Drugs and Myasthenia Gravis

Drugs that may aggravate
Myasthenia Gravis [contd]

For use only by anaesthetists
It is essential to let the anaesthetist know that MG is present, and
that the anaesthetic takes place in a hospital that has an ICU with
the ability to provide mechanical ventilation, should the need arise.

Inhalation Anaesthetics
Can increase the effect of the neuromuscular blocking
drugs used during the same operation.
Botulinum Toxin Avoid use

It can have distant as well as local effects.
A brief guide for patients,

doctors and dentists.
A brief guide for patients,

doctors and dentists.
Interferon Alpha Avoid use if possible

that may
aggravate
Myasthenia
Gravis
that may
aggravate
Myasthenia
Gravis

Neuromuscular Blocking Drugs
These are used to cause paralysis of muscles during an
anaesthetic. On occasions this paralysis can be profound
and last for days or weeks in a myasthenic. Must only be
used when mechanical ventilation is possible.
Drugs
Drugs
General Anaesthetic Agents
Use needs to be carefully considered on an individual basis.
Narcotics (eg Morphine) Use with caution

The MG Support Group recommends
General effects of narcotics may worsen MG. Cholinesterase

inhibitors such as Pyridostigmine (Mestinon) can increase
the effect of the narcotics.
Local Anaesthetics Can be used safely

eg Lignocaine (Xylocaine) Bupivacaine (Marcaine )etc
that myasthenics discuss this pamphlet

with their practitioner as MG is a disease
www.myastheniawa.info
(08) 9459 7168
in which it is particularly important to

individualise treatment.
X-ray Examinations with Contrast

The newer, non-ionic contrast agents are safe to use.
A Note on Vaccinations
Live vaccines should be used with great caution if a
patients immunity is low due to immunosuppressive
treatment. They do not have a direct effect on the MG itself.
Inactivated vaccines are safe to use in MG.
Acknowledgements
With grateful thanks for

Research:

Advice:

Assistance:

Graphic Design:
Dr Jean Foster GP
Dr Robert H Edis, Consultant Neurologist
Dr Stephen Reddel, Consultant Neurologist
National Prescribing Service
Rosalie Okely
(08) 9459 7168
Myasthenia Gravis Friends and Support Group WA, October 2007
Magnesium
eg in laxatives, antacids, magnesium supplements. In renal
failure, the magnesium levels can rise and cause muscle
weakness, and myasthenics are particularly prone.
It is strongly recommended that health professionals

refer to the more detailed version of this guide at
Introduction
This pamphlet is a practical guide to drugs that may affect
Myasthenia Gravis [MG]. Information is arranged under the
heading of diseases or conditions to make it easier for the
doctor or dentist to quickly see which drugs can be used.
The MG Support Group recommends that myasthenics discuss
this pamphlet with their practitioner as MG is a disease in
which it is particularly important to individualise treatment.
Drugs may worsen MG by
interfering with neuromuscular transmission. As MG also affects
neuromuscular transmission, it may lead to worsening symptoms.
The better controlled the MG, the less the risk of these drugs
being a problem.
increasing muscle weakness in a more general manner, thus

making the MG weakness more noticeable.
There are a few clear cut examples of drugs that can actually cause a
temporary form of autoimmune MG which usually settles once the
drug is ceased. It is less clear whether these drugs will worsen preexisting MG.
The drugs in this list have been rated according to those which should
be avoided if possible and those that can be used with caution. In
deciding which drugs to use, there are other factors to take into
account: eg. a drug may be essential, so will be used despite the
likelihood of worsening the MG. On the other hand, a drug may be less
likely to cause worsening of MG, but there will be other drugs which
will do the job just as well, so it will be avoided.
Many reports of drugs affecting MG
have caused problems in only a few
people. The majority of MG patients
can take the drugs without problems.
LEGEND:
Be Alert!
Its important that
patients and doctors be
alert to the early signs
of an exacerbation of
MG when a new drug is
commenced, even if it
is not on this list.
Drugs used in the treatment of

Myasthenia Gravis:
Primaxin (Imipenem) only available for intravenous

treatment of serious infections in hospitalised patients.
Pyridostigmine (Mestinon) and Neostigmine can aggravate the

weakness if the dose is too high. More is not necessarily better.
Drugs that may aggravate

Myasthenia Gravis
1. Class 1 Anti-arrhythmics:
Antimicrobials
1. Antibiotics.
Telithromycin (known as Ketek in the USA, UK and
Europe) is not yet available in Australia. It stands alone
in being the one medication that has been contraindicated in MG and should not be used in any MG
patient, even if their disease is well controlled. Another
antibiotic should be used instead. Beware when
travelling overseas, as this is an oral drug, and can
therefore be given by a GP or as outpatient treatment.
2. The other antibiotics most likely to cause problems are only

available as intramuscular and intravenous preparations
(with the exception of clindamycin). They may need to be used
for life threatening infections.

Aminoglycosides
Gentamicin, Amikacin, Tobramycin. (Kanamycin,
Streptomycin and Neomycin are rarely used).

Bacitracin and Polymixin

Safe as topical preparations.
Colistin
lindamycin (oral form available. Also available as skin

C
lotion and vaginal cream, with appreciable systemic
absorption), Lincomycin.
3. Use the following antibiotics with caution:
Should only be used in a setting where ventilatory

support in a hospital is available.
May worsen MG but are usually tolerated.
Quinolone antibiotics. Ciprofloxacin, Norfloxacin,

Moxifloxacin, (topical preparations eg ear drops, unlikely
to present a problem).
Use with caution.
Macrolide antibiotics - Erythromycin/Azithromycin.
Tetracyclines - Doxycycline, Minocycline etc.
Sulfonamides (eg Septrin, Bactrim).
not a problem for the majority of people with MG.

Have been shown to cause a temporary form
of MG (autoimmune).
uinine family Chloroquine, Hydroxychloroquine,

Q
Quinidine.
Corticosteroids (eg. Prednisone, Prednisolone) Transient worsening

of MG with high dose steroids (50mg/day or more) is common, but
benefits outweigh disadvantages. Start with a low dose and build up
if possible.
Likely to worsen MG
Have caused problems in rare cases but are
4. Malaria treatment.
Ampicillin (little evidence of problems with other

penicillins)
5. Worming treatment. Available without prescription.

Pyrantel (Combantrin, Anthel, Early Bird)
Anti Epileptic Drugs (Anti Convulsants)

Phenytoin (Dilantin). Avoid use if possible
Trimethadione (rarely used now)
Use the following agents with caution:

Barbiturates.
thosuximide (Zarontin) and

E
Carbamazepine (Tegretol).
Cardiovascular Drugs
eg Procainamide, Lignocaine (IV)
They should only be used in a hospital setting for life
threatening arrhythmias when there are no alternatives.

Quinidine has largely been superceded.
2. Beta Blockers:
There are many in this class, often identifiable by the olol
ending eg Atenolol (Noten, Tenormin), Metoprolol
(Betaloc, Minax) etc.
Drugs Used in Psychiatry

Lithium Use with caution.
It is common for Lithium to cause weakness, even in people
without MG. It usually improves within 2 4 weeks.

Chlorpromazine (Largactil) Avoid use.
The newer anti-psychotic medications appear to be safer,
but use them with caution.
Benzodiazepines eg Diazepam (Valium), Oxazepam
(Serepax), Temazepam (Normison, Temaze). Use with
caution if respiratory function compromised.
3. Calcium Channel Blockers:

erapamil (Veracaps, Isoptin). Documented case of

V
worsening MG with this drug. Use others in class with
caution.
4. Cholesterol lowering drugs:

Statins eg. Simvastatin (Lipex), Atorvastatin (Lipitor),
Pravastatin (Pravachol). Benefits in established IHD
usually outweigh the risks.
5. Alpha Blockers:

Anti Spasmodics
eg Propantheline, Oxybutinin, Atropine, Buscopan
These are anti-cholinergics, and have the opposite effect
to Pyridostigmine (Mestinon). For this reason they may be
marked as contra-indicated in the drug company literature.
However, they work on different receptors and for many
myasthenics they do not seem to cause problems at normal
dosages. Nevertheless, a few do experience significant
worsening of symptoms. Propantheline and Atropine are
used for side effects of Mestinon (bowel cramps).
Alpha Methyldopa (Aldomet, Hydopa)
Ocular Drugs (Eye Drops)
6. Diuretics:
Monitor potassium as low levels can increase
muscle weakness.
Rheumatic Disease

Penicillamine Use with caution.
Chloroquine (Chlorquin), Hydroxychloroquine

(Plaquenil) Avoid use if possible.
Acetazolamide.
Proparacaine/tropicamide.

Beta Blocker eye drops
eg Betaxolol (Betoptic, Betoquin), Timolol (Tenopt,
Timoptol).

Ecothiophate
Thyroid Disease
Hyperthyroidism or excess thyroid hormone replacement
can worsen MG.
(08) 9459 7168

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Drugs that may aggravate

Myasthenia Gravis [contd]

Botulinum Toxin Avoid use

A brief guide for patients,

A brief guide for patients,

Interferon Alpha Avoid use if possible

General Anaesthetic Agents

Use needs to be carefully considered on an individual basis.

Narcotics (eg Morphine) Use with caution

General effects of narcotics may worsen MG. Cholinesterase

Local Anaesthetics Can be used safely

eg Lignocaine (Xylocaine) Bupivacaine (Marcaine )etc

that myasthenics discuss this pamphlet

(08) 9459 7168

in which it is particularly important to

X-ray Examinations with Contrast

The newer, non-ionic contrast agents are safe to use.

(08) 9459 7168

Myasthenia Gravis Friends and Support Group WA, October 2007

It is strongly recommended that health professionals

increasing muscle weakness in a more general manner, thus

Drugs used in the treatment of

Primaxin (Imipenem) only available for intravenous

Pyridostigmine (Mestinon) and Neostigmine can aggravate the

Drugs that may aggravate

2. The other antibiotics most likely to cause problems are only

Bacitracin and Polymixin

 lindamycin (oral form available. Also available as skin

3. Use the following antibiotics with caution:

Should only be used in a setting where ventilatory

May worsen MG but are usually tolerated.

Quinolone antibiotics. Ciprofloxacin, Norfloxacin,

Use with caution.

Macrolide antibiotics - Erythromycin/Azithromycin.

Tetracyclines - Doxycycline, Minocycline etc.

Sulfonamides (eg Septrin, Bactrim).

not a problem for the majority of people with MG.

 uinine family Chloroquine, Hydroxychloroquine,

Corticosteroids (eg. Prednisone, Prednisolone) Transient worsening

Have caused problems in rare cases but are

Ampicillin (little evidence of problems with other

5. Worming treatment. Available without prescription.

Anti Epileptic Drugs (Anti Convulsants)

Phenytoin (Dilantin). Avoid use if possible

Trimethadione (rarely used now)

Use the following agents with caution:

 thosuximide (Zarontin) and

Quinidine has largely been superceded.

Drugs Used in Psychiatry

3. Calcium Channel Blockers:

 erapamil (Veracaps, Isoptin). Documented case of

4. Cholesterol lowering drugs:

Alpha Methyldopa (Aldomet, Hydopa)

Ocular Drugs (Eye Drops)

Penicillamine Use with caution.

Chloroquine (Chlorquin), Hydroxychloroquine

(08) 9459 7168

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General effects of narcotics may worsen MG. Cholinesterase

increasing muscle weakness in a more general manner, thus

Primaxin (Imipenem) only available for intravenous

lindamycin (oral form available. Also available as skin

Quinolone antibiotics. Ciprofloxacin, Norfloxacin,

Macrolide antibiotics - Erythromycin/Azithromycin.

uinine family Chloroquine, Hydroxychloroquine,

Ampicillin (little evidence of problems with other

thosuximide (Zarontin) and

erapamil (Veracaps, Isoptin). Documented case of

Chloroquine (Chlorquin), Hydroxychloroquine