47
Table 7. Nervous System Toxicities
G2: Some symptoms interfering
with ADLs.
Myasthenia Gravis Foundation of
America (MGFA) severity class
I (ocular symptoms and findings
only) and MGFA severity class II
(mild generalized weakness).
• Hold ICPi and may resume in G2 patients
(MGFA 1 and 2) only if symptoms resolve and
steroid taper completed.
• Neurolog y consultation.
• Strongly consider in-patient care as patients can
deteriorate quickly.
• Pyridostigmine starting at 30 mg PO TID and
gradually increase to maximum of 120 mg PO
QID as tolerated and based on symptoms and
wean based on improvement. These procedures
should be done in close collaboration with the
neurologist.
• Administer corticosteroids (prednisone 0.5
mg/kg* orally daily). Wean based on symptom
improvement.
G3–4: Limiting self-care and
aids warranted, weakness limiting
walking, ANY dysphagia, facial
weakness, respiratory muscle
weakness, or rapidly progressive
symptoms or MGFA severity
class III–V (moderate to
severe generalized weakness to
myasthenic crisis).
Follow G2 recommendations as listed, with the
following additions for G3–4:
• Permanently discontinue ICPi.
• Admit patient, may need ICU-level monitoring.
• Continue steroids, taper should begin 3–4 weeks
after initiation then wean based on symptom
improvement.
• Initiate IVIG 2 G/kg IV over 5 days (0.4 G/kg/
day) or plasmapheresis × 5 days.
• Consider adding rituximab if refractory to IVIG
or plasmapheresis.
• Frequent pulmonary function assessment.
• Daily neurologic review.
*
e divergence from 1 mg/kg in the setting of MG is due to the potential short-term exacerbation
of MG with high dose steroid.
(cont'd)
