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Drugs To Avoid in Myasthenia Gravis
Drugs To Avoid in Myasthenia Gravis
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http://dig.pharm.uic.edu/faq/myasthenia.aspx
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prednisone
Analgesics
narcotics
Anesthetics, local
Maalox, Mylanta
Antiarrhythmics
Antibiotics
Anticonvulsants
phenytoin
Antihypertensives
Antimanics
lithium salts
Antipsychotics
chlorpromazine
Antirheumatic
chloroquine
Arthritis agents
chloroquine, hydroxychloroquine
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http://dig.pharm.uic.edu/faq/myasthenia.aspx
response to the expression of interferon on motor endplates. The onset is from 6 to 9 months,
and it has been reported to last up to 7 months after discontinuation.
Corticosteroids, although a mainstay in the management of moderate to severe myasthenia
gravis, can also cause an exacerbation of muscle weakness.1-3 Patients are generally started
on high doses of prednisone (60 to 100 mg/day) until the disease is in remission, then the
dose is tapered to the lowest possible daily dose, and eventually switched to an every
other-day regimen. Approximately 20% to 50% of patients initiated on high dose prednisone
will have an exacerbation of their disease in the first days to weeks of therapy, which is then
followed by a period of remission.
Overdoses of cholinesterase inhibitors may also exacerbate myasthenia gravis.3 Excessive
doses can result in acetylcholine accumulation, which causes increased bronchial secretions
leading to difficulty swallowing or breathing. It has been suggested that weakness 1 hour after
administration of pyridostigmine could indicate overdose, while weakness 3 or more hours
following a dose could indicate a suboptimal response to therapy.
Aminoglycosides are cited in numerous case reports involving their concomitant use with
neuromuscular blockers.1,3,4 Postoperative respiratory depression was reported in nearly all
cases. Limb or facial weakness has also been reported. Aminoglycosides have also been
documented to exacerbate preexisting myasthenia gravis, and have lead to worsening
symptoms within 1 hour of administration.
Summarized below are various medications that have been associated with exacerbations of
myasthenia gravis.
Table 1. Medications to be used with caution in myasthenia gravis.3-7
Drug
Resolution
Prednisone
1 to 2 weeks
1 to 20 days
Streptomycin
<24 hours
minutes
2 to 48 hours
Botulinum toxin
minutes
2 weeks
Procainamide
2 days to 2 weeks
12 hours to 10 days
Erythromycin
Ciprofloxacin
4 hours to 2 days
Several days
Ampicillin
48 hours
Quinidine
72 hours
48 hours
Lithium
10 days to 3 months
3 to 4 days
Timolol, acebutolol,
propranolol, oxprenolol,
practolol
24 hours to 8 weeks
Penicillamine
8 months
6 to 10 months
Chloroquine
5 days to 14 weeks
Phenytoin
4 to 6 years
2 to 3 months
Imipenem-cilastin
2 days
48 hours
Verapamil
4 days
2 weeks
Trimethaphan
2 to 17 hours
Procaine
7 minutes
Lidocaine
7 minutes
Aprotinin
during infusion
10 to 90 minutes
Levocarnitine
3 weeks
Several other drugs have been found to worsen myasthenia gravis including telithromycin,
magnesium, oxytocin, neuromuscular blockers, and anticholinergics.3-7 The Myasthenia
Gravis Foundation of America has a resource document for healthcare professionals that
discusses medications that may exacerbate myasthenia gravis (http://www.myasthenia.org
/hp_medicationsandmg.cfm). The document was last updated in January 2007.
In summary, many drugs have been implicated as a cause of myasthenia gravis or disease
exacerbation. Although the literature regarding implicated medications is limited, caution and
close monitoring when prescribing these agents is recommended, especially during an acute
exacerbation.
References
1. Barrons RW. Drug-induced neuromuscular blockade and myasthenia gravis.
Pharmacotherapy. 1997;17(6):1220-1232.
2. Vincent A, Palace J, Hilton-Jones D. Myasthenia gravis. Lancet. 2001;357:2122-2128.
3. Wittbrodt ET. Drugs and myasthenia gravis: an update. Arch Intern Med.
1997;157:399-408.
4. Karcic AA. Drugs that can worsen myasthenia gravis. Postgrad Med. 2000;108(2):25.
5. Pascuzzi R. Myasthenic crisis. Postgrad Med. 2000;107(4):211-222.
6. Yarom N, Barnea E, Nissan J, Gorsky M. Dental management of patients with
myasthenia gravis: A literature review. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2005;100(2):158-163.
7. Kuczkowski KM. Labor analgesia for the parturient with neurological disease. Arch
Gynecol Obstet. 2006;247(3):41-46.
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