Treatments

Our organization is committed to supporting education by providing information about therapies available to people diagnosed with myasthenia gravis (MG). This list provides a snapshot. Review this list and compare it to your current treatment. This is not a complete list, and not every treatment is appropriate for every person with MG. Ask your physician whether any of the newer targeted therapies may be right for you, and make sure you receive both the potential benefits and the risks before making treatment decisions. Treatment choices often depend on antibody status, disease severity, age, other medical conditions, access, and prior response to treatment. Some treatments may be used off labe.

Pyridostigmine (Mestinon)

• Mechanism: Pyridostigmine is an acetylcholinesterase inhibitor that increases the availability of acetylcholine at the neuromuscular junction, helping improve muscle contraction and strength.
• Administration: Oral; in some settings, related agents may be given by injection.
• Type: Symptomatic treatment.
• Type of Myasthenia Gravis (MG) Antibodies: Often used across MG types for symptom relief, though some people with MuSK-positive MG may respond poorly or tolerate it less well.
• Vaccination Required: None.
• Common Side Effects: Gastrointestinal discomfort, diarrhea, abdominal cramping, increased salivation, sweating, and muscle cramps.  

Prednisone

• Mechanism: Prednisone is a corticosteroid that suppresses immune activity and reduces the antibody-driven attack on the neuromuscular junction.
• Administration: Oral.
• Type: Immunosuppressant.
• Type of MG Antibodies: Commonly used in both AChR-positive and MuSK-positive MG.
• Vaccination Required: Vaccination planning should be discussed with the physician before or during immunosuppressive therapy; inactivated vaccines are generally preferred when immunosuppressed.
• Common Side Effects: Weight gain, mood changes, insomnia, elevated blood sugar, hypertension, osteoporosis, cataracts, and infection risk.
• Important Note: Steroids can sometimes temporarily worsen MG when first started, so dose strategy matters.  

Intravenous Immunoglobulin (IVIG)

• Mechanism: IVIG uses pooled antibodies from donors to alter immune signaling and reduce the impact of harmful autoantibodies.
• Administration: Intravenous (IV).
• Type: Immunomodulatory.
• Type of MG Antibodies: Used for worsening symptoms, exacerbations, and sometimes maintenance treatment, regardless of antibody type.
• Vaccination Required: No specific vaccine is required solely for IVIG, but treatment timing can affect vaccine response.
• Common Side Effects: Headache, fever, chills, fatigue, infusion reactions, rash, and rarely blood clots or kidney complications.  

Subcutaneous Immunoglobulin (SCIG)

• Mechanism: Similar to IVIG, SCIG provides immunoglobulin to help modulate the immune response.
• Administration: Subcutaneous (Subq).
• Type: Immunomodulatory.
• Type of MG Antibodies: Sometimes used in selected patients as maintenance therapy.
• Vaccination Required: None specifically required.
• Common Side Effects: Injection site reactions, headache, fatigue, flu-like symptoms.
• Important Note: This is used in some centers and situations, but it is not one of the newer targeted MG drugs.  

Azathioprine (Imuran)

• Mechanism: Azathioprine reduces lymphocyte activity by interfering with purine synthesis.
• Administration: Oral.
• Type: Immunosuppressant.
• Type of MG Antibodies: Commonly used in AChR-positive and MuSK-positive MG.
• Vaccination Required: Vaccination planning should be discussed before or during treatment because immunosuppression can increase infection risk.
• Common Side Effects: Nausea, vomiting, liver toxicity, low white blood cell count, and infection risk.  

Cyclosporine (Neoral, Sandimmune, Gengraf)

• Mechanism: Cyclosporine inhibits calcineurin, reducing T-cell activation.
• Administration: Oral.
• Type: Immunosuppressant.
• Type of MG Antibodies: Used in some patients with generalized MG.
• Vaccination Required: Vaccination planning should be individualized because of immunosuppression.
• Common Side Effects: Kidney toxicity, high blood pressure, tremor, gum enlargement, excess hair growth, infection risk.  

Tacrolimus (Prograf)

• Mechanism: Tacrolimus also inhibits calcineurin, suppressing immune activation.
• Administration: Oral.
• Type: Immunosuppressant.
• Type of MG Antibodies: Used in some patients with generalized MG, including refractory disease.
• Vaccination Required: Vaccination planning should be individualized.
• Common Side Effects: Kidney toxicity, tremor, headache, high blood pressure, elevated blood sugar, infection risk.  

Plasmapheresis / Plasma Exchange (PLEX)

• Mechanism: PLEX removes circulating antibodies from the blood.
• Administration: Apheresis procedure.
• Type: Rapid immunomodulatory therapy.
• Type of MG Antibodies: Used for acute worsening, crisis, or preoperative stabilization, regardless of antibody type.
• Vaccination Required: None specifically required.
• Common Side Effects: Low blood pressure, catheter complications, infection risk, bleeding issues, electrolyte abnormalities.
• Important Note: Often works faster than long-term therapies but is not usually a permanent solution by itself.  

Mycophenolate Mofetil (CellCept)

• Mechanism: Mycophenolate reduces lymphocyte proliferation by blocking inosine monophosphate dehydrogenase.
• Administration: Oral.
• Type: Immunosuppressant.
• Type of MG Antibodies: Used in generalized MG, including AChR-positive and MuSK-positive disease.
• Vaccination Required: Vaccination planning should be discussed because of immunosuppression.
• Common Side Effects: Diarrhea, nausea, low blood cell counts, infection risk, liver test abnormalities.  

Methotrexate (Xatmep, Otrexup, Rasuvo)

• Mechanism: Methotrexate affects folate metabolism and slows immune cell replication.
• Administration: Oral or injection.
• Type: Immunosuppressant.
• Type of MG Antibodies: Sometimes considered in selected patients when other treatments are not suitable or have not worked well.
• Vaccination Required: Vaccination planning should be discussed because of immunosuppression.
• Common Side Effects: Nausea, mouth sores, liver toxicity, low blood cell counts, infection risk.  

Efgartigimod (Vyvgart)

• Mechanism: Efgartigimod is an FcRn blocker that lowers pathogenic IgG antibodies.
• Administration: Intravenous (IV).
• Type: Targeted biological therapy.
• Type of MG Antibodies: FDA-approved for adult patients with generalized MG who are AChR-antibody positive.
• Vaccination Required: Age-appropriate vaccines should be evaluated before treatment; live vaccines are generally avoided during treatment.
• Common Side Effects: Respiratory tract infections, headache, urinary tract infections, infusion-related reactions.  

Efgartigimod + Hyaluronidase (Vyvgart Hytrulo)

• Mechanism: Same targeted FcRn blockade concept as IV efgartigimod, lowering pathogenic IgG antibodies.
• Administration: Subcutaneous (Subq).
• Type: Targeted biological therapy.
• Type of MG Antibodies: FDA-approved for adult patients with generalized MG who are AChR-antibody positive.
• Vaccination Required: Age-appropriate vaccines should be reviewed before treatment; live vaccines are generally avoided during treatment.
• Common Side Effects: Injection site reactions, respiratory tract infections, headache.
• Important Note: This is the subcutaneous version, not IV.  

Nipocalimab-aahu (Imaavy)

• Mechanism: Nipocalimab is an FcRn-blocking monoclonal antibody that lowers circulating IgG autoantibodies.
• Administration: Intravenous (IV).
• Type: Targeted biological therapy.
• Type of MG Antibodies: FDA-approved for generalized MG in adults and pediatric patients age 12 and older who are AChR- or MuSK-antibody positive.
• Vaccination Required: Vaccine needs should be assessed before treatment; live vaccines are generally avoided during treatment.
• Common Side Effects: I cannot confirm a short “most common side effects” list without pulling the full label language, but as an FcRn-targeting therapy, infection monitoring is important.
• Important Note: This is one of the major newer additions missing from your page.  

Eculizumab (Soliris)

• Mechanism: Eculizumab blocks complement protein C5, reducing complement-mediated damage at the neuromuscular junction.
• Administration: Intravenous (IV).
• Type: Targeted biological therapy.
• Type of MG Antibodies: FDA-approved for AChR-antibody positive generalized MG.
• Vaccination Required: Meningococcal vaccination is required before treatment because of the risk of serious meningococcal infection.
• Common Side Effects: Headache, upper respiratory symptoms, infusion reactions, serious infection risk.  

Ravulizumab (Ultomiris)

• Mechanism: Ravulizumab also blocks complement protein C5, but with a longer dosing interval than eculizumab.
• Administration: Intravenous (IV).
• Type: Targeted biological therapy.
• Type of MG Antibodies: FDA-approved for AChR-antibody positive generalized MG.
• Vaccination Required: Meningococcal vaccination is required before treatment.
• Common Side Effects: Upper respiratory infections, headache, infusion reactions, serious meningococcal infection risk.  

Rozanolixizumab-noli (Rystiggo)

• Mechanism: Rozanolixizumab is an FcRn blocker that lowers pathogenic IgG antibodies.
• Administration: Subcutaneous (Subq) infusion.
• Type: Targeted biological therapy.
• Type of MG Antibodies: FDA-approved for adult patients with generalized MG who are AChR-positive or MuSK-positive.
• Vaccination Required: Vaccination status should be reviewed before treatment; live vaccines are generally avoided during treatment.
• Common Side Effects: Headache, diarrhea, fever, hypersensitivity reactions, nausea.  

Zilucoplan (Zilbrysq)

• Mechanism: Zilucoplan is a complement C5 inhibitor that blocks the terminal complement cascade.
• Administration: Daily subcutaneous injection.
• Type: Targeted biological therapy.
• Type of MG Antibodies: FDA-approved for adult patients with generalized MG who are AChR-antibody positive.
• Vaccination Required: Meningococcal vaccination is required before treatment; REMS-related precautions apply because of infection risk.
• Common Side Effects: Injection site reactions, upper respiratory infection, diarrhea.
• Important Note: Your current text should be updated here because meningococcal vaccination is not optional.  

Rituximab (Rituxan)

• Mechanism: Rituximab targets CD20-positive B cells, reducing antibody production.
• Administration: Intravenous (IV).
• Type: Biological therapy.
• Type of MG Antibodies: Often used off-label, especially in MuSK-positive MG and some refractory AChR-positive cases.
• Vaccination Required: Vaccination timing should be reviewed before therapy because B-cell depletion can reduce vaccine response.
• Common Side Effects: Infusion reactions, infections, fatigue, low immunoglobulins in some patients.
• Important Note: Widely used in practice, but not one of the classic FDA-approved MG drugs listed above.  

Cyclophosphamide (Cytoxan)

• Mechanism: Cyclophosphamide suppresses immune cell replication by interfering with DNA.
• Administration: Oral or intravenous (IV).
• Type: Immunosuppressant.
• Type of MG Antibodies: Reserved for severe, refractory MG.
• Vaccination Required: Vaccination planning should be individualized because of significant immunosuppression.
• Common Side Effects: Nausea, vomiting, bone marrow suppression, bladder toxicity, infertility risk, infection risk.  

Thymectomy

• Mechanism: Thymectomy is surgery to remove the thymus gland. It is not a drug, but it is an important treatment option in selected patients.
• Administration: Surgical procedure.
• Type: Surgical treatment.
• Type of MG Antibodies: Most strongly recommended or discussed for generalized AChR-antibody positive MG, especially in appropriate age groups; it is also required when a thymoma is present.
• Vaccination Required: None specifically for the surgery itself, though routine pre-op planning applies.
• Common Side Effects/Risks: Pain, bleeding, infection, anesthesia risks, recovery time.
• Important Note: Benefits may take months to years to show. Thymectomy may reduce symptom burden and lower long-term steroid needs in appropriate patients.