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Although the number of therapeutic options available has increased greatly over the past three decades, experts in the field continue to debate over the therapeutic approach that awards the greatest success for patients with myasthenia gravis (MG). There is no standard measure of disease severity, and no therapy has been demonstrated efficacious by rigorous, prospective controlled studies. Because 22% of untreated patients achieve remission and another 18% experience marked improvement, it is difficult to sort out therapeutic improvement from the natural history of the disease. [1] However, with current modes of therapy the 25% mortality of untreated patients [1] has clearly decreased, suggesting that untreated patients are at risk for exacerbation. The art of providing safe care for patients with MG lies in deciding when to treat and when not to treat aggressively.
No single regimen is appropriate for all patients. The goal of therapy is to produce normal function, with rapid onset of the effect. The ideal therapy should have minimal side effects, be easy to administer, and be available at low cost. A number of factors influence the decision process. The rate of progression, along with the severity and distribution of the weakness, is the most important consideration for immediate therapeutic decisions. Long-term therapy is also influenced by age, gender, the presence of concomitant disease, and the response to previous therapy. Concern for the potential presence of a thymoma is greater in some patients and will alter the plan for therapy.
Clinical considerations also include the general health of the patient, the presence of other diseases such as diabetes mellitus or thyroid disease, and the resources or ability to comply with a therapeutic strategy. At any point in the course, there are influences that may unmask the degree of weakness (Table 1 and Table 2).
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Table 1. …
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