Treatment of Myasthenia Gravis in the Aged

Myasthenia gravis is diagnosed at a progressively later age and the incidence continuously increases in the aged with a clear male predominance. People above the age of 65 constitute more than 50% of the newly diagnosed. Commonly, patients present with focal (ocular or bulbar) weakness. A high index of suspicion is needed to achieve early diagnosis and improve prognosis. Management options include acetylcholinesterase inhibitors, steroids, and immunosuppressants. Of the immunosuppressants, azathioprine is one of the most widely used due to its demonstrated effect and favorable side-effect profile. Others include cyclosporine, tacrolimus, mycophenolate mofetil, and cyclophosphamide. The use of mycophenolate mofetil is still controversial. Monoclonal antibodies, like rituximab, eculizumab, and belimumab, are relatively new therapeutic options in autoimmune diseases. Rituximab is of special interest in muscle-specific tyrosine kinase antibody-positive patients. A novel skeletal muscle activator and stem cell transplantation are being studied. There is no place for standard thymectomy in the older age groups except for thymomas and with computer-assisted endoscopy. Generally, the disease responds well to treatment at this age but comorbidities make medication choice more complex. Successful treatment is associated with improved survival, and quality of life can be remarkably improved during the whole survival period. As the median age of onset is 65 years and has been increasing steadily, it appears necessary to review the subject of treatment of myasthenia gravis in the aged.