Pharmacological and speech-language pathology management of dysphagia in patients with myasthenia gravis

Myasthenia gravis (MG) is a rare, complex autoimmune neuromuscular disorder characterized by fluctuating muscle weakness. Bulbar involvement, particularly dysphagia (difficulty swallowing), is a common and debilitating symptom that significantly increases the risk of aspiration pneumonia, malnutrition, and dehydration, profoundly impacting quality of life. The management of myasthenic dysphagia requires a sophisticated, interdisciplinary approach. This review aims to provide a comprehensive overview of the current and emerging pharmacological treatments for myasthenia gravis and to detail the specific assessment and management strategies employed by speech-language pathologists (SLPs) for associated dysphagia. A narrative review of the literature was conducted, focusing on the pathophysiology, classification, and treatment of MG, with a specific emphasis on bulbar dysfunction. The review synthesizes evidence for traditional immunosuppressants, novel targeted biologics (complement inhibitors and FcRn antagonists), and evidence-based speech-language pathology interventions. Pharmacological management has evolved from symptomatic treatment (anticholinesterases) and broad immunosuppression (corticosteroids, azathioprine) to highly specific, targeted therapies. Complement inhibitors (e.g., eculizumab, ravulizumab) and neonatal Fc receptor (FcRn) antagonists (e.g., efgartigimod, rozanolixizumab) have demonstrated significant and rapid efficacy in reducing autoantibody load and improving clinical scores (MG-ADL, QMG) in generalized MG, including for patients with refractory disease. Concurrently, SLP management is critical for functional safety and efficacy. This includes precise assessment using clinical (e.g., EAT-10, bedside swallowing evaluations) and instrumental methods (VFSS, FEES) to characterize the pathophysiology of weakness and fatigability. Management is individualized, focusing on compensatory strategies (e.g., postural adjustments, diet modification standardized by the IDDSI framework) and behavioral techniques, all timed to coincide with peak medication efficacy. The treatment landscape for MG has been revolutionized by targeted biologics, offering profound improvements for many patients. Effective management of dysphagia, however, relies on the synergy between optimal medical therapy and specialized SLP intervention. This integrated approach is essential to ensure swallowing safety, nutritional adequacy, and improved quality of life for individuals living with myasthenia gravis.