Treatment and clinical research in myasthenia gravis: how far have we come?

Although once an often fatal illness, myasthenia gravis can now be well managed with relatively safe and effective therapies. Prior to 1960 mortality for myasthenia gravis was approximately 30%. In the current era, mortality should be less than 5%. Major therapeutic advances by decade were: physostigmine and thymectomy (1930s); mechanical ventilation (1950s); corticosteroids and plasmapheresis (1960s); azathioprine (1960s-1970s); cyclosporine (1980s); intravenous gamma globulins (1980s-1990s); and most recently mycophenolate mofetil (1990s-2000s). Modern management involves a graded approach, beginning with cholinesterase inhibitors for mild symptoms and advancing to immunomodulating medications for more severe weakness. We now have several immunomodulating agents from which to choose: selection is based largely on time to clinical effect and adverse effects. The various available treatment modalities all have their limitations. In addition, some controversies remain regarding the effectiveness of some of the commonly used myasthenia gravis treatments. Recently completed and ongoing clinical trials suggest that there is still equipoise regarding the benefit of mycophenolate mofetil and thymectomy. Hopefully, the future will be promising, with clinical trials involving novel immunotherapeutic strategies.