Skill Checkup: A 57-Year-Old Woman With Dyspnea, Droopy Right Eye, and Mild Crackles at Both Lower Lung Fields

Raghav Govindarajan, MD


May 06, 2022

AChE inhibitors and immunomodulating therapies are the mainstays of myasthenia gravis treatment. Pyridostigmine is used for symptomatic treatment only. It does not treat the underlying disease. Edrophonium is primarily but rarely used as a diagnostic tool to predict the response to longer-acting cholinesterase inhibitors. Neostigmine, unlike physostigmine, does not cross the blood-brain barrier. By inhibiting AChE, more acetylcholine is available in the synapse; therefore, more of it can bind to the fewer receptors present in myasthenia gravis and can better trigger muscular contraction.

PD-1 inhibitors, such as nivolumab and pembrolizumab, are used as immunotherapy in certain cancers (eg, metastatic melanoma and non–small cell lung cancer). These drugs enhance immune responses and have been reported to trigger autoimmune myasthenia gravis.

Aminoglycosides and neuromuscular blocking agents have established pharmacologic adverse effects on neuromuscular transmission. Use of these drugs can further reduce the effectiveness of neuromuscular transmission in a patient with myasthenia gravis and cause increased clinical weakness.


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