Intravenous immunoglobulin to prevent myasthenic crisis after thymectomy and other procedures can be omitted in patients with well-controlled myasthenia gravis

Abstract

Background: Myasthenic crisis (MC) is a potentially life-threatening complication of myasthenia gravis. Its precipitating factors include surgical procedures, particularly thymectomy. The role of preoperative intravenous immunoglobulin (IVIg) in preventing MC in patients scheduled for thymectomy and other surgery with general anaesthesia is unknown. Our objective was to test the hypothesis that preoperative IVIg is effective in preventing myasthenic crisis in patients with myasthenia gravis scheduled for surgery under general anaesthesia, including thymectomy. Methods: A prospective, randomized, double-blind, single-centre study was conducted over a 4-year period. The treatment group received IVIg, 0.4 g/kg/day preoperatively for 5 consecutive days, and the placebo group received saline solution under the same conditions. The two groups were age-matched, with similar functional status, and Myasthenia Gravis Foundation of America class. All patients had well-controlled myasthenia gravis with minimal manifestations before surgery. The primary outcome measured was MC. Intubation times, time in the recovery room, number of postoperative complications, and days of hospitalization were the secondary outcomes measured. Results: A total of 47 patients were randomized, 25 to the IVIg group and 22 to placebo. There were 19 men and 28 women, with a mean age of 58.6 years, mean body mass index of 27.8 kg/m2, and mean acetylcholine receptor antibodies of 12.9 nmol/l. The mean forced vital capacity was 84.4%. The mean quantitative myasthenia gravis sum score was 6.3. Ten patients (five in each arm) had a history of MC. Thymectomy was performed in 16 patients. Only one patient in the placebo group presented with MC requiring non-invasive ventilation (but no reintubation) for 6 days. Neither differences between groups in the univariate analysis nor risk factors for MC in the multivariate analysis were found. Conclusions: Preoperative IVIg to prevent MC does not appear to be justified in well-controlled myasthenia gravis patients. This study provides class I evidence that preparation with IVIg to prevent MC is not necessary in well-controlled myasthenia gravis patients scheduled for surgery with general anaesthesia.

Intrapericardial Thymoma Presented as Pericardial Tamponade with Post-Operative Myasthenia Gravis

“…Some studies suggest that mature T cells are transferred into the peripheral blood before removal, potentially stimulating autoantibody production [ 14 ]. According to the study performed by Gamez et al [ 15 ], preoperative intravenous immunoglobulin (IVIg) to prevent myasthenia crisis is not warranted in well-controlled MG patients. It was concluded that IVIg therapy to prevent myasthenia crisis is not necessary in well-controlled myasthenia gravis patients scheduled for surgery.…”

Intravenous immunoglobulins may prevent prednisone-exacerbation in myasthenia gravis

“…Only those meeting the eligibility criteria were included (the inclusion and exclusion criteria are specified in Supplementary Table S1). As other international recent studies 32,36 , we also included mild generalized MG patients (MGFA class IIA of the MGFA functional class and minimal manifestations category of the MGFA Post-Intervention Status at study inclusion).…”

“…Currently there is class A evidence to use IVIG to treat exacerbations of MG 31 . In addition, some authors recommend IVIG or PLEX before thymectomy to prevent a myasthenic crisis 22 , although a recent clinical trial did not demonstrate such benefit for IVIG 32 . Other authors suggest that treatment with IVIG or PLEX can prepare patients who are to receive immunosuppressives 22,33 , and an international consensus on the management of MG has stated that treatment with IVIG and PLEX before starting corticosteroids is appropriate in an effort to prevent or minimize exacerbations 34 .…”

Prevention of Adverse Outcomes and Treatment Side Effects in Patients with Neuromuscular Disorders

“…Similarly, routine preoperative IVIg is not warranted in well-controlled MG patients. 219 A single-center study comparing preoperative IVIg to PLEX showed that IVIg was superior with reduced intubation period and surgical time, 220 whereas another study showed that both modalities may be equi-efficacious. 221 In general, surgical planning requires a multidisciplinary approach involving the treating neurologist, surgeon, and anesthesiologist for optimizing the outcome.…”