Other neurocritical care

This chapter will review the pharmacotherapy for management of myasthenia crisis, Guillain-Barre syndrome, and antithrombotic-induced intracranial hemorrhage according to expert opinion.

Myasthenia crisis


Myasthenia gravis (MG)

Autoimmune disease targeting acetylcholine receptors on the postsynaptic side of neuromuscular junctions.

Myasthenia crisis

Worsening of MG with respiratory failure.

Precipitating factors

  • Respiratory infection

  • Emotional stress

  • Physiological stress (e.g., trauma, surgery)

  • Tapering of immunosuppressants

  • Drugs: aminoglycosides, fluoroquinolones, macrolides, tetracyclines, neuromuscular blocking agents, magnesium, β-blockers, verapamil, procainamide, quinidine

Management ( table 14.1 )

Table 14.1

Common Therapies for MG

Data from Sanders DB, Wolfe GI, Benatar M, et al. International consensus guidance for management of myasthenia gravis. Neurology . 2016;87(4):419–425.

Rapid Immunotherapies
Plasma exchange 1–7 days 1–3 weeks Directly removes acetylcholine receptor antibodies
More effective and works faster than IVIG (2016 international consensus statement by the Myasthenia Gravis Foundation of America)
Intravenous immunoglobulin (IVIG) 0.4 g/kg IV daily × 5 days or 1 g/kg IV daily ×1–2 days 1–2 weeks 1–3 weeks Clinical trials show equivalence to plasma exchange
Symptomatic Therapy
Pyridostigmine PO: 60–120 mg q6h
IV/IM: 2–4 mg q6h (off-label)
10–15 min 2 h

  • Acetylcholinesterase inhibitor

  • Hold during myasthenia crisis requiring mechanical ventilation to reduce airway secretions; restart at a lower dose after response to plasma exchange or IVIG

Chronic Immunotherapies (PO)
Prednisone Initial: 20 mg daily
Target: 1 mg/kg/day
Max: 100 mg/day
2–3 weeks 5–6 months

  • For patients who remain symptomatic on pyridostigmine

  • Most commonly used initial immunosuppressant due to rapid onset

Azathioprine 1–3 mg/kg/day 6–12 months 1–2 yr

  • First-line steroid-sparing agent

  • Avoid in active liver disease and lymphopenia

  • Monotherapy or in conjunction with glucocorticoids and/or pyridostigmine

Mycophenolate 0.5–1.5 g BID 6–12 months 1–2 yr

  • Alternative to azathioprine

  • Avoid in lymphopenia

  • Monotherapy or in conjunction with glucocorticoids and/or pyridostigmine

Cyclosporine 2.5 mg/kg BID ∼6 months ∼12 months

  • Second-line

  • Monotherapy or in conjunction with glucocorticoids and/or pyridostigmine

Tacrolimus 3–5 mg daily
Thymectomy 1–10 yr 1–10 yr

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Feb 28, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Other neurocritical care

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