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Liu et al. Developing treatment guidance for myasthenia gravis

solicit the expert panel’s opinion and quantify the level to maintain an adequate response.”
of approval. However, if this does not meet the stated
objectives, the recommendations of the consolidated Round 1 votes: median 9, appropriate. Range 6-9.
expert group will be revised and the above steps will Agreement: yes.
be repeated so that the views will be recognized to the
maximum benefit. Consensus had been achieved; however, based on
panel input and discussion, the statements were
The advantages of group decisions are obvious. A modified and re-voted.
group is less likely than an individual to draw a wrong
conclusion. If panelists are properly chosen, they can Round 2 statement: “A non-steroid IS agent should
represent a wide range of knowledge and experience. be used alone when steroids are contraindicated or
Their interaction stimulates debate and consideration refused. A non-steroid IS should be used initially in
of many opinions that may challenge previously well- conjunction with steroids when the risk of steroid side
accepted ideas and stimulate new ones. effects is high based on medical co-morbidities. A
non-steroid IS should be added to steroids when: (a)
However, formal consensus has its own pitfalls: (1) only steroid side effects, deemed significant by the patient
one person can speak at a time, limiting the number of or the treating physician, develop; (b) response to an
ideas expressed and discussed; (2) a social pressure adequate trial of steroids is inadequate; (c) symptoms
might induce to agree with the majority or a “powerful” relapse upon steroid taper.”
voice in public; (3) the desire to reach agreement may
override concerns about the accuracy of the result and Round 2 votes: median 9, appropriate. Range 8-9.
may result in premature closure without consideration Agreement: yes.
of all possible alternatives.
Final statement on the publication: “A non-steroid
When uncertainty and differences of opinions exist, IS agent should be used alone when corticosteroids
the RAM process of summarizing judgements helps are contraindicated or refused. A nonsteroidal IS
to identify areas of agreement and establish areas agent should be used initially in conjunction with
of disagreement. The combination of face-to-face corticosteroids when the risk of steroid side effects is
discussion at early stage and the solicitation of high based on medical comorbidities. A nonsteroidal
anonymous votes and comments handled by a non- IS agent should be added to corticosteroids when: (a)
voting facilitator are effective in maximizing the input of steroid side effects, deemed significant by the patient
all experts’ knowledge and experience. or the treating physician, develop; (b) response to
an adequate trial of corticosteroids is inadequate; or
The case of developing MG international (c) the corticosteroid dose cannot be reduced due to
consensus guidance using RAM symptom relapse.”
More than two years passed between the initial
appointment of the MGFA Task Force to develop Example 2 – difficult consensus
treatment guidance for MG in October 2013 and the Considerable effort was needed to reach consensus
final acceptance of the publication of the international on statements about thymectomy in childhood MG.
consensus guidance in July 2016. At the beginning, all
definitions obtained consensus easily and all guidance Round 1 statement: “In children and adolescents aged
statements were eventually agreed upon as being 5-10 years, thymectomy should be considered only after
appropriate by the panel by the time of publication. failure of symptomatic therapy and immunotherapy.”
However, not all topics took the same effort to reach
consensus. Here are some examples of extreme cases Round 1 votes: median 6, range 1-9, uncertain/
during the RAM process. equivocal.

Example 1 – easy consensus Round 2 statements (modified based on discussion):
The panelists easily reached consensus on statements “(A) in patients under 15 years of age, thymectomy
about immunotherapy. should be considered in generalized MG after
unsatisfactory response to AChEs and immunotherapy;
Round 1 statement: “If high steroid doses are needed (B) there is wide consensus that thymectomy is
chronically to achieve or maintain an adequate indicated in peri-pubertal and post-pubertal children
response, a steroid-sparing agent should be added, with moderate to severe AChR-ab+ MG; (C) published
typically along with the steroid, to permit subsequent reports also suggest that early thymectomy (within the
reduction of the steroid dose to the lowest necessary first 12 months of onset of symptoms) is more effective
Neuroimmunology and Neuroinflammation ¦ Volume 4 ¦ March 30, 2017 57