As many of you know, I recently underwent surgical repairs of both inguinal and umbilical hernias. I was quite familiar with the inguinal hernia repair as I had previously had two of those surgeries many years ago. Now, however, there are new techniques using robotics that make the surgery easier, less painful and requiring less recovery time. Unfortunately, I wasn’t a candidate for this new procedure due to having Myasthenia Gravis. They utilize paralytics (a form of anesthesia) during this procedure and paralytics are contraindicated for someone with MG.
I recently was diagnosed with another medical condition and quickly learned some of the treatments and procedures for this condition may not be safe for people with MG. This got me to wondering, what other treatments and procedures for coexisting conditions could be influenced by Myasthenia Gravis. I went to my friend Grok, to find out. (Please remember that although Grok can provide general information, it should not be relied upon for medical advice. Always consult reliable sources like the Myasthenia Gravis Foundation of America (MGFA) or your neurologist for personalized advice.) Please also note that sometimes your doctor may still prescribe a treatment, medication, or procedure because the benefit of using that particular item may outweigh the risks. Let’s take a look at a few of the most well-known examples.
Drug Interactions and Contraindications: Many common medications can worsen MG symptoms by further impairing neuromuscular transmission. For that reason, providers and patients must review all prescriptions carefully. Some examples are:
- Antibiotics – Certain classes, like fluoroquinolones (e.g., ciprofloxacin) and aminoglycosides, are associated with exacerbations and should be avoided when possible. Macrolides (e.g., azithromycin) may also pose risks.
- Beta-blockers – Used for heart conditions or hypertension (e.g., propranolol, metoprolol), these can increase muscle weakness.
- Other common culprits – Magnesium-containing drugs, some statins for cholesterol, botulinum toxin (Botox), and certain anesthetics or contrast agents.
Anesthesia and Surgical Procedures: Surgery poses significant risks for MG patients due to sensitivity to neuromuscular blocking agents (NMBAs) and potential postoperative respiratory failure.
- MG patients are highly sensitive to non-depolarizing NMBAs (e.g., rocuronium), requiring reduced doses or avoidance.
- Depolarizing agents like succinylcholine may have prolonged effects in some cases.
- Preferred approaches: Regional or neuraxial anesthesia (e.g., epidural) over general anesthesia when possible. Volatile anesthetics are generally safe, but short-acting agents minimize respiratory depression.
- Preoperative optimization: Ensure MG is stable, possibly with plasma exchange or IVIG. Assess respiratory function (e.g., vital capacity).
- Postoperative care: Monitor for myasthenic crisis, especially after major surgery like thymectomy (common in MG) or procedures for unrelated conditions (e.g., heart surgery, abdominal operations).
- Elective surgeries: Should be scheduled when symptoms are controlled, ideally in the morning when muscle strength is higher.
Cancer Treatment Considerations: MG is associated with thymoma (thymus tumor) in 10%-15% of cases, but there’s also an increased risk of extrathymic cancers, particularly in late-onset MG. Oncology teams must monitor closely, and MG specialists should be involved for rapid intervention with IVIG or plasma exchange.
- Immunosuppressive therapies for MG (e.g., long-term corticosteroids or azathioprine) may slightly elevate cancer risks, though evidence is mixed.
- Conversely, some cancer treatments trigger or worsen MG: Immune checkpoint inhibitors (e.g., pembrolizumab, nivolumab for melanoma or lung cancer) can induce MG or severe exacerbations, sometimes leading to a myasthenic crisis.
- Chemotherapy: Certain agents (e.g., cisplatin) have been linked to myasthenic crisis in thymoma patients.
Dental Procedures: Even routine dental care requires modifications due to involvement of facial, jaw, and throat muscles. Remember that oral infections can exacerbate MG, so preventive care is crucial.
- Schedule short morning appointments to capitalize on peak strength.
- Use supportive chair positions and minimize stress, which can trigger weakness.
- Local anesthetics with vasoconstrictors are safe, but it’s recommended to avoid sedation that depresses respiration.
- For anxious patients, nitrous oxide may help. Use IV sedation cautiously.
- Risk of aspiration: Good suctioning and positioning are key.
- Mildly affected MG patients can be treated in general practice, but severe cases may require hospital settings.
Other Procedures and General Considerations
- Infections of stress from any illness/procedure can precipitate crises and require prompt treatment
- Radiologic contrast: Some iodizing agents may worsen symptoms, so use cautiously.
- Vaccinations: Generally safe, but avoid live vaccines in immunosuppressed.
The key to all of this is make sure you communicate your Myasthenia Gravis with all healthcare providers. Inform every specialist (e.g., surgeons, dentists, oncologists) about your MG diagnosis, medications and triggers. A medical alert bracelet and updated medication list can be lifesavers.
With careful planning, most procedures and treatments for other conditions can be managed safely, allowing MG patients to receive the treatment they need in a safe manner. It may require different and sometimes less advanced techniques, but the goal is to get you healed without causing any worsening of your MG condition. Advances in MG therapies continue to improve outcomes, but awareness of these interactions remains key to preventing complications.
Remember: Always consult reliable sources like MGFA or your neurologist for personalized advice. If you have MG and face an upcoming procedure, discuss risks and optimizations early.