weakness). As with all medications, you should check with your neurologist and primary care doctor before taking new medications to make sure they do not affect your myasthenia gravis or other medical conditions.

Q : 11

What other diseases have similar symptoms to MG? My husband has MG symptoms, but not exactly as described and we are wondering if it could be something else.

Myasthenia gravis often is not diagnosed early due to confusion with other conditions, stroke, dental problems, sinus disease, pulmonary and cardiac disease, and depression. We often also make sure that the diagnosis is truly myasthenia gravis. Other disorders include muscle disorders, nerve disease, thyroid disorders.

Q : 12

I was wondering if you have seen your patients have an exacerbation of their symptoms after certain vaccinations (i.e dtap, flu, pneumonia etc.) I understand that live vaccines are contraindicated but do the inactive vaccines cause worsening of symptoms?

I generally recommend that my patients keep up with their vaccinations. I would recommend avoiding live vaccines. The vaccines (flu, pneumonia) contain inactivated proteins. An immune response is mounted to proteins. There is a small immune reponse caused by the vaccine, but not to the same degree as an actual flu virus. These immune responses can transiently aggravate the MG.

Q : 13

I am a 38-year-old teacher with MG and I am very concerned about taking immunosuppressants. What are the dangers of taking Imuran or other drugs like it and working in a school setting? I don't want to be sick all the time on top of feeling bad because of MG.

You are correct, there are risks and benefits to all medical interventions for myasthenia gravis. Mestinon is often our first line of therapy. It treats the symptoms of MG, but it does not alter the immune process. The next line of therapy is steroids. As you may be aware steroids are a great drug for MG, but they come with a long list of side effects, including increased susceptibility to infections. We tend to like steroids for younger individuals. Imuran, Cell Cept, and Cyclosporin are other immunosuppressive drugs with fewer side effects compared to steroids, however, we use them in caution in women who are considering pregnancy and due to the long term risk of lymphoma (20 years after starting these medications). We monitor effects of these drugs on the blood counts, liver and kidneys. These drugs also suppress the immune system, you have to be careful around individuals with infectious symptoms, and practice good hand washing. You should discuss with your neurologist the risks and benefits of the therapy for your MG.

Q : 14

I was just diagnosed with myasthenia gravis, but the doctors couldn't tell me much about the disease. Can you tell me what types of medications I should need, and what causes this disease?

Myasthenia gravis is an autoimmune disease. You have an immune attack on the muscle at the nerve - muscle junction. This results in weakness and fatigue. People often first present with drooping eyelids and double vision. Other symptoms can include arm and leg weakness, shortness of breath, troubles chewing, swallowing, and talking. Everyone is very different in their presentation. The choice of medications is also individualized. Medication choice is based on your symptoms, severity of the disease, rapidity of the disease onset, your age, and other medical problems. The Myasthenia Gravis Foundation of America (MGFA) is a great site for patient information. They have information on MG, diagnostic tests, all the medications we use to treat MG and medications that can make MG worse. If there are no support groups in your area, you can contact the North American Chapter of MGFA for more information and to talk with someone with MG.

Q : 15

Can someone who has been experiencing MG symptoms consistently over several years have MG even if labs and EMGs have been negative?

There are conditions that can mimic myasthenia gravis. It is important to be evaluated when there is any question on the diagnosis. I generally recommend being seen at a University Hospital with a Neuromuscular Center. About 50 percent of individuals with ocular MG have acetylcholine receptor antibodies (ACHR Ab). About 65 percent of individuals with generalized MG have ACHR Ab. The repetitive nerve stimulation test is positive in about 65 percent of cases. The single fiber EMG is positive 95 percent of cases, but can be abnormal in other conditions.

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