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REVIEWS

Myasthenia gravis autoantibody


characteristics and their implications
for therapy
Nils Erik Gilhus1,2, Geir Olve Skeie1,2, Fredrik Romi1,2, Konstantinos Lazaridis3,
ParaskeviZisimopoulou3 and Socrates Tzartos3

Abstract | Myasthenia gravis (MG) is an autoimmune disorder caused by autoantibodies that


target the neuromuscular junction, leading to muscle weakness and fatigability. Currently
available treatments for the disease include symptomatic pharmacological treatment,
immunomodulatory drugs, plasma exchange, thymectomy and supportive therapies. Different
autoantibody patterns and clinical manifestations characterize different subgroups of the
disease: early-onset MG, late-onset MG, thymoma MG, muscle-specific kinase MG, low-density
lipoprotein receptor-related protein4 MG, seronegative MG, and ocular MG. These subtypes
differ in terms of clinical characteristics, disease pathogenesis, prognosis and response to
therapies. Patients would, therefore, benefit from treatment that is tailored to their disease
subgroup, as well as other possible disease biomarkers, such as antibodies against cytoplasmic
muscle proteins. Here, we discuss the different MG subtypes, the sensitivity and specificity of the
various antibodies involved in MG for distinguishing between these subtypes, and the value of
antibody assays in guiding optimal therapy. An understanding of these elements should be useful
in determining how to adapt existing therapies to the requirements of each patient.

Department of Clinical
Medicine, University of
Bergen, Postboks 7804,
5020 Bergen, Norway.
2
Department of Neurology,
Haukeland University
Hospital, Postbox 1400,
5021 Bergen, Norway.
3
Department of Neurobiology,
Hellenic Pasteur Institute,
127Vassilissis Sofias
Avenue115 21, Ampelokipi,
Athens, Greece.
Correspondence to N.E.G.
nils.gilhus@uib.no
1

doi:10.1038/nrneurol.2016.44
Published online 22 Apr 2016

Myasthenia gravis (MG) is an autoimmune disorder caused


by antibodies targeting the neuromuscular junction. In
MG, these antibodies bind to the postsynaptic muscle
end-plate and attack and destroy postsynaptic molecules.
This process leads to impaired signal transduction and,
consequently, muscle weakness and fatigability the hallmark symptoms of MG14. The weakness can be focal or
generalized, and usually affects ocular, bulbar and proximal
extremity muscles. Respiratory muscle weakness develops
only rarely, but can be life-threatening. Weaknessis typically symmetrical, except in affected external eye muscles,
in which the weakness is usually asymmetrical14.
In most populations, the prevalence of MG is 150300
per 1,000,000 individuals, with an annual incidence of
more than 10 in 1,000,000 people5,6. Both prevalence and
incidence increase with age. With modern treatment,
MG should not increase mortality7. Therapeutic options
in MG include symptomatic pharmacological treatment, immunomodulatory pharmacological treatment,
plasma exchange, thymectomy and supportive treatment4,8. The treatment should be tailored to the indivi
dual patient depending on their MG subgroup, which
can be defined on the basis of biomarkers and clinical
characteristics. Immunosuppressive therapy can lead to

rapid improvement even when the disease is in a chronic


phase, as the synthesis of postsynaptic molecules is continuously increased in MG to counteract the destruction
of molecules by autoantibodies. However, well-controlled
therapeutic studies in MG are rare, and have not taken
into account variability between MG subgroups.
Recommendations for clinical management, therefore,
rely partly on consented guidelines and expert reviews.
Autoantibodies against proteins in the postsynaptic
membrane are the most important biomarkers in guiding diagnosis of MG (BOX1) and helping to define which
MG subtype a patient has. Moreover, an improved understanding of the autoantibody-associated pathophysiology
in MG could facilitate therapeutic decision-making. In
this Review, we discuss the antibodies involved in MG
pathogenesis, sensitivity and specificity of various antibody assays, as well as the value of these assays in guiding
optimal therapy.

Autoantibodies in myasthenia gravis


Antigenic targets
MG serves as a prototypical antibody-mediated disease because the physiological function, antigenic
targets, and immune responses to autoantibodies at the

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Key points
The characteristic muscle weakness in myasthenia gravis (MG) is caused by antibodies
directed against the neuromuscular junction
MG is divided into subgroups on the basis of specific antibodies, other biomarkers,
and clinical characteristics, such as age of onset, presence of thymoma, and
involvement of ocular muscles
The most common antibodies detected in MG are antibodies against acetylcholine
receptors (AChRs), muscle-specific kinase (MuSK) and low-density lipoprotein
receptor-related protein4 (LRP4)
Additional antibodies of interest in MG are directed against agrin, titin, KV1.4,
ryanodine receptors, collagenQ, and cortactin
Therapy should be tailored to the individual patient and guided by MG subgroup, and
can include symptomatic drug therapy, immunosuppressive drug therapy,
thymectomy and/or supportive therapy
The aim of treatment should be normal or near-normal function, which in most
patients requires long-term immunosuppressive treatment with a drug combination
that is individualized for the patient for optimal effectiveness

neuromuscular junction are well understood (FIG.1a).


The major antigen in MG is the acetylcholine receptor
(AChR) on the muscle membrane14. Some patients without AChR antibodies have autoantibodies against the
muscle specific kinase (MuSK), a protein responsible for
AChR clustering and maintenance of the neuromuscular
junction4,9. A fraction of patients with MG who do not
have either AChR or MuSK antibodies have antibodies
against low-density lipoprotein receptor-related protein4
(LRP4), a receptor for neural agrin that relays the signal
to MuSK to initiate AChR clustering4,10. Patients without
detectable antibodies against any of these three antigens
are referred to as seronegative. Some patients with MG
also have antibodies against cytoplasmic muscle proteins;
although these antibodies are not pathogenic, they can
serve as diseasemarkers1114.

AChR antibodies
Prevalence. AChR antibodies can be detected with routine assays in 70% of all patients with MG14. In another
510% of patients, AChR antibodies can only be detected
with more-sensitive, cell-based assays15,16.

Antigenic modulation
Bivalent antibodies can
causecrosslinking of
receptorsand subsequent
receptorinternalization.

Epitope pattern
An epitope is a localized region
on an antigen capable of
eliciting an immune response,
and the epitope pattern refers
to all epitopes involved in an
immune response.

Pathophysiological role. Invivo studies have shown that


the AChR antibodies bind to extracellular domains of the
receptor17 (BOX2), thereby impairing signal transduction.
AChR antibodies mostly belong to the IgG1 and IgG3 subclasses, which activate the complement cascade, leading
to damage of the postsynaptic membrane. In addition, as
the antibodies are bivalent, they are capable of antigenic
modulation. Some AChR antibodies target the acetyl
choline binding site of the receptor, potentially blocking
the signalling pathway; however, such antibodies are rare
and are probably clinically relevant in fewpatients3.
Antibodies against the subunit of the AChR are more
pathogenic than those against the subunit; therefore,
the AChR epitope pattern influences disease severity18.
Total AChR antibody concentration does not correlate
with symptom severity when patients are compared14,
although fluctuations in AChR antibody concentration
in an individual patient have been reported to correlate with the severity of muscle weakness and to predict

exacerbations19. Such correlations remain to be convincingly demonstrated, but repeated testing for antibodies
can influence therapeutic decisions: an increase in antibody concentration is thought to indicate exacerbation of
MG, whereas a stable or decreasing concentration could
indicate stable disease. However, loss of functional AChRs,
not the AChR antibody concentration, is what leads to the
symptoms of MG: reduced numbers of receptors correlate
with disease severity, and the loss of receptors depends not
only on total AChR-antibody concentration, but also on
autoantibody pattern and non-antibody factors14.
Testing. A radioimmunoprecipitation assay based on
a mixture of solubilized embryonic and adult AChRs
is the most rigorously validated test for AChR antibodies, and is the most reliable among the validated AChR
antibody tests. These testing kits are commercially available. Positive test results have a near 100% specificity for
MG in symptomatic individuals14. Such specificity is
crucial for a first-line screening test that is used also in
patients with vague muscular symptoms or fatigue as the
primarysymptom.
Although ELISA and immunofluorescence assays
have been developed as non-radioactive alternatives
with good sensitivity and specificity, they are inferior to
radioimmunoprecipitation20 and have not been widely
adopted in clinical practice. Cell-based assays, in which
AChR molecules are clustered on the membranes of cultured test cells, offer better sensitivity, and enable detection of low-affinity antibodies: they can detect antibodies
in 466% of patients with generalized MG in whom antibodies cannot be detected with radioimmunoassay15,21,22.
Antibodies that are detected with different tests all belong
to the same IgG subclasses, indicating that the aetiology
and pathogenesis is the same in patients with AChR antibodies that can only be detected in cell-based assays as
in those with antibodies that are detected in routine tests.
The radioimmunoassay is recommended as the firstline test because it has been used successfully in clinical practice; moreover, it not only detects the presence
of AChR antibodies but can also quantify their levels.
Supplementary cell-based testing should be performed
when MG is suspected but the patient is negative for
anti-AChR and anti-MuSK antibodies.

MuSK antibodies
Prevalence. Antibodies against MuSK can be detected in
110% of patients with MG14. These antibodies are present in patients from the Mediterranean area more often
than in those from Northern Europe, possibly owing to a
combination of genetic and environmental factors14.
Pathophysiology. In contrast with AChR antibodies, IgG
antibodies against MuSK belong mostly to the IgG4 subclass. Their mode of action also differs: AChR antibodies
bind to complement and crosslink their antigenic target,
whereas MuSK antibodies are directly pathogenic, even
if they do not bind to complement, and remain functionally monovalent23. Instead of modulating AChR
function, MuSK antibodies reduce the postsynaptic density of AChRs and impair their alignment between the

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motor nerve terminal and the postsynaptic membrane
(FIG.1b). Most MuSK antibodies bind to the extracellular
Nterminal Iglike domains of the AChR (BOX3).
Testing. In patients with MuSK-MG, concentrations of
anti-MuSK antibody tend to correlate with disease severity, and changes in antibody concentration over time
can reflect disease activity24. Immunoprecipitation with
radioimmunoassays is the standard technique for MuSK
antibody detection, and ELISA tests are also available,
although neither are as sensitive as cell-based assays23,25:
a large screening study showed that a cell-based assay
could detect MuSK antibodies in 13% of MG serum
samples that had been classified as seronegative using
radioimmunassay or ELISA11. Some of these patients
had ocular MG. The specificity of the cell-based assay is
estimated to be 9798%.
MuSKMG and AChRMG are distinct disease entities and rarely occur in the same patient. Nevertheless, a
few single-patient reports have demonstrated the existence of both AChR and MuSK antibodies in the same
patient, particularly when the most sensitive antibody
detection techniques are used16.

LRP4 antibodies
Prevalence. The likelihood of detecting LRP4 antibodies in MG depends on the assay and the examined
population. LRP4 antibodies are detected in 15%
ofpatients with MG of any type26,27, and in 733% of MG
patientswithout AChR and MuSK antibodies27,28.
Pathophysiology. In LRP4immunized mice, LRP4
antibodies are directly pathogenic and induce muscular weakness through disruption of the interaction
between LRP4 and agrin (BOX4), and inhibition of AChRmediated neuromuscular transmission29 (FIG1). The disease in the LRP4antibody mouse model was similar
to that seen in mice immunized with AChRs, and to
the muscle weakness seen in the human disease. LRP4
antibodies observed in these mice mainly belong to the
complement-binding IgG1 subclass30.

Box 1 | Differential diagnosis of myasthenia gravis


Myasthenia gravis (MG) needs to be distinguished from other neuromuscular disorders,
such as:
Genetic and toxic myasthenic syndromes
Autoantibody-mediated LambertEaton myasthenic syndrome
Neuromyotonia
Miller Fisher variant of GuillainBarr syndrome
In patients with muscle symptoms and a positive test for antibodies against the
acetylcholine receptor (AChR) or muscle-specific kinase (MuSK), the diagnosis of MG
isconsidered established and no further tests are needed to confirm the disease.
In patients with no detectable antibodies, neurophysiological tests are necessary.
Suchtests include:
Repetitive nerve stimulation67
Single-fibre electromyography67
The sensitivity and specificity of the diagnostic rely on the quality of the investigation.
The response (or lack thereof) to pharmacological treatment with anticholinesterase
drugs also has diagnostic value.

The fact that LRP4 antibodies are primarily reported


in MG patients without AChR or MuSK antibodies suggests that LRP4-MG is a distinct disorder26. However,
LRP4 antibodies have recently been detected in several
patients with either AChR or MuSK antibodies, in patients
with other autoimmune disorders, and in patients with
amyotrophic lateral sclerosis26,27,31. The presence of LRP4
antibodies is associated with milder MG symptoms, and
LRP4MG can manifest purely as ocular MG26,27,31.
Testing. No commercial tests for LRP4 antibody are
available. Optimal testing conditions and thresholds for
sensitivity and specificity in a clinical setting have not yet
beendefined.

Other antibodies
Agrin antibodies. Agrin autoantibodies can be detected
in a minority of patients with MG, either with or without
antibodies against AChR, MuSK or LRP4 (REFS32,33).
Agrin antibodies have been detected only in patients
with MG, suggesting that these antibodies are specific to
thedisease.
Agrin is a heparan sulfate proteoglycan released from
the motor nerve terminal34. It regulates the formation,
maintenance and regeneration of the neuromuscular
junction34, and interference with agrin function leads to
insufficient neuromuscular transmission34. To date, no
directly pathogenic effect of agrin antibodies has been
established, although such antibodies inhibit MuSK
phosphorylation and AChR clustering invitro3234.
Titin antibodies. Antibodies against titin the largest of
all known proteins can be detected in 2030% of MG
patients with AChR antibodies, mostly in patients with
thymoma-associated disease or late-onset MG11,35. Titin
is located intracellularly and is essential for muscle contractility36. Given its intracellular location, titin antibodies
should not interfere with muscle function. Nevertheless,
their presence indicates a more severe form of MG with
mild myopathy and a need for immunosuppressive treatment11. Moreover, antibodies against titin are a sensitive
marker of thymoma in patients with MG whose symptom
onset occurs before the age of 50years11,35. Most titin antibodies target a 30kDa region of the protein, called myasthenia gravis titin30, that is located near the AI junction
in muscle, thereby potentially interfering with the role of
titin in mediating muscle elasticity37. A commercial kit is
available for titin antibody testing.
KV1.4 antibodies. Antibodies against the subunit of
the voltage-gated K+ channel KV1.4 in skeletal muscle
are detected in 1020% of patients with MG14,38. KV1.4
channels are widely expressed in the CNS, where they are
concentrated in axonal membranes or near axons, and are
also present in the endocardium. In MG, KV1.4 antibodies seem to cross-react with voltage-gated K+ channels in
the heart muscle14,38. In a Japanese patient cohort39, KV1.4
antibodies were associated with severe MG and heart
complications, but the findings could not be confirmed
in European patients38. Invivo antibody binding to KV1.4
in MG has not been confirmed.

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a

Axonal terminal

Pathogenic
Present in MG
(unproven pathogenicity)

Action potential
Agrin

Ca2+

Ca2+

Choline

Acetic acid
Acetylcholine

Acetylcholine

Acetylcholinesterase
K+

Muscle

KV1.4

LRP4
MuSK
MuSK
AChR
clustering
Folding

Na2+

Cortactin
Actin
Myosin
Titin

ColQ

AChR

RyR

Muscle contraction
Muscle bre

Sarcoplasmic
reticulum

Auto-reactive T cell

Thymoma

Action potential

B cell activation
and auto-antibody
production

Ca2+

Ca2+
Complement
activation

Antigenic
Fold
modulation
destruction 2

C1 complement
1

MAC

AChR
internalization

Blocking
antibody

Clustering
Folding
Muscle contraction

Cell lysis
AChR degradation

c Thymectomy

Thymoma

B cell activation
and auto-antibody
production

Azathioprine
Mycophenolate
mofetil
Methotrexate
Cyclosporine

Plasma exchange
immunoadsorption

Ca2+

Ca2+

Complement
activation

Rituximab

Action potential

Acetylcholinesterase
inhibitor
Pyridostigmine
Ambenonium chloride
Neostigmine

Fold

destruction

Antigenic
modulation

AChR
internalization

Clustering
Folding

Cell lysis
Muscle contraction

AChR degradation
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Ryanodine receptor antibodies. Antibodies against
the ryanodine receptor (RyR) are present in 70%of
AChR-MG patients with thymoma and in 14%
ofpatients with late-onset AChR-MG8,40. The RyR is
the Ca2+ channel in sarcoplasmic reticulum12. It opens
upon depolarization of the sarcolemma and participates in muscle contraction through release of calcium from the sarcolemma into the cytoplasm12. The
presence of anti-RyR antibodies indicates severe MG,
though the pathogenic role of these antibodies has not
been established12.
Collagen Q antibodies. CollagenQ is a protein that
concentrates and anchors acetylcholinesterase at the
neuromuscular junction, where it is localized in the
extracellular matrix and is, thus, accessible to antibodies; collagenQ is found only at the neuromuscular
junction. Antibodies against collagenQ were recently
detected in the serum of 12 of 415 (3%) patients with
MG41. In seven of these patients, no other antibodies
were found. As mutations in collagenQ can lead to
myasthenic syndromes41, anti-collagenQ antibodies
might be pathogenic. However, anti-collagenQ antibodies have also been detected in healthy controls11, and
any diagnostic or pathogenic significance of these antigens, or a capacity to interfere with anticholinesterase
therapies, remains to be proven.

with various autoimmune disorders, including myositis11. Any relevance to MG pathogenesis, diagnosis or
treatment remains to beproven.

Subgroups of myasthenia gravis


Patients with MG can be stratified into subgroups
according to clinical presentation and biomarkers3,4.
The criteria for these subtypes include clinical symptoms, age of onset, thymic pathology and most
importantly autoantibodies (TABLE1). Each patient
should be assigned to only one subgroup. In the following discussion, we have excluded neonatal MG
and arthrogryposis, as these disorders are usually not
regarded as autoimmune MG4.

Autoantibody-based subgroups
AChR-MG. MG with anti-AChR antibodies is divided
into early-onset MG (symptom onset before 50years)
and late-onset MG (onset after 50years). In both subgroups, symptoms are generalized. In non-AChR-MG
subtypes, the distinction between early and late onset
does not have any proven value for prognostication
ortreatment.
In AChR-MG, the early-onset and late-onset disease types differ with respect to thymic pathology, HLA
genotype and other genetic variables, autoimmune
comorbidity, and response to therapy. For example,
thymectomy has clear clinical benefits in early-onset
Cortactin antibodies. Cortactin is a cytosolic actin- MG, but its benefits in late-onset MG are more quesbinding protein in the skeletal muscle that promotes tionable and possibly non-existent8,43. Moreover, the
actin assembly42. Moreover, it has a role as a signalling response to immunosuppressive drugs, as well as the
protein involved in AChR clustering mediated by the risks and clinical relevance of adverse effects, can differ
agrinMuSK complex 42. Cortactin antibodies were between early-onset and late-onset forms2,4,8 (TABLE1).
recently detected in 20% of MG patients without AChR
MG onset can occur in childhood. The clinical
or MuSK antibodies,but also in 5% of MG patients with course of childhood and juvenile MG is similar to
AChR antibodies, healthy controls, and 13% of patients that of early-onset MG in adults4. Juvenile MG is most
common in East Asian populations44.
Figure 1 | Neuromuscular junction in myasthenia gravis (MG). a | Normal function
of neuromuscular junction, with major components implicated in MG shown. Action
potential at the presynaptic nerve terminal causes opening of voltage-dependent
Ca2+ channels, triggering release of acetylcholine and agrin into the synaptic cleft.
Acetylcholine binds to acetylcholine receptors (AChRs), which promote sodium channel
opening, which in turn triggers muscle contraction. Agrin binds to the complex formed
by low-density lipoprotein receptor-related protein4 (LRP4) and muscle-specific kinase
(MuSK), causing acetylcholine receptor (AChR) clustering, which is required for
maintenance of the postsynaptic structures of the neuromuscular junction. b | Major
pathogenic mechanisms of the AChR antibodies in MG include complement activation
at the neuromuscular junction, which causes formation of membrane attack complexes
(MACs) on the muscle membrane and destruction of the typical folds in the sarcolemma
(1); antigenic modulation that results in internalization and degradation of surface
AChRs (2); and binding of AChR antibodies at the AChR ligand binding site (3), which
could directly block acetylcholine binding and, consequently, channel opening.
Anti-MuSK and anti-LRP4 antibodies have been shown to block the intermolecular
interactions of MuSK or LRP4 respectively, and could thus inhibit the normal mechanisms
for maintenance of the organization of the neuromuscular junction (4). Antibodies with
known pathogenic involvement in MG are shown in red. c | MG treatment can restore
function of the neuromuscular junction by increasing the levels of available acetylcholine
(acetylcholinesterase inhibitors; green), which improves signal transduction, or by
reducing the concentration of autoantibodies (immunosuppressive drugs, plasma
exchange/immunoadsorption, B-cell-targeting therapies; red), which alleviates the
pathogenic mechanisms described in (b). KV1.4, voltage-gated potassium channel1.4;
RyR, ryanodine receptor.

MuSK-MG. The presence of anti-MuSK antibodies


is usually associated with more-severe and generalized muscle weakness and, sometimes, with muscular
atrophy45. The great majority of anti-MuSK-positive
patients with MG are female25,45. In MuSK-MG, muscle strength fluctuates less than it does in other MG
subtypes, and bulbar and facial muscles are usually also
involved early in the disease25,45. Limb weakness is less
common than in AChR-MG, and ocular muscles can
be spared45. Importantly, respiratory weakness is more
likely in patients with MuSK-MG than in the other subgroups45. The clinical presentation can lead to a suspicion of MuSK-MG, but there are no specific, absolute
clinical criteria for this subgroup.
LRP4-MG. MG with LRP4 antibodies is less well characterized than the other subgroups. Patients in this
group tend to have milder symptoms, both at initial
presentation and over the course of the disease progression26,27. Only very rarely do these patients experience a myasthenic crisis that necessitates respiratory
support. Thymoma is not reported. A few patients have
been reported to have a combination of anti-AChR,

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Box 2 | Structure and function of AChR
The acetylcholine receptor (AChR; top and side views shown) is composed of five
homologous subunits (pictured in different colours) that form a cation pore (middle).
Subunit composition changes with the age of the individual: 2 is the predominant
subunit composition in embryonic muscle tissue, and 2 in adult muscle tissue17,68.
Although AChRs have several targeted epitopes, the majority of anti-AChR antibodies
are directed against the main immunogenic region (MIR [17), a group of overlapping
epitopes located on the AChR subunit; the central core of these subunits is formed by
amino acids 6776.
MIR
MIR
AChR

Ocular MG. Approximately 60% of patients with


MG have ptosis and/or diplopia at onset, and nearly
all experience ocular symptoms during the course of
the disease46. In a minority of patients, the symptoms
remain restricted to the extraocular muscles. Patients
with ocular symptoms are always categorized as having
ocular MG, irrespective of antibodies, thymic pathology (except thymoma) and disease duration. At 2years
after onset, 1520% of patients with ocular MG still have
purely ocular MG, and MG will persist as a focal weakness in more than 90% of these patients46. The prevalence of ocular MG is similar among MG patients with
anti-AChR and anti-LRP4 antibodies46, whereas ocular MG with MuSK antibodies is nearly non-existent.
Patients with purely ocular weakness but MGspecific
pathology detected with neurophysiological testing
of non-ocular muscles are still regarded as having
ocular MG. Such patients have an increased risk of
generalization.

Subgroups based on other characteristics


Seronegative MG. Patients with MG but no positive
test results for anti-AChR, anti-MuSK or anti-LRP4
antib odies are characterized as having seronegative
MG, and constitute about 10% of generalized (nonocular) MG patients14, depending on the sensitivity of
the antibody tests used. The seronegative MG group is
heterogeneous, as it includes patients with antibodies
that have affinities or concentrations too low to detect,
patients with antibodies against relevant antigens that
have not yet been defined and cannot be tested for, and
patients with myasthenic symptoms that are not mediated by antibodies, including late-onset genetic forms
associated with mutations in rapsyn or other relevant
muscle proteins. Repeated testing can, in some patients,
lead to a diagnostic revision from the seronegative
MG subgroup to one of the other subgroups owing to
increased antibody concentration, epitope spreading,
or increased test sensitivity. We recommend repeated
testing in seronegative MG 618months after the initial
assessment.

Therapies
Symptomatic drug therapy
The acetylcholinesterase inhibitor pyridostigmine
represents the first-choice treatment in all types of
autoi mmune MG 4,8. Neostigmine, another acetyl
cholinesterase inhibitor with a shorter half-life, can also
be used14. Ambenonium chloride is another acetyl
cholinesterase inhibitor, though for most patients, it is
less effective than pyridostigmine or neostigmine. All
these drugs inhibit acetylcholine degradation, thereby
increasing the availability of acetylcholine in the
synapse. All MG subgroups besides MuSK-MG usually
respond well to this treatment14, but individual variation
isconsiderable.
In MuSK-MG, the response to acetylcholinesterase
inhibition is often insufficient, reflecting differences
between MG subgroups with respect to antibody-
induced pathology in the postsynaptic muscle membrane. A recent study reported a good response in
only 50% of patients with MuSKMG, and 10% did not
respond at all16. In such patients, 3,4diaminopyridine,
which increases presynaptic release of acetylcholine,
should be tried45. This drug blocks neuronal efflux
through K+ channels, which increases the duration of
action potentials and results in prolonged Ca2+ channel opening, thereby promoting acetylcholine release
at the muscle endplate45. The beneficial effect of pyridostigmine is specific to MG. The dose should be
adjusted to achieve the optimum according to therapeutic effect and adverse effects; most patients are able
to do this on their own. Unfortunately, 3,4diaminopyridine provides only a mild positive effect for most
patients14.

Thymoma-associated MG. MG attributed to thymoma


constitutes about 10% of all MG cases. Approximately
30% of patients with thymoma develop MG, and
another 15% have anti-AChR antibodies without MG
symptoms2,4. Thymoma is not associated with MG that
involves antibodies other than those against AChR, and
not with autoimmune disorders in general.

Immunosuppressive drug therapy


Nearly all patients with late-onset MG, thymoma MG,
and MuSK-MG require immunosuppressive therapy to
suppress autoantibody production and autoantibody-
induced detrimental effects at the neuromuscular
junction. Early-onset MG can sometimes be alleviated
by symptomatic therapy alone, but the majority of

Reviews
| Neurology
anti-MuSK and anti-LRP4Nature
antibodies;
these
patients
16
tend to have more-severe MG and should, in our
opinion, be categorized according to the relevant AChR
antibody subgroup.

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patients with early-onset MG require pharmacological
immunosuppression; however, in many of them, this
need istemporary.
LRP4-MG is usually relatively mild, and immunosuppression is often not needed. For ocular MG, there
are two treatment aims: to improve symptoms (ptosis
and diplopia) and prevent generalized weakness.
Immunosuppression can do both46.
First-line treatments. First-line immunosuppressive
drug therapy for MG comprises either prednisone or
prednisolone, or the combination of prednisone or prednisolone with azathioprine47. These drugs have a broad
action on the immune system, and have been shown to
be beneficial in all MG subgroups, though the benefit
varies depending on the subgroup.
According to current recommendations, prednisolone alone should be given only as short-term treatment
(<1year)8,46. Long-term prednisolone monotherapy
could be considered for the treatment of ocular MG, but
for the majority of other patients with MG, combination immunosuppressive treatment is recommended to
obtain maximum effect with minimal adverse effects8,46.
Controlled studies of immunosuppression in MG
are scarce, and virtually none have described subgroup-
specific effects. However, uncontrolled studies and
clinical experience have proven the effect of this treatment for MuSK-MG, late-onset MG and thymoma MG,
as well as for early-onset MG and LRP4-MG, which
usually have milder symptoms. Whereas azathioprine
(23mg/kg daily) takes 615months to yield an optimal effect, prednisolone exerts its full effect during the
first few weeks and months of treatment. Alternate-day
dosing and gradual dose increases are widely used in
an attempt to avoid adverse effects. Once the optimal
improvement has been reached, the dose of prednisolone
should be slowly reduced to the lowest effective dose.
Two studies have indicated that prednisolone treatment
of ocular MG reduces the risk of MG generalization,
in addition to the beneficial effect on the ocular symptoms48,49. Any added value of azathioprine for ocular MG
has not beenshown.
If immunosuppressive therapy induces pharmacological remission or a marked improvement, it should
be maintained in the long-term, but the dose should be
reduced to avoid adverse effects. Full drug withdrawal
will often lead to new exacerbations, particularly in
MuSKMG, thymoma MG and late-onset MG. The
presence of additional antibodies, particularly against
RyR and titin, is an indication for long-term treatment, as these antibodies are more common in severe
MG8,11. Prednisolone and azathioprine can be safely
administered during pregnancy and lactation50.
Second-line treatments. Priorities for second-line
immunosuppressive therapy are debated. No controlled
studies have compared different drugs in MG. Formal
studies examining specific therapies in well-defined MG
cohorts, including different MG subgroups, are sparse.
For moderate and mild MG, mycophenolate mofetil is
an option after the failure of first-line therapy owing

to insufficient benefit or problematic adverse effects51.


Evidence that supports the use of this drug is strongest
in AChR-MG51. Even though open studies and clinical
experience point to an effect, two well-controlled studies failed to show an additional benefit of mycophenolate mofetil as an addon to prednisone52,53. It should
also be noted that mycophenolate mofetil carries a
teratogenic risk50 and should be avoided in females of
childbearingage.
Rituximab has emerged as a potent drug in MG14,8.
This monoclonal antibody binds specifically to the
B-lymphocyte surface antigen CD20. For severe MG,
and for MuSK-MG in particular, rituximab can be given
if the first-line immunosuppressive therapy fails54,55.
Arecent meta-analysis confirmed that rituximab was
more effective in MuSK-MG than in AChR-MG56, possibly via effective depletion of cells that produce IgG4
antibodies. Overall, more than 80% of patients with
severe or refractory MG responded to rituximab56.
Optimal treatment regimens with rituximab for MG
as a whole or for specific MG subtypes are not known.
Most studies to date have used the same induction regimen as for rheumatoid arthritis and then repeated the
treatment only if symptoms recurred after many months.
The major limiting factor in rituximab treatment of MG
is the risk of precipitating other autoimmune disorders

Box 3 | Structure and function of MuSK


The muscle-specific kinase (MuSK; schematic drawing on
the left, domains with known structure on the right6971)
exerts its role at the neuromuscular junction by interacting
via its extracellular domain with a number of proteins.
Anti-MuSK antibodies have been demonstrated to inhibit
MuSKcollagenQ and MuSKLRP4 complexes; this
inhibition interferes with MuSK functions, such as AChR
clustering24,72.
MuSK
Ig1
Ig2

Ig1+Ig2

Ig3

Frizzled

Frizzled

Transmembrane
segment
Juxtamembrane
segment
Kinase

Kinase

Ig, immunoglobulin-like domain; Nature


LRP4, low-density
Reviews |lipoprotein
Neurology
receptor-related protein4.

NATURE REVIEWS | NEUROLOGY

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MG crisis
Severe worsening of
myasthenic weakness that
requires intubation or
noninvasive ventilation
toavoidintubation.

or JCvirus-related progressive multifocal leukoencephalopathy. Treatmentsspecifically targeting Bcells represent an attractive strategy for all antibody-mediated
disorders, including all MG subgroups, and emerging monoclonal antibodies are promising. However,
concerns about the consequences of highly effective
immunosuppression persist.
Alternative second-line treatments and third-line treatments. Alternative second-line and third-line treatment
options for MG include methotrexate, cyclosporine, tacrolimus and cyclophosphamide14,8. Cyclosporine has a
proven effect in well-controlled studies, but its use has
been limited by a high risk of adverse effects. Response
rates for the different MG subgroups have not been
defined. The presence of antibodies that have been linked
to more-severe disease (that is, antibodies against RyR,
titin or KV1.4) increases the need for active treatment. The
effects of these treatments in the presence of antibodies
against agrin, collagenQ and cortactin are notknown.
Intravenous immunoglobulin (IvIg) is predominantly
used as short-term immunoactive therapy in acute situations. IvIg and plasma exchange have similar effects on
MG exacerbations5760. Such treatment should always be
given for an ongoing or imminent MG crisis, and is also
recommended shortly before situations in which muscle
weakness is expected to deteriorate or lead to complications, such as surgery. The effect of IvIg and plasma
exchange occurs 25days after treatment and lasts for

Box 4 | Structure and function of LRP4agrin complex


Low-density lipoprotein receptor-related protein4 (LRP4; magenta) is a single
transmembrane protein with a large extracellular domain that contains multiple
low-density lipoprotein repeats as well as epidermal-growth-factor-like and propeller
repeats; it also has a transmembrane domain and a short Cterminal region without an
identifiable catalytic motif29. LRP4 is expressed in various tissues, including muscle and
nerve tissues, and has important functions during development and morphogenesis of
limbs, ectodermal organs, the lung and the kidney73. In adult skeletal muscle, LRP4 is
expressed by subsynaptic myonuclei, and the protein is concentrated at the
neuromuscular junction, where it binds to the extracellular matrix proteoglycan agrin74
(turquoise). Formation of the LRP4agrin complex triggers activation of muscle-specific
kinase (MuSK) and the signalling cascade required for acetylcholine receptor (AChR)
clustering and postsynaptic differentiation75.
LRP4Agrin complex

23months5760. A series of IvIg or plasma exchange is


usually combined with intensified immunosuppressive
treatment. MG crisis is a reversible condition and should
be treated vigorously, even in the cases where treatment
response is delayed. All MG subgroups even sero
negative MG respond in a similar way to IvIg and
plasma exchange, implying that seronegative patients also
have circulating antibodies that are pathogenic. Antigenspecific immunoadsorption with selective antibody
removal is a promising approach61, but further studies
are needed before its clinical application. Antigen-specific
immunosuppression or immunotolerance for AChR,
MuSK and LRP4 should be the aim for futuretreatment62.

Thymectomy
Thymic abnormalities in MG, such as hyperplasia and
thymoma, strongly suggest a role for a thymus-mediated
immune response in MG43,63. Active germinal centres and
an ongoing export of disease-inducing Tlymphocytes
will be effectively stopped by thymectomy43,63.
Early-onset MG. Many controlled studies have shown
that patients with early-onset MG who are thymectomized have a more favourable outcome than those who
are not63,64. However, none of the studies have been prospective or included matched control groups. Present evidence clearly favours early and complete thymectomy in
patients with early-onset MG who are not symptom-free
on symptomatic drugs alone. The fact that thymic hyperplasia is common in this subgroup supports a therapeutic
effect of thymectomy performed early after MG onset.
Early thymectomy will prevent export of AChR-specific
Tcells from the thymus to lymph nodes and peripheral
lymphoid tissue43,63. For a positive outcome, removal of
all thymus tissue is essential; the results of various video-
assisted and robotic surgical procedures and traditional
methods are similar65.
Late-onset MG. Late-onset MG is traditionally regarded
as less responsive or nonresponsive to thymectomy63,64;
however, the evidence regarding thymectomy in patients
with late-onset MG is sparse. The fact that the thymus of
patients in this subgroup is usually atrophic (an age-normal finding) does not provide any support to the use of
thymectomy. However, the onset age of 50years implies
that thymus function has no strong influence on pathogenesis. In patients with MG onset at 5065years who have
thymic hyperplasia, the response to thymectomy might
be expected to be similar to that in early-onset MG, and
thymectomy should be considered in selectedpatients.
Antibodies against titin and RyR are most common in
late-onset MG. Although not tested in controlled studies,
such antibodies probably indicate that no response will be
seen to thymectomy. Biomarkers are needed to establish
indications for thymectomy in late-onset MG.
Thymoma-associated MG. In thymoma MG, the thymoma of the thymus gland should always be removed to
treat the cancer. The response of MG to thymectomy is
variable, and improvement of MG symptoms is usually
more limited than in early-onset MG.

Nature Reviews | Neurology


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Table 1 | Characteristics of myasthenia gravis subgroups
Subgroup

Antibody

Additional Age at
antibodies onset

Proportion of Thymus
patients (%)

Clinical benefit
of thymectomy

Early-onset

Anti-AChR

Rare

<50years

1525

Hyperplasia
common

Proven

Late-onset

Anti-AChR

Common

>50years

3545

Atrophy common

Not proven
(butpossible)

Thymoma

Anti-AChR

Very
common

Any

10

Lymphoepithelioma Proven

MuSK

Anti-MuSK

Rare

Any

110

Normal

None

LRP4

Anti-LRP4

Rare

Any

15

Normal

None

Seronegative None of the


Variable
above detected

Any

1015

Variable

None

Ocular

Any

15

Variable

None

Variable

Rare

AChR, acetyline choline receptor; LRP4, low-density lipoprotein receptor-related protein4; MuSK, muscle-specific kinase.

Conclusions and perspectives


MG is mediated by several different autoantibodies, all directed against proteins in the postsynaptic
membrane of the neuromuscular junction, thereby
inducing muscle weakness. The exact clinical pictures,
responses to symptomatic and immunoactive therapy,
Ocular MG. Thymectomy has not been shown to pre- and disease pathogenesis vary between MG subgroups
vent generalization in ocular MG, or to induce remis- defined on the basis of autoantibody pattern. AChR,
sion. Thymectomy, is therefore, not recommended for MuSK and LRP4 are the three well-defined antigen
targets for symptom-inducing antibodies identified to
ocularMG46.
date. Epitope specificity and antibody characteristics
Seronegative MG. Thymectomy is not indicated in are more important for disease severity than is total
seronegative patients, except in cases where the sub- antibody concentration
As discussed above, patients with MG can also have
group diagnosis is revised after the detection of low-
affinity anti-AChR antibodies. New and more sensitive muscle antibodies that react with non-junctional antigens, such as titin, KV1.4 and RyR. Such antibodies
biomarkers are needed for this heterogeneous group.
can be used as markers of disease severity and patho
genesis, as well as of response to therapy. In addition,
Monitoring, management, and supportive therapy
In MG crisis, respiratory support and treatment of any the number of junctional and non-junctional antibodies
precipitating or complicating infections are crucial. reported in patients with MG particularly in those
Careful monitoring during pregnancy and at birth is with late-onset MG, thymoma MG and those previously
important, particularly given that 15% of babies born thought to be seronegative is expanding, increasing
to mothers with MG have transient neonatal myasthe- diagnostic specificity and providing potential markers
nia caused by transplacental transfer of IgG antibod- for predicting response to therapies.
MG treatment should be personalized for each
ies (against AChR, MuSK or LRP4)50. Moreover, some
women experience worsening of MG during pregnancy. patient. Correct MG subgrouping is a first step when
More than 30 drugs that are currently in use (includ- selecting therapy. Autoantibody pattern, age of onset,
ing muscle relaxants, penicillamine and some antibiotics) thymus pathology and the extent of muscle weakness
can theoretically interfere with neuromuscular transmis- are fundamental for such subgrouping. Therapy
sion. The clinician should always be aware of the possi- includes symptomatic and immunos uppressive
bility that these drugs induce increased neuromuscular drugs, supportive measures and sometimes thymecimpairment and worsening of MG symptoms14,8 and tomy. Specialized followup is necessary to adapt
therapy tothe actual symptoms and to prevent new
avoid prescribing them to patients with MG.
Particular attention should be directed towards the exacerbations.
Most MG patients have a well-controlled disease
optimal treatment of comorbid conditions66: it can be
difficult to distinguish between MGrelated reduction with minimal or moderate symptoms. The aim should
in physical capacity and heart and lung diseases and be to develop more-specific therapy that suppresses or
systemic disorders. All comorbid disorders should have induces tolerance to the well-characterized and spethe attention of the treating physician. Maintaining a cific autoimmune reactions that lead to autoantibody
healthy weight is beneficial, as being overweight can production and muscle weakness. Until such an antifurther interfere with physical function. Physical activ- gen-specific therapy is available, it remains a challenge
ity should be encouraged, and adapted training should to optimize the use of available treatments for each
individual MG patient.
beinstituted.
MuSK and LRP4-MG. MuSK-MG and LRP4-MG have
no proven connection to the thymus or thymus pathology. Case reports of single patients improving after
thymectomy have been published, but owing to very
scarce evidence, thymectomy is not recommended14,8.

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Acknowledgements

N.E.G., G.O.S. and F.R. have received funding from Torbjrg


Hauges Legacy for Neurological Research and from the
Norwegian Muscle Disease Association. S.J.T., K.L. and P.Z.
have received grants from the Muscular Dystrophy
Association of the USA and from the Greek National Strategic
Reference Framework (NeuroID ISR3257).

Author contributions

All authors researched data for the Review, made substantial


contributions to the discussion of the content of the article
and reviewed and edited the manuscript before submission.
N.E.G and S.T. wrote the article.

Competing interests statement

N.E.G. has received speakers honoraria from Octapharma,


Baxter and Merck Serono.

www.nature.com/nrneurol
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