# Association of British Neurologists Management Guideline for Myasthenia Gravis: Generalised Myasthenia

**Developed by**: Association of British Neurologists

**Description**:
This corresponds to the treatment guideline for generalised myasthenia gravis by the Association of British Neurologists
## Treatment of Generalized Myasthenia Gravis

### Initial Treatment
1. **Pyridostigmine**:
   - Start with 30 mg four times daily, increase gradually.
   - Consider thymectomy if ACh-R antibody seropositive and under 45 years.
   - If symptomatic, start **prednisolone** (alternate days).

2. **Prednisolone**:
   - If relapse occurs on doses ≥7.5-10 mg/day, introduce immunosuppression.
   - Use immunosuppression for corticosteroid side effects.

### Pyridostigmine Dose Escalation Protocol
1. **Dosing**:
   - Start at 30 mg, increase to 60 mg, then 90 mg as needed.
   - Manage side effects with propantheline or mebeverine.

2. **Withdrawal**:
   - Maintain the lowest effective dose.
   - If asymptomatic with prednisolone, withdraw pyridostigmine slowly.

### Prednisolone Initiation Protocol
1. **Starting Dose**:
   - 10 mg on alternate days, increase by 10 mg every three doses.
   - Max dose: 100 mg alternate days or 1.5 mg/kg.

2. **Monitoring**:
   - Watch for diabetes mellitus.
   - Use daily dosing for better glycemic control if needed.

### Bone Protection Protocol
- Follow local guidelines for bone protection with corticosteroids.

### Prednisolone Withdrawal Protocol
1. **Tapering**:
   - Reduce by 10 mg/month to 40 mg alternate days.
   - Then 5 mg/month to 20 mg, 2.5 mg/month to 10 mg, and 1 mg/month below 10 mg.

2. **Relapse**:
   - Follow guidance for managing myasthenic relapse.

### Maintenance Dose & Immunosuppression
- Introduce immunosuppression if dose >15-20 mg alternate days or for intolerable side effects.

### Non-responsive Patients
- If no response after 3 months, seek specialist advice.