CAUTIONARY DRUGS

Certain medications and over the counter preparations may cause worsening of MG
symptoms. Remember to tell any doctor or dentist about your MG diagnosis. It is
important to check with your doctor before starting any new medication including over
the counter medications or preparations.

Drugs to avoid or use with caution in MG* • Telithromycin: antibiotic for community
acquired pneumonia. The US FDA has
Many different drugs have been associated with designated a “black box” warning for this drug
worsening myasthenia gravis (MG). However, in MG. Should not be used in MG.
these drug associations do not necessarily mean
• Fluoroquinolones (e.g., ciprofloxacin,
that a patient with MG should not be prescribed
moxifloxacin and levofloxacin): commonly
these medications. In many instances, reports of
prescribed broadspectrum antibiotics that are
worsening MG are very rare. In some instances,
associated with worsening MG. The US FDA
there may only be a “chance” association (i.e. not
has designated a “black box” warning for these
causal).
agents in MG. Use cautiously, if at all.
In addition, some of these drugs may be necessary • Botulinum toxin: Avoid.
for a patient’s treatment and should not be deemed
• D-penicillamine: used for Wilson disease
“off limits”. It is advisable that patients and
and rarely for rheumatoid arthritis. Strongly
physicians recognize and discuss the possibility
associated with causing MG. Avoid.
that a particular drug might worsen the patient’s
MG. They should also consider, when appropriate, • Quinine: occasionally used for leg cramps.
the pros and cons of an alternate treatment, if Use prohibited except in malaria in US.
available. • Magnesium: potentially dangerous if given
intravenously, i.e. for eclampsia during late
It is important that the patient notify his or her
pregnancy or for hypomagnesemia. Use only
physicians if the symptoms of MG worsen after
if absolutely necessary and observe for
starting any new medication. Only the more
worsening.
common prescription drugs with the strongest
evidence suggesting an association with worsening
MG are provided in this list.
 • Macrolide antibiotics (e.g., erythromycin, • Desferrioxamine: Chelating agent used for
azithromycin, clarithromycin): commonly hemochromatosis. May worsen MG.
prescribed antibiotics for gram-positive • Beta-blockers: commonly prescribed for
bacterial infections. May worsen MG. hypertension, heart disease and migraine but
Use cautiously, if at all. potentially dangerous in MG. May worsen MG.
• Aminoglycoside antibiotics Use cautiously.
(e.g., gentamycin, neomycin, tobramycin): • Statins (e.g., atorvastatin, pravastatin,
used for gram-negative bacterial infections. rosuvastatin, simvastatin): used to reduce
May worsen MG. Use cautiously if no serum cholesterol. May worsen or precipitate
alternative treatment available. MG. Use cautiously if indicated and at
• Corticosteroids: A standard treatment for lowest dose needed.
MG, but may cause transient worsening within • Iodinated radiologic contrast agents: older
the first two weeks. Monitor carefully for this reports document increased MG weakness,
possibility. but modern contrast agents appear safer. Use
• Procainamide: used for irregular heart cautiously and observe for worsening.
rhythm. May worsen MG. Use with caution. * From the International Consensus Guidance for the Management of
Myasthenia Gravis, http://n.neurology.org/content/87/4/419.long

Addendum from MGFA’s Medical and Scientific Advisory Board:

Checkpoint inhibitors: Immunotherapy for cancer is an Likewise, doctors evaluating new-onset weakness in cancer
exciting treatment advance for many types of cancers. patients on immunotherapy should consider MG. Additionally,
However, one newly recognized rare side effect of some of MG with ICIs can be accompanied by inflammation of skeletal
these treatments is myasthenia gravis (MG). MG is recognized and/or heart muscle. MG patients who experience worsening
as a rare complication of immune checkpoint inhibitors (ICIs) weakness following ICI treatment should contact their
for cancer (immunotherapy). People who did not have MG neurologist and oncologist immediately.
before beginning immunotherapy have a higher likelihood
of developing the disease, although worsening of myasthenic Examples of immune checkpoint inhibitors (ICIs):
weakness has been reported in people with existing, previously- • Pembrolizumab (Keytruda)
diagnosed MG. The average onset of MG symptoms is within • Nivolumab (Opdivo)
6 weeks (range 2–12 weeks) of starting immunotherapy. To
• Atezolizumab (Tecentriq)
date, development or exacerbation of MG has been reported
for pembrolizumab, although it has also been seen with • Avelumab (Bavencio)
nivolumab, ipilimumab and other ICIs. Risk may increase • Durvalumab (Imfinzi)
with administration of combinations of ICIs. Patients with MG • Ipilimumab (Yervoy)
and cancer considering cancer immunotherapy should talk to
their oncologist and neurologist about this possible side effect.

The MGFA mission is to facilitate the timely diagnosis and optimal care of individuals affected by myasthenia gravis and
closely related disorders and to improve their lives through programs of patient services, public information, medical research,
professional education, advocacy and patient care.

This publication is intended to provide the reader with general information to be used solely for educational purposes. As such, it does not
address individual patient needs, and should not be used as a basis for decision making concerning diagnosis, care, or treatment of any
condition. Instead, such decisions should be based upon the advice of a physician or health care professional who is directly familiar with
the patient. The information contained in this publication reflects the views of the authors, but not necessarily those of the Myasthenia
Gravis Foundation of America (MGFA). Any reference to a particular product, source, or use does not constitute an endorsement.
MGFA, its agents, employees, directors, its Medical/Scientific Advisory Board, and its Nurses Advisory Board or their members make no
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for any particular purpose, or reliability regarding the information contained herein, and assume no responsibility for any damage or
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