Management of Myasthenia Gravis in Patients Receiving Paxlovid

Medication Considerations

The American College of Physicians recommends avoiding beta-blockers, IV magnesium, fluoroquinolones, aminoglycosides, and macrolide antibiotics in patients with myasthenia gravis, as they can worsen myasthenic symptoms 1, 2, 3

The American Thoracic Society suggests measuring negative inspiratory force (NIF) and vital capacity (VC) before starting Paxlovid, and applying the "20/30/40 rule" to identify patients at risk 1, 3
Patients with compromised respiratory function are at higher risk of decompensation during COVID-19 infection 1

The American Heart Association recommends performing ECG and checking troponin if the patient has any respiratory insufficiency or elevated CPK 1
Myasthenia gravis patients can develop concurrent myocarditis, which has high mortality rates 4

The American Academy of Neurology recommends performing daily neurological evaluation focusing on muscle strength and bulbar symptoms 1
The American Thoracic Society suggests monitoring respiratory function frequently, especially in patients with generalized myasthenia gravis (MGFA class III-V) 1

The American Academy of Neurology recommends maintaining pyridostigmine bromide (30-120 mg orally up to four times daily) unless the patient becomes intubated 1, 3
The American College of Rheumatology suggests continuing corticosteroids if already prescribed (prednisone 1-1.5 mg/kg/day) 1, 3

The American College of Emergency Physicians recommends hospitalizing immediately for ICU-level monitoring if respiratory compromise develops 1, 3
The American Academy of Neurology suggests administering high-dose corticosteroids: methylprednisolone 1-2 mg/kg/day IV 1, 3
The American Society for Blood and Marrow Transplantation recommends initiating rapid immunomodulation with either plasmapheresis (5 sessions over 5 days) OR IVIG (2 g/kg total dose over 5 days) 1, 3

The American College of Physicians recommends not relying on pulse oximetry or arterial blood gases as early indicators of respiratory failure, as these may not capture early decompensation 1