Involve Specialist Support

Key Point:

The course of MG is difficult to predict [12].

A MG patient in crisis will need ICU admission for one or more of the following:

• Respiratory support
• Fluid and electrolyte management
• Intravenous immunoglobulins: 2 g/kg given over 2-5 days [8-9]
• Plasmapheresis: 2-3 L of plasma is removed three times a week until improvement. Most patients require a total of five or six exchanges [8-9]

In a recent study in the US, the trend of IVIG utilisation has increased compared to plasma exchange and thymectomy [7].

Although there are reports of successful treatment of MC with continuous intravenous infusion of pyridostigmine, there is generally no role for cholinesterase inhibitors in the acute setting of MC. There is a risk of life-threatening cardiac arrhythmias due to the muscarinic effects of intravenous cholinesterase inhibitors [8,11].

Learning bite

All MG patients who present to ED with signs of MG exacerbation or a complication associated with MG treatment require admission and expert evaluation.

Learning bite

Continuous infusion of cholinesterase inhibitors is associated with life-threatening cardiac arrhythmias and is unsafe.