1. Prednisone for MG Richard J. Barohn, MD Gary Gronseth, MD
Richard J. Barohn, MD
Gary Gronseth, MD
Chair, Department of Neurology
Vice Chair, Department of Neurology
Gertrude and Dewey Ziegler Professor of Neurology
University Distinguished Professor
Vice Chancellor for Research
University of Kansas Medical Center
Kansas City, KS

2. Treatment of MG Cholinesterase Inhibitors
Pyridostigmine (Mestinon)
Prostigmine (Neostigmine)
Immunosuppressive Drug Therapies
Plasmapheresis
Surgery
Thymectomy

3. Benefit from Alternate-Day Prednisone in Myasthenia Gravis
5 MG Pts
Prednisone 100mg every other day
Single AM dose
With daily K⁺, antacids, low Na/ carb diet
All improved in hrs
1 CR
JR Warmolts, WK Engel. N Engl J Med 1972; 286:17-20

4. Treatment of Myasthenia Gravis with Prednisone Jenkins RB. Lancet
8 MG pts Rx with prednisone for between 6 and 25 months
Alternate day trials
7/8 improved

5. ALERNATE-DAY PREDNISONE: PRELIMINARY REPORT OF A DOUBLE-BLIND CONTROLLED STUDY
Howard et al, Ann NYAS 1976
13 Pts: 6 Pred / 7 Plac
100 mg qod x 6 mo vs. plac
All on Anticholinesterase
Imp No Imp Rem
Pred
Plac
Rep Stim - No Diff
Conc: No stats 2° small #s Not all Pred pts imp Some Plac pts imp

6. Prednisone Rx For MG U. Virginia Experience: Pascuzzi & Johns
116 Pts – Anals Neurol 1984;15:291
Dose – Initiation mg/day
Maintenance alternate day
Early exacerbation 48%
9% required intubation
28% asymptomatic – pharmacologic remission
52% marked improvement
15% moderate improvement
5% no improvement
Mean Time t o Max Benefit – 5.5 Months
Range 2 weeks to 6 years
Only 14% of Responders were able to D/C Prednisone
Thymectomy did not improve likelihood of D/C steroids: 8/51 vs. 5/42
Sghirlanzoni et al, Neurol 1984;34:170
60 pts; Imp 72%
Evoli et al, Eur Neurol 1992;32:31
104 pts; Imp 81.7%

7. Treatment of myasthenia gravis with a methylprednisolone pulse: a double blind study Lindberg, Andersen, Lefvert. Acta Neurol Scand 1998;97:
20 pts
10 IVMP / 10 PLAC
2 grams IVMP x 2 days
At 2 weeks:
IVMP imp muscle fatigue by 27 points
PLAC unchanged; P =
8/10 responded in IVMP group & 1/9 in PLAC
Duration of imp – 4, 6, 6, 8, 10, 14 weeks
1 pt in IVMP reported initial worsening
No other AE’s

8. Prednisone Rx for MG High Dose
100 mg/day x 2 weeks
Then 100 mg qod until much better
Then taper 5 mg q 2 wks
Requires initial inpatient admission
Low / Slow Approach
Seybold & Drachman 1974
Gradual inc to avoid initial worsening
10 mg/day; inc by 10 mg q 5-7 days
Then switch to qod
In-between Approach
Mycophenolate trial protocol
- Pred 20 mg/day
No randomized trial of prednisone in MG, but it works!
Probably most effective drug for MG
Even given potential side effects

9. MG Treatment Side effects of prednisone Type 2 muscle fiber atrophy
But true steroid myopathy rare
Hypertension
Glucose intolerance (diabetes)
Low potassium
Fluid retention and weight gain
Cataracts
Risk of infection
Osteoporosis, aseptic femoral necrosis

10. MG Treatment Concurrent Management
Chest X-ray and PPD or new Quantiferon TB blood test prior to treatment
Vitamin D and calcium supplementation for prophylaxis against osteoporosis
Baseline bone density DEXA scan and then annual
Alendronate (Fosamax) as needed
Dietary consult to instruct on low carbohydrate, low sodium diet
Check potassium, glucose, blood pressure, eyes on follow-up

11. Corticosteroid Treatment for MG
Rx for MG since 1970
Pred can decrease AChR-Ab level (Tindall, 1980)
Improvement begins to occur in 2-4 weeks
Maximum benefit in 6 months
Transient worsening occurs in 50% of patients during first week
“Remission” is often steroid dependent
Still most effective therapy for MG