Drugs to avoid or use with caution in patients with myasthenia

gravis*

Anesthetic agents
Neuromuscular blocking agents (eg, rocuronium, vecuronium, succinylcholine) ¶

Antibiotics
Aminoglycosides Δ (eg, amikacin, gentamicin, neomycin, tobramycin)

Fluoroquinolones Δ (eg, ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin)

Macrolides (eg, azithromycin, clarithromycin, erythromycin)

Cardiovascular drugs
Beta blockers (eg, atenolol, labetalol, metoprolol, propranolol)

Procainamide

Quinidine

Others
Botulinum toxin

Chloroquine

Deferoxamine (desferrioxamine)

Glucocorticoids (eg, dexamethasone, prednisone) ◊

Statins (HMG-CoA reductase inhibitors; eg, atorvastatin, pravastatin, rosuvastatin)

Hydroxychloroquine

Immune checkpoint inhibitors (eg, atezolizumab, ipilimumab, nivolumab, pembrolizumab)

Iodinated contrast §

Magnesium ¥

Penicillamine ‡

Quinine

HMG-CoA: hydroxymethylglutaryl coenzyme A; IVIG: intravenous immune globulin.

* This is not a complete list of all drugs that may, in individual patients, adversely affect
neuromuscular transmission and worsen myasthenia gravis symptoms. If such drugs are
used, they should be administered cautiously with appropriate monitoring. Refer to
UpToDate for additional information.
¶ Response to neuromuscular blocking agents is unpredictable in patients with
myasthenia. Use only when necessary, guided by neuromuscular monitoring.
Δ Reserve use for hospitalized patients when alternative agents are unavailable.
◊ Glucocorticoids at high dose may cause transient worsening of symptoms during first
one to two weeks of treatment. They should be used with caution; when administered for
hospitalized patients in myasthenic crisis, concurrent plasmapheresis or IVIG should be
coadministered.
§ Increased weakness in MG has been reported with use of older iodinated contrast
agents; modern iodinated contrast agents appear generally safe.
¥ Intravenous administration (eg, with magnesium sulfate, magnesium chloride) is
relatively contraindicated due to significant inhibitory effect on acetylcholine release.
‡ Strongly associated with worsening myasthenia gravis; avoid use.

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