Identifying and Managing Myasthenia Gravis Flares

Clinical Features and Assessment

A myasthenia gravis flare is identified by worsening or new-onset fatigable muscle weakness, particularly affecting ocular, bulbar, or respiratory muscles, with symptoms that fluctuate throughout the day and worsen with activity, according to the American College of Physicians 1, 2
Progressive or worsening ptosis (eyelid drooping) that worsens as the day progresses or with sustained upgaze is a key clinical feature to monitor, as recommended by the American Academy of Neurology 1, 2
New or worsening diplopia (double vision) from extraocular muscle weakness, typically asymmetric, is another important symptom, as noted by the American College of Physicians 2, 3
Dysarthria (slurred speech) that worsens with prolonged talking is a critical warning sign, according to the American Academy of Neurology 1, 3
Dysphagia (difficulty swallowing) is a particularly concerning sign requiring immediate assessment, as emphasized by the American College of Physicians 1, 2

Assess respiratory function immediately in any patient with generalized symptoms - measure vital capacity (VC) and negative inspiratory force (NIF), as recommended by the American Thoracic Society 1, 3
Evaluate bulbar function by testing swallowing ability and speech clarity, according to the American Academy of Neurology 1, 2
Check creatine phosphokinase (CPK), aldolase, ESR, CRP to evaluate for concurrent myositis, as suggested by the American College of Rheumatology 1
Obtain troponin T and perform ECG/echocardiography if respiratory insufficiency or elevated CPK present, as recommended by the American Heart Association 1

The MGFA classification helps determine urgency, with classes ranging from I (ocular symptoms only) to V (myasthenic crisis requiring intubation), as noted by the Myasthenia Gravis Foundation of America 1, 3
Avoid medications that worsen MG, including β-blockers, IV magnesium, fluoroquinolones, aminoglycosides, and macrolides, as warned by the American Academy of Neurology 2, 3
Do not delay respiratory assessment - respiratory compromise can develop rapidly and requires immediate intervention, as emphasized by the American Thoracic Society 1, 3
Grade 3-4 symptoms require IVIG (2 g/kg over 5 days) or plasmapheresis, according to the American Society for Apheresis 2, 3