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Therapy for myasthenia gravis can be divided into four groups: symptomatic treatment; immunosuppressive medication; short-term immunosuppressant treatment; and surgical thymectomy (removal of the thymus gland).
Symptomatic treatment
The anticholinesterase drugs (such as pyridostigmine and neostigmine) improve strength by improving neuromuscular junction transmission without altering the autoimmune disorder. They are therefore useful only to lessen symptoms and are usually used in combination with another form of more substantive treatment. High doses of anticholinesterases can cause paradoxical weakness and be confused with a worsening of the symptoms of the disease.
Immunosuppressive medication
Prednisone and azathioprine remain the main immunosuppressive agents used in the treatment of myasthenia gravis. The choice of agent depends on the goals of therapy.
Prednisone (a corticosteroid) given daily in a high dose is both effective and rapid in onset of action. It carries however both short- and long-term potential side effects. Additionally, high-dose daily corticosteroids can cause a transient, potentially severe exacerbation of weakness in about a quarter of patients during the first week of treatment. In this situation, the drug is then often given on alternate days only.
Azathioprine is an effective drug but usually requires three to 12 months of use prior to the onset of a therapeutic benefit. It can be used alone in mild cases or added as a steroid-sparing drug to allow the dose of prednisone to be reduced. The main complications involve bone marrow suppression and altered liver function.
Cyclosporine has only recently been introduced in the treatment of myasthenia gravis. It is used in cases that do not respond to conventional treatment and for those intolerant of corticosteroids. It can affect kidney function and cause high blood pressure.
Short-term immunosuppressant treatment Short-term immunosuppressant treatments include plasma exchange and intravenous gamma globulin. Both promote rapid improvement in muscle weakness. Although these treatments are known to alter the function of the immune system, the actual mechanism of action is not clear. They are mainly used in myasthenic crisis, other less severe exacerbations of the disease and preparation of a weak patient for thymectomy. Both are expensive, but they have a limited role in maintenance therapy in some patients.
Surgical thymectomy
Thymectomy is considered the only therapy for myasthenia gravis that offers a significant chance for a drug-free remission. Additionally, the procedure is essential in those patients with thymomas for removal of the growth. Early surgical removal of as much of the thymus gland as possible appears to offer the best therapeutic benefits.
For most patients with pure ocular (eye) or very mild generalized myasthenia gravis, symptomatic treatment alone is enough. Occasionally, the disabling symptom of double vision will necessitate the use of immunosuppressive drugs, but for the most part these medicines are reserved for significant generalized disease.
Surgical thymectomy is usually indicated as the first line of treatment for patients with significant generalized myasthenia gravis between puberty and about 50 years of age, as well as all patients with a thymoma.
Patients with late-onset generalized myasthenia gravis frequently have marked difficulty with swallowing and breathing; high-dose corticosteroids are consequently often needed to prevent aspiration and/or respiratory insufficiency.
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There are three therapeutic options in the TCM treatment of myasthenia gravis: the regularization of disharmony patterns, use of Chinese patent medicines and acupuncture therapy.
Therapeutic regimens for disharmony patterns
| Qi-deficiency in the spleen and stomach |
Therapeutic aim: To Tonify the spleen and benefit the qi
Prescription: Buzhong yiqi decoction (modified)
| dang shen |
pilose asiabell root |
| huang qi |
milk-vetch root |
| bai zhi |
large head atractylodes root |
| sheng ma |
cimicifuga rhizome |
| chai hu |
Chinese thorowax root |
| chen pi |
dried tangerine peel |
| dang gui |
Chinese angelica |
| sheng jiang |
fresh ginger |
| da zao |
Chinese date |
| yi yi ren |
coix seed |
| fu ling |
Indian bread |
In this prescription, pilose asiabell, milk-vetch and large head atractylodes roots are used to tonify the spleen and benefit the qi. Cimicifuga rhizome and Chinese thorowax root improve the transformation and transportation functions in the spleen. Dried tangerine peel regulates the qi movement; Chinese angelica aids the blood; and fresh ginger and Chinese date improve the communication between the interior and exterior of the body. Coix seed and Indian bread invigorate the spleen and expel dampness evil. Used in combination, these ingredients invigorate the spleen and stomach, increasing production of nutrient essence and relieving symptoms.
| Yang-deficiency in the spleen and kidneys |
Therapeutic aim: To warm and tonify the spleen and kidneys
Prescription: Yougui bolus (modified)
| fu zi |
monkshood |
| rou gui |
cassia bark |
| lu jiao jiao |
deerhorn glue |
| shu di |
processed rehmannia root |
| shan yu rou |
Asiatic cornelian cherry |
| tu si zi |
dodder seed |
| gou qi chi |
Chinese wolfberry fruit |
| du zhong |
eucommia |
| dang gui |
Chinese angelica |
| dang shen |
pilose asiabell root |
| huang qi |
milk-vetch root |
| shan yao |
common yam root |
| bai zhi |
large head atractylodes root |
In this prescription, monkshood, cassia bark and deerhorn glue warm and invigorate the spleen and kidneys. Rehmannia root, Asiatic cornelian cherry, dodder seed, wolfberry and eucommia are used for nourishing the spleen-yin and kidney-yin. Chinese angelica replenishes the blood; and pilose asiabell, milk-vetch, common yam and large head atractylodes roots replenish the qi and tonify the spleen.
| Yin-deficiency in the liver and kidneys |
Therapeutic aim: To nourish and invigorate the liver and kidneys
Prescription: Zuogui bolus (modified)
| sheng di |
fresh rehmannia rhizome |
| gou qi chi |
Chinese wolfberry fruit |
| shan yu rou |
Asiatic cornelian cherry |
| lu jiao jiao |
deerhorn glue |
| gui jiao |
tortoise shell glue |
| tu si zi |
dodder seed |
| niu xi |
achyranthes root |
| shan yao |
common yam root |
In this prescription, fresh rehmannia rhizome is used in quantity for effective nourishment of the kidney-yin. Wolfberry replenishes the essence and improves visual acuity; and Asiatic cornelian reduces depletion of essence and calms the liver. Deerhorn glue invigorates the yang; and tortoise shell glue nourishes the yin. A combination of these two glues can replenish essence and bone marrow. Dodder seed and achyranthes root reinforce the lumbar (lower back) region and knees, and strengthen the tendons and bones. Common yam root tonifies the spleen and aids the kidneys.
| Deficiency in both qi and blood |
Therapeutic aim: To invigorate and replenish the qi and blood
Prescription: Bazhen decoction (modified)
| ren shen |
ginseng |
| fu ling |
Indian bread |
| bai zhi |
large head atractylodes root |
| gan cao |
liquorice root |
| dang shen |
pilose asiabell root |
| bai shao |
white peony root |
| shu di |
processed rehmannia root |
| chuan xiong |
Szechwan lovage root |
| sheng jiang |
fresh ginger |
| da zao |
Chinese date |
In this prescription, ginseng, Indian bread, large head atractylodes root and liquorice root invigorate the spleen and benefit the qi. Pilose asiabell, white peony and rehmannia roots nourish the heart and blood. Szechwan lovage root improves the blood circulation; when combined with pilose asiabell root and rehmannia root, it increases blood production without causing an increase in viscosity (thickening). Fresh ginger and Chinese date help the ginseng and Indian bread to regulate the spleen and kidneys.
Chinese patent drugs
These drugs are available in small dosages and are readily absorbed on ingestion. They are more convenient to use because they are not bulky to carry about and are therefore more appropriate to a busy lifestyle. Taking a pill or a bolus is often easier for those who do not wish to consume large volumes of liquid or who do not like the bitter taste of decoctions. Examples of patent medicines used in the treatment of myasthenia gravis are:
Qi-deficiency in the spleen and stomach: Buzhong yiqi bolus
Yang-deficiency in the spleen and kidneys: Ginseng yangrong bolus
Yin-deficiency in the liver and kidneys: Liuwei dihuang bolus
Deficiency in both qi and blood:
Jinkui shenqi bolus
Acupuncture therapies
Use of acupuncture stimulates the meridians. These connect the internal organs with the limbs and their stimulation results in:
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activation of qi and blood |
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regulation of yin and yang |
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strengthening of the tendons and bones, and |
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lubrication of the joints. |
Acupuncture can be used therefore as the main or an adjuvant therapy.
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| Acupuncture |
General method of acupuncture
Treatment is given daily over 10 days; four to five acupoints are selected each time and the needle retained for 20 to 30 minutes.
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For drooping eyelids, acupoints are selected on the face: zan-zhu, yang-bai, yu-yao, si-bai and jing-ming. |
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For limb weakness: he-gu, nei-guan, wai-guan, san-yin-jiao, tai-chong, da-zhui, pi-yu, shen-yu and zu-san-li are used. |
Otopuncture therapy
This therapy is used weekly and applied to each ear alternately. The method involves acupoint embedding of the needle under the skin.
The acupoints used are spleen, kidney, liver and points for endocrine functions.
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