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Guideline for the management of myasthenic syndromes.
Wiendl, Heinz; Abicht, Angela; Chan, Andrew; Della Marina, Adela; Hagenacker, Tim; Hekmat, Khosro; Hoffmann, Sarah; Hoffmann, Hans-Stefan; Jander, Sebastian; Keller, Christian; Marx, Alexander; Melms, Arthur; Melzer, Nico; Müller-Felber, Wolfgang; Pawlitzki, Marc; Rückert, Jens-Carsten; Schneider-Gold, Christiane; Schoser, Benedikt; Schreiner, Bettina; Schroeter, Michael; Schubert, Bettina; Sieb, Jörn-Peter; Zimprich, Fritz; Meisel, Andreas.
  • Wiendl H; Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, Münster 48149, Germany.
  • Abicht A; Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany.
  • Chan A; Universitätsklinik für Neurologie, Inselspital Bern, Bern, Switzerland.
  • Della Marina A; Klinik für Kinderheilkunde I, Universitätsklinikum Essen, Essen, Germany.
  • Hagenacker T; Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany.
  • Hekmat K; Herzzentrum, Uniklinik Cologne, Cologne, Germany.
  • Hoffmann S; Charité - Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany.
  • Hoffmann HS; Klinik für Thoraxchirurgie, Krankenhaus Barmherzige Brüder, Regensburg, Germany.
  • Jander S; Klinik für Neurologie, Marien Hospital Düsseldorf, Düsseldorf, Germany.
  • Keller C; Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany.
  • Marx A; Pathologisches Institut, Universitätsklinikum Mannheim, Mannheim, Germany.
  • Melms A; Facharztpraxis für Neurologie und Psychiatrie, Stuttgart, Germany.
  • Melzer N; Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany.
  • Müller-Felber W; Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU Munich, Munich, Germany.
  • Pawlitzki M; Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany.
  • Rückert JC; Chirurgische Klinik, Charité - Universitätsmedizin Berlin, Berlin, Germany.
  • Schneider-Gold C; Neurologie, Katholisches Klinikum Bochum, Bochum, Germany.
  • Schoser B; Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany.
  • Schreiner B; Klinik für Neurologie, Universitätsspital Zürich, Zürich, Switzerland.
  • Schroeter M; Klinik und Poliklinik für Neurologie, Uniklinik Cologne, Cologne, Germany.
  • Schubert B; Deutsche Myasthenie Gesellschaft e.V., Bremen, Germany.
  • Sieb JP; Helios Hanseklinikum Stralsund, Stralsund, Germany.
  • Zimprich F; Universitätsklinik für Neurologie, AKH-Wien, Wien, Austria.
  • Meisel A; Charité - Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany.
Ther Adv Neurol Disord ; 16: 17562864231213240, 2023.
Article en En | MEDLINE | ID: mdl-38152089
ABSTRACT
Myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS), and congenital myasthenic syndromes (CMS) represent an etiologically heterogeneous group of (very) rare chronic diseases. MG and LEMS have an autoimmune-mediated etiology, while CMS are genetic disorders. A (strain dependent) muscle weakness due to neuromuscular transmission disorder is a common feature. Generalized MG requires increasingly differentiated therapeutic strategies that consider the enormous therapeutic developments of recent years. To include the newest therapy recommendations, a comprehensive update of the available German-language guideline 'Diagnostics and therapy of myasthenic syndromes' has been published by the German Neurological society with the aid of an interdisciplinary expert panel. This paper is an adapted translation of the updated and partly newly developed treatment guideline. It defines the rapid achievement of complete disease control in myasthenic patients as a central treatment goal. The use of standard therapies, as well as modern immunotherapeutics, is subject to a staged regimen that takes into account autoantibody status and disease activity. With the advent of modern, fast-acting immunomodulators, disease activity assessment has become pivotal and requires evaluation of the clinical course, including severity and required therapies. Applying MG-specific scores and classifications such as Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, and Myasthenia Gravis Foundation of America allows differentiation between mild/moderate and (highly) active (including refractory) disease. Therapy decisions must consider age, thymic pathology, antibody status, and disease activity. Glucocorticosteroids and the classical immunosuppressants (primarily azathioprine) are the basic immunotherapeutics to treat mild/moderate to (highly) active generalized MG/young MG and ocular MG. Thymectomy is indicated as a treatment for thymoma-associated MG and generalized MG with acetylcholine receptor antibody (AChR-Ab)-positive status. In (highly) active generalized MG, complement inhibitors (currently eculizumab and ravulizumab) or neonatal Fc receptor modulators (currently efgartigimod) are recommended for AChR-Ab-positive status and rituximab for muscle-specific receptor tyrosine kinase (MuSK)-Ab-positive status. Specific treatment for myasthenic crises requires plasmapheresis, immunoadsorption, or IVIG. Specific aspects of ocular, juvenile, and congenital myasthenia are highlighted. The guideline will be further developed based on new study results for other immunomodulators and biomarkers that aid the accurate measurement of disease activity.
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