Myasthenia gravis: balancing traditional immunotherapies and newer medications

AAt the annual meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM), Michael Hehir, MD, of the University of Vermont in Burlington, participated in a panel discussion on the integration of new and traditional therapies in the management of myasthenia gravis.

In this video, Hehir discusses various considerations, including effectiveness, side effects, and costs, that help guide optimal treatment.

Here is a transcript of his remarks:

2024 is an exciting time when it comes to the development of treatments for myasthenia gravis. Since 2017, five new therapies have been approved for the treatment of our patients in two main therapeutic classes. Some of these treatments are intravenous, others are administered subcutaneously. And the two major classes are FcRn inhibitors, which cause a reduction in overall antibody circulation, and complement inhibition, which impacts the complement system, which is one of the major pathways of muscle damage in myasthenia gravis.

And these drugs have proven effective for patients in clinical trials and in clinical practice. One of their main uses has been to treat patients who do not respond to the more traditional immunotherapies that we have used in the past.

At the AANEM meeting, we held an initial panel session to discuss where we should place some of these new drugs in the treatment paradigm for patients with myasthenia gravis versus other therapies, which also work. Some of the data we have looked at concerns the likelihood that older and new generation therapies may cause myasthenia gravis patients to have minimal or no symptoms, whether or not new generation or more traditional therapies have better side effect profile than others. And then a big concern – and something I talked about in my discussion – is the cost of therapy, particularly new generation therapies.

So I think the main takeaway is that we still have a lot of work to do. We have therapies that have been around for many years and are very effective in helping patients have few or no symptoms over time. But some of these therapies can take a long time for this to happen. Newer therapies may be more effective in achieving this better clinical state, and these other therapies may be more effective in maintaining this good clinical state.

And what we really need to do is start thinking about how to compare these different treatments head to head. We need to think about effectiveness, but also about treatment burden and whether newer or older drugs are more effective in terms of treatment burden. So things like side effects or difficulty getting your therapy. Do you have to drive to an infusion center? Do you have to sit in an infusion chair? Is this a self-administered medication? There are a lot of questions that I think we need to answer as a community and hopefully in a research setting, to understand what the best strategies are for particular patients.

I think the take-home message is that there are many options for treating patients with myasthenia gravis in 2024, and that it’s really important to engage your patient in a discussion about the types of things that are important to them . Is this a patient who needs oral therapy because they travel a lot? Is this a patient who would agree to come and receive periodic infusions? Is this a patient whose treatment has failed in the past and needs a newer medication because they’re just not doing well? And then while thinking about distributive justice as physicians, we have to consider the cost, and our healthcare system over time might not be able to support those costs, so we might not be able to afford them. use for each patient. We might want to be more selective.