Individualized sequencing of targeted immunotherapies in generalized myasthenia gravis across distinct patient profiles

Targeted immunotherapies have expanded treatment options for acetylcholine receptor antibody-positive generalized myasthenia gravis (gMG), but evidence regarding their sequencing and individualized therapeutic pathways remains limited.

We describe seven selected adults with AChR-positive gMG managed through individualized targeted-treatment pathways involving administered and, in some cases, planned sequential therapy. Treatment selection was guided by disease severity, corticosteroid-related risks, presence of thymoma, comorbidities, peripheral venous access and the need for rapid clinical improvement and/or sustained disease management.

Across the seven cases, FcRn antagonists were used for rapid symptom control, corticosteroid dose reduction and bridging therapy while the appropriate vaccinations required before planned complement inhibition or B-cell depletion therapy were completed. Rituximab was selected as a long-term B-cell-directed immunosuppressive strategy, particularly in recent-onset gMG. Ravulizumab was planned as a long-term, non-steroidal immunosuppressive therapy in thymoma-associated myasthenia gravis and in chronic gMG with symptoms refractory to conventional non-steroidal immunosuppressive therapy and dependent on corticosteroids.

These seven cases illustrate how targeted immunotherapies may be used sequentially and individualized according to their onset of action, MG subgroup, treatment goal, required vaccinations and route of administration.