Getting to Remission What it Takes

Getting to Remission What it Takes

Living a Symptom-Free Life with Myasthenia Gravis: Understanding Remission and Treatment Options

By Richard J. Nowak, MD, as told to Keri Wiginton

Myasthenia Gravis

Living with myasthenia gravis (MG), a chronic autoimmune condition, can be challenging. But the good news is that it is treatable. With the right treatment plan, tailored to each individual’s needs, achieving remission becomes a possibility. Remission means living symptom-free or close to it. Let’s dive into what remission entails and how to reach it.

What is Remission?

Remission is a term that is often loosely used, but there are specific definitions for it. The Myasthenia Gravis Foundation of America (MGFA) provides a comprehensive breakdown of remission stages. The first and most challenging stage to achieve is complete stable remission. To be classified as such, a person should show no evidence of disease activity or muscle weakness during a check-up and be off medication for at least one year. It’s important to note that even if someone is symptom-free earlier than the 12-month mark, it does not technically qualify as remission based on the definition.

A more common scenario is referred to as pharmacological remission. This category shares the same definition as complete stable remission, but individuals in this stage require medication or therapy to manage their MG symptoms. Another group that exists is called minimal manifestations status. Although not classified as remission, individuals in this group experience minimal impact on daily life and may have occasional muscle weakness or fatigue.

How Can Remission be Achieved?

While symptoms may disappear on their own, spontaneous remission in MG is rare. More often, treatment is needed to target the immune system. The treatment options will depend on various factors such as disease severity, specific muscle weakness areas, age, other existing health conditions, and positive antibody test results.

For those with mild symptoms, muscle-strengthening drugs like pyridostigmine may be sufficient to control the symptoms. However, it’s essential to note that this medication does not target the underlying cause of MG.

If the disease is more aggressive, stronger treatment is necessary to gain symptom control. Corticosteroids, such as prednisone, are often the first line of treatment. These drugs work quickly, typically within days to weeks, but they are not a long-term solution due to potential side effects like weight gain, osteoporosis, and elevated blood sugars. After symptom control is achieved, it is common to transition to other medications with fewer side effects, such as azathioprine or mycophenolate, which can take 6 to 12 months to show results.

For individuals with MuSK antibody-positive generalized MG, rituximab may be recommended. This treatment has shown promising results, with some achieving remission after two to four cycles. Evidence regarding the effectiveness of rituximab for acetylcholine receptor (AChR) antibody-positive generalized MG is mixed. Additionally, newer immunotherapies like C5 complement inhibitors and FcRn inhibitors have been approved to treat AChR-associated MG, but they may not work for everyone.

The Role of Thymectomy

Thymectomy, the removal of the thymus gland, has been proven to reduce MG symptoms and the need for immunosuppressive therapies like steroids. Elective thymectomy is often recommended for younger individuals with AChR antibody-positive generalized MG, mainly those in their 20s to early 50s. However, there is insufficient data to support thymectomy as a routine recommendation for individuals aged 65 and older.

It’s always important to discuss thymectomy with your doctor, as it might be a viable option for your specific condition.

What Does Remission Look Like?

Achieving remission means different things to different individuals. Some experience complete symptom resolution and claim they feel as if they don’t have the disease at all. However, partial recovery is also considered remission. In some cases, “fixed weakness” may persist due to long-standing disease and muscle damage. For example, individuals may have a subtle or moderate eyelid droop that remains even in remission.

It’s worth noting that individuals with MG often have other health conditions, which may continue to cause pain, weakness, or mobility problems despite being in MG remission.

Finding the Right Remission Treatment

Determining the best treatment for remission is an ongoing challenge due to a lack of markers indicating which drugs may lead to complete or partial response, or even a lack of response. However, your neurologist should discuss all available treatment options, their risks, and benefits with you. It is crucial to maintain open communication with your doctor regarding your progress and discuss any significant symptoms or exacerbations. Regular follow-ups are necessary, as exacerbations can occur even after achieving remission, especially triggered by infections.

Living a symptom-free life with MG may be within reach, thanks to the range of treatment options available. By working closely with your healthcare team and exploring all possible avenues, the goal of remission becomes more attainable. Remember, each case is unique, so finding the right treatment plan tailored to your specific needs is essential.