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deficient should be performed to reduce the risk of includes reduction of white blood cells count, loss of
irrevesible marrow lesion. hair, nausea, vomit, diarrhea, hemorrhagic cystitis
and long term suppression of bone marrow mediated
Cyclosporin A: this is an immunosuppressant for cancer risk.
generalized and ocular MG, which starts to effect
3-6 months after administration. This is mainly Mycophenolate mofetil (MMF): MMF is not the
used when glucocorticoid and azathioprine are first line agents for MG but it is also used with
not effective. Cyclosporin A could also be used glucocorticoid at the early stage of treatment but
with glucocorticoid for improving the MG with a not azathioprine. Usually, it will be administered
decreasing blood level of AchR antibody. Cyclosporin at rate of 0.5-1 g and twice a day. When compared
A could be used in long term with a similar effect to azathioprine and cyclosporine, MMF is safer and
as azathioprine but with lesser side effect. Usually with less hepatic and renal side effect. Common side
cyclosporin A was taken in orally in 2-4 mg/kg/day. effect includes alimentary symptoms, nausea, vomit
The blood level of cyclosporin A was monitored in and diarrhea. For MG patients taken MMF, their
order to adjust the dose. The main side effect includes whole blood count will be performed once a week at
hypertension, tremor, renal dysfunction, muscle the first month, twice a month at the second and third
ache, gingival hyperplasia and flu-like symptoms. months and once a month after 3 months. If there is a
Blood test, hepatic and renal functions are regularly reduction of neutrophils, patients should stop taking
checked every month. any MMF.

Tacrolimus (FK-506): This is also a potent Anti-human CD20 monoclonal antibody (Rituximab):
immunosuppressant used for those patients Rituximab is proven to be effective in treatment of
not susceptible to glucocorticoid and other autoimmune diseases. In treatment of MG, rituximab
[10]
immunosuppressant, particularly those RyR antibody is suitable for patients, particularly those with MuSK
positive. This is also used with glucocorticoid at positive, who have no significant improvement
the early stage of treatment to reduce the usage in treatment of glucocorticoid and traditional
of glucocorticoid and corresponding side effect. immunosuppressants. As single agent of MG treatment,
The therapeutic effect of FK-506 onset rapidly and recommended dose for adult is in rate of 375 mg/m
2
significant effect should be observed around 2 weeks (i.v.) once a week. The treatment course is 22 days and
after administration. FK-506 is usually prescribed at agent is totally administered for 4 times.
3.0 mg/day for oral dose. Blood level of FK-506 should
be monitored in order to adjust the dose. MG patients Treatment with rituximab should be performed with
with rapid metabolism should receive large dose till facility of resuscitation. When there are any respiratory
a significant effect observed. Side effects include symptoms or hypotension, patients receiving this
alimentary symptoms, numbness, tremor, headache, treatment should be monitored for 24 hours. Treatment
hypertension, hyperglycemia, hyperkalemia, has to be terminated when there are any adverse effects
hypomagnesimia and renal failure. If no significant such as dyspnea, bronchospasm and hypoxemia.
side effect, FK-506 could be chronically used. Blood Other side effects include fever, chills, bronchospasm,
glucose, hepatic and renal functions should be leukopenia, thrombocytopenia and progressive
monitored every month. multifocal leukoencephalopathy. It is also crucial to
monitor any syndromes of cytokines release.
Cyclophosphamide: this agent will be used when other
immunosuppressants fail to provide any therapeutic During this treatment, hepatic and renal functions,
effect on to severe cases MG or MG with thymus tumor. blood and urine biochemistries have to be monitored
Cyclophosphamide should also be administered with regularly. Treatment should be immediately
glucocorticoid, which could be reduced in dose 6-12 terminated if there is any immunosuppression
months after treatment started. For adult, 400-800 mg mediated side effects. For patients with HBsAg positive
cyclophosphamide per week should be intravenously and compromised hepatic function, nucleotides (NAs)
perfused. Patients could also receive 100 mg/day in should be administered 2-4 weeks before treatment.
two oral doses till the total amount reaches 10-20 g
(for some cases, patients need 30 g). For children, 3-5 Intravenous administration of g-globulin
mg/kg/day (totally amount should not exceed 100 mg)
in two oral doses was administered. When there is This is for acute situation and pre-operative
improvement of symptoms, dose could be reduced to treatment for MG patients, usually combined
[11]
2 mg/kg/day. Extra caution should be paid for children with immunosuppressants and glucocorticoid.
patient receiving cyclophosphamide. Side effects g-globulin will be intravenously perfused at rate of

6 Neuroimmunol Neuroinfammation | Volume 3 | Issue 1 | January 20, 2016