Learn The BasicsMany different therapeutic approaches can be used to treat myasthenia gravis (MG).
These include:
- Cholinesterase inhibitors like pyridostigmine (Mestinon)
- Corticosteroids like prednisone (Rayos)
- Nonsteroidal immunosuppressive therapies like azathioprine (Imuran), cyclosporine, mycophenolate mofetil (CellCept), methotrexate and rituximab (Rituxan)
- Monoclonal antibodies like rozanolixizumab-noli (Rystiggo), nipocalimab (Imaavy) and efgartigimod alfa-fcab (Vyvgart)
- Complement inhibitors like eculizumab (Soliris), ravulizumab (Ultomiris) and zilucoplan (Zilbrysq)
Cholinesterase inhibitors
Cholinesterase inhibitors work by blocking the action of the enzyme that breaks down acetylcholine, a neurotransmitter or chemical that transports electrical signals from nerve cells to muscle cells.
In MG, the immune system mistakenly attacks the receptors to which acetylcholine binds. So by allowing more acetylcholine to be present, this therapy aims to increase signal transmission to muscle cells.
The first-line therapy for MG is the cholinesterase inhibitor pyridostigmine marketed under the brand name Mestinon.
Cholinesterase inhibitors cannot cure MG but can improve muscle strength in some people with MG.
The side effects of these drugs include nausea, diarrhea and excessive sweating and salivation.
Corticosteroids
Corticosteroids work by reducing inflammation and suppressing the action of the immune system in an attempt to preserve the function of the neuromuscular junction, the connection between nerve and muscle cells where acetylcholine receptors are found.
The main corticosteroid used to treat MG is prednisone, marketed under the brand name Rayos.
The use of corticosteroids in the long term can cause serious side effects such as weight gain, bone thinning, diabetes and an increased risk of infections.
Nonsteroidal immunosuppressive therapies
These drugs dampen the action of the immune system and prevent it from attacking healthy cells and tissues.
Azathioprine (Imuran) is the first-line immunosuppressant used to treat MG. However, some doctors may prefer other immunosuppressants as first-line therapy, such as mycophenolate mofetil or methotrexate.
Cyclophosphamide (Cytoxan) and rituximab (Rituxan) may be prescribed in some refractory cases.
These drugs are usually used together with corticosteroids and can take a few months to start working.
Side effects include increased risk of infections and kidney or liver damage, which can be serious.
Monoclonal antibodies
Monoclonal antibodies work by targeting proteins found on the cells of the immune system to reduce their activity.
Monoclonal antibodies that can be used to treat MG include rozanolixizumab-noli, marketed under the brand name Rystiggo, nipocalimab marketed as Imaavy and efgartigimod alfa-fcab, known as Vyvgart.
They are delivered intravenously and are usually used if other treatments do not work.
They can have serious side effects, including allergic reactions, fatigue, fever, muscle pain, nausea, vomiting, diarrhea and low blood pressure.
Complement inhibitors
The immune system comprises a so-called “complement system” that eliminates damaged cells and targets infectious agents.
Complement inhibitors target the complement system to reduce the immune attack against the body’s healthy tissues, as in the case of MG.
The three main complement inhibitors that are used to treat MG are eculizumab, marketed under the brand name Soliris, ravulizumab, marketed as Ultomiris and zilucoplan, marketed as Zilbrysq.
These drugs are only available through a Risk Evaluation Mitigation Strategy (REMS) program due to the increased risk of meningitis.
Reviewed by Debjyoti Talukdar, M.D., on June 17, 2025.