Beyond Steroids: New Myasthenia Gravis Treatment Options Offer Hope for Improved Symptom Control

A growing number of new treatments for myasthenia gravis (MG) are changing how doctors manage the disease and offering new options for people whose symptoms aren’t fully controlled.

In recent years, the U.S. Food and Drug Administration (FDA) has approved several targeted therapies for generalized MG, including eculizumab (Soliris), efgartigimod alfa (Vyvgart), ravulizumab (Ultomiris), rozanolixizumab (Rystiggo), zilucoplan (Zilbrysq), and nipocalimab-aahu (Imaavy).

In the last decade, there have been great advances in myasthenia gravis treatments, says Benjamin Becker, MD, a neuromuscular neurologist at University of Michigan Health in Ann Arbor.

“More recently, a few newer classes of medications have shown lots of promise in myasthenia, particularly for those who don’t respond to the more traditional immunosuppressants or who desire fewer or different side effects,” says Dr. Becker.

The newer drugs don’t replace older treatments for everyone, but they offer a more precise way to interrupt the immune attack that causes MG symptoms.

For decades, MG treatment has relied on medications that either improve muscle function or broadly suppress the immune system.

Corticosteroids, such as prednisone, are still widely used to reduce immune activity.

“Steroids are still helpful; they are a relatively quick-onset treatment that works in nearly all persons with myasthenia gravis,” says Becker. Because of that, they are often used early to bring symptoms under control while slower-acting treatments take effect.

Immunosuppressants such as azathioprine, mycophenolate mofetil, cyclosporine, methotrexate, or tacrolimus have also been used and can work quite well, says Becker.

Many of the newer MG treatments are biologics or biologic type therapies.

“What distinguishes these treatments is their precision: The new treatments target one part of the immune system, so they are much more tailored in their approach,” says Becker.

FcRn Blockers Lower Harmful Antibodies

FcRn blockers reduce levels of harmful antibodies that drive myasthenia gravis.

These medications target the neonatal Fc receptor (FcRn), a protein that normally helps recycle IgG antibodies. Blocking FcRn accelerates the breakdown of these antibodies, including those that attack the neuromuscular junction and cause symptoms of MG.

Examples include:

• efgartigimod alfa (Vyvgart)
• rozanolixizumab (Rystiggo)
• nipocalimab-aahu (Imaavy)

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“FcRn inhibitors are considered more immunomodulatory rather than immunosuppressive; they modulate how your immune system reacts,” says Becker.

Because of this, they may carry a lower risk of infection compared with broader immunosuppressive therapies — though infection risk with traditional treatments remains relatively low when appropriately managed, he adds.

Complement Inhibitors Help Prevent Muscle Damage

Another class of therapies targets the complement system — part of the immune response that contributes to damage at the neuromuscular junction.

Examples include:

• eculizumab (Soliris)
• ravulizumab (Ultomiris)
• zilucoplan (Zilbrysq)

“Complement inhibition decreases the degree that immune activation damages your neuromuscular junction,” says Becker.

B-Cell–Targeting Therapy

Another strategy focuses on B cells, a type of white blood cell that produces antibodies to fight infection.

Rituximab (Rituxan) targets CD20, a protein found on B cells. By reducing these cells, it can lower the production of harmful antibodies over time.

Factors such as antibody type, disease severity, response to prior therapies, and other health conditions are also considered when choosing a biologic treatment.

Potential side effects, and which would be tolerable given a person’s symptoms and other health conditions, are also weighed along with other factors, says Becker.

• New myasthenia gravis treatments target specific parts of the immune system, offering a more precise alternative to older therapies.
• Steroids remain important, especially for quickly controlling symptoms.
• Newer options, including FcRn blockers and complement inhibitors, are expanding choices for people with difficult-to-control MG.
• Treatment decisions are highly individualized. You will need to work with your doctor to find the right medication or combination for you.