Myasthenia Gravis 3

8. Therapy1. AnticholinesterasePiridostigmin 30-120 mg can be administered orally every 3 hours or Prostigmin bromide 15-45 mg orally every 3 hours. Piridostigmin usually react slowly. Combination therapy did not show a striking result.If necessary, Prostigmin methyl sulfate can be administered subcutaneously or intramuskularis (15 mg orally equivalent to 1 mg subcutaneously / intramuskularis), preceded by the administration of atropine 0.5 to 1.0 mg.Prostigmin can inactivate or destroy cholinesterase that acetylcholine is not immediately destroyed. As a result of muscle activity can be restored close to normal, at least 80-90% of its original strength and durability. Giving Anticholinesterase will be very beneficial in myasthenia gravis group IIA and IIB. Side effects caused by stimulation of the parasympathetic Anticholinesterase, including the constriction of the pupil, colic, diarrhea, berkebihan salivation, sweating, lacrimation, and excessive bronchial secretions.Gastro intestinal side effects (muscarinic side effects) as cramping or diarrhea can be overcome by giving propantelin bromide or atropine. It is important for patients to realize that these symptoms are a sign of too much drug is taken, so the next dose should be reduced to avoid a cholinergic crisis. Because Prostigmin tend easiest muscarinic effects, the drug may be given first to make the patient understand how the real effects of these smping.
2. SteroidsAmong the preparations steroid, prednisolone most suitable for myasthenia gravis, and is given once a day alternately (alternate days) to avoid side effects. Initial dose should be small (10 mg) and increased gradually (5-10 mg / week) to prevent exacerbations, as well as when starting with a high dose of the drug.Increasing the dose to control symptoms or dose reached 120 mg alternately. In severe cases, prednisolone can be given with a high initial dose, every day, taking into account any possible side effects. It has to be an immediate clinical improvement. It is suggested that given extra potassium preparations.When there is clinical improvement the dose is gradually reduced (5 mg / month) in order to obtain the minimal effective dose. Sudden change of prednisolone should be avoided.
3. AzathioprineAzathioprine is an immunosuppressive drug, also gave good results, fewer side effects when compared with steroids and especially in the form of gastrointestinal disorders, elevated liver enzymes, and leukopenia. The drug is administered at a dose of 2.5 mg / kg for 8 weeks. Every week should do a complete blood count and liver function. After that laboratory tests done every month. Prednisolone together with azathioprine is highly recommended.
4. TimektomiIn particular patient needs to be done timektomi. Postoperative care and control of the airway should be properly addressed. The weakening of the patient a few days after surgery and was not beneficial provision Anticholinesterase often a sign of a lung infection. It should be treated with physiotherapy and antibiotics.
5. PlasmapheresisEvery day is done 3-8 times as much plasma replacement with a dose of 50 ml / kg. This will give a clear improvement in a short time. Plasmapheresis when combined with drugs imusupresan will be very useful for severe cases. However, there is no clear evidence that such therapy can give good results, so patients can live or stay at home. Padakrisi miastenik plasmapheresis may be effective because of its ability to dispose of antibodies to acetylcholine receptors, but not useful in the treatment of chronic cases.
Crisis In Myasthenia GravisIn myasthenia gravis is said to be in crisis if he can not swallow, clearing secretions, or adequately breathe without the aid of tools. There are two types of crises, namely:a. Crisis miastenikMiastenik the crisis situation that requires Anticholinesterase more. This situation can occur in cases that do not get enough drugs and can be triggered by an infection. Action against such cases is as follows:- Control of the airway- Provision of Anticholinesterase- If necessary: ​​immunosuppressive drugs and plasmapheresisWhen the crisis miastenik patients continued to receive artificial respiration (respirator), Anticholinesterase drugs are not given first, since these medicines may increase the secretion of the respiratory tract and can accelerate cholinergic crisis. After the crisis passed, the drugs can be started gradually, and often the dose can be lowered.
b. Cholinergic crisisCholinergic crisis situation resulting from the excess of Anticholinesterase drugs. This is probably because the patient had inadvertently excessive medication or dose may be exaggerated due to spontaneous remission. This group is difficult to control with medication and therapeutic boundaries between doses that are too few and narrow overdose. Their response to drugs is often only partial. Actions against demikianadalah case as follows:- Control of the airway- Termination Anticholinesterase for a while, and can be given atropine 1 mg intravenously and can be repeated if necessary. If given atropine, the patient should be closely monitored, because the secret airways can become so difficult to suck thick clumps or perhaps bronchial mucus can clog, causing atelectasis. Anticholinesterase then be given again at a lower dose.- If necessary: ​​immunosuppressive drugs and plasmapheresis.
To distinguish the two types of crises can be tensilon 2-5 mg intravenously. This medicine will provide temporary improvement in miastenik crisis, but will not provide repair or even aggravate the symptoms of cholinergic crisis.

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