Myasthenia Gravis in Acute Care
- Contact on call neurology registrar as soon as possible (including out of hours) for patients with a history of Myasthenia Gravis (MG) who are experiencing MG related issues.
- Contact on call neurology registrar after admission for patients with a history of MG but are not experiencing symptoms.
Symptoms of MG
- Difficulty swallowing, speaking or chewing
- Double vision and ptosis
- Neck and limb weakness
- Type II respiratory failure.
- It is crucial not to withhold MG medicines for any significant length of time, i.e. >2 hours, or to miss any doses of pyridostigmine or steroids as there is a risk of myasthenic crisis.
- Before prescribing any new medicine, check if the medicine may affect patients with MG by referring to the GGC guideline Myasthenia Gravis or Lambert-Eaton Myasthenia Syndrome, medicines that may affect patients.
- High risk situations include: nil by mouth status, infection and surgical procedures.
- It is important for pyridostigmine to be administered at exact times. Ensure no missed doses. For further guidance see Pyridostigmine for Myasthenia Gravis Q&A.
- Where a patient does not have an individual supply of pyridostigmine (Mestinon®), this must be obtained urgently via pharmacy during working hours or via the local emergency cupboard, hospital co-oridinator, ward 67 at the Queen Elizabeth University Hospital or the on call pharmacist via switchboard if out of hours.
- Overdose of pyridostigmine can lead to cholinergic crisis. For further guidance, refer to Pyridostigmine for Myasthenia Gravis Q&A).
Nil by mouth
- Administration of medication via nasogastric (NG) feeding tube is the preferred option in patients who are unable to swallow. Pyridostigmine and prednisolone (not enteric coated, E/C) tablets can be crushed and mixed with water. See Pyridostigmine for Myasthenia Gravis Q&A for further guidance.
- Any delays in passing NG tube, or if NG insertion is not possible, seek senior medical and neurology advice as soon as possible.
- Continue regular immunosuppressant drugs.
- Stable MG patients may not require any change in steroid dose.
Severe infection or sepsis
- Withhold regular immunosuppressant drugs (and discuss with MG team).
- Consider increasing steroid dose after consulting with MG/neurology team.
Patients with stable MG can usually revert to baseline steroid dose once infection is treated (provided <3 weeks on higher dose). Patients with active MG may require slower reduction in steroid dose (consult MG team).
Patients undergoing surgical procedures
- Patients should continue with regular medication for MG pre- and post-operatively.
- Discuss on a case by case basis with an anaesthetist and MG team.
Guideline reviewed: April 2023
Page last updated: May 2023