gMG Rescue Therapy Access Varies by Hospital: Richard Nowak, MD, MS

When generalized myasthenia gravis (gMG), a fluctuating autoimmune disease, flares into a moderate or severe exacerbation, the choice between the 2 standard rescue therapies often comes down to which hospital a patient has access to, Richard Nowak, MD, MS, associate professor of neurology at Yale School of Medicine and global principal investigator of the MINT trial (NCT04524273), explained.

Exacerbations can range from mild to severe, with the most serious cases involving bulbar or respiratory muscle weakness severe enough to require mechanical ventilation or a temporary feeding tube. It is not uncommon for these exacerbations to require hospitalization, and those stays can be prolonged while clinicians wait for rescue therapy to take effect.

2 Rescue Therapy Options

Rescue therapy for a gMG exacerbation involves 2 strategies: intravenous immunoglobulin (IVIG) and plasmapheresis, also called plasma exchange or PLEX. IVIG is given intravenously over 2 to 5 days, depending on how the dose is divided, and is generally the simpler of the 2 to administer. Plasmapheresis works differently, filtering the blood to remove pathogenic autoantibodies along with pro-inflammatory cytokines and other factors driving the autoimmune attack.

"It's a bit more invasive in that it does require central catheter placement, something called a Quinton catheter, and it's much more invasive," Nowak said, comparing plasmapheresis with IVIG.

Access Depends on Hospital Tier

Both therapies are commonly used for gMG exacerbations, but which one a patient actually receives often comes down to logistics rather than clinical preference, Nowak said. IVIG's simpler intravenous administration makes it easier to offer broadly. By contrast, plasmapheresis remains largely unavailable at community hospitals and is typically reserved for larger, tertiary centers equipped to place a central catheter.

Even when access is not the deciding factor, both procedures remain burdensome to patients. They are commonly administered in the inpatient setting, with hospitalizations that can stretch on as clinicians wait for a patient's status to improve enough for discharge.

"It depends on the center that a patient is hospitalized in and their access or availability of one vs the other," Nowak said.