title: Acetylcholinesterase inhibitor treatment for myasthenia gravis.
abstract: BACKGROUND
  In myasthenia gravis, antibody-mediated blockade of acetylcholine receptors at the neuromuscular junction abolishes the naturally occurring 'safety factor' of synaptic transmission. Acetylcholinesterase inhibitors provide temporary symptomatic treatment of muscle weakness, but there is controversy about their long-term efficacy, dosage and side effects.
  
  
  OBJECTIVE
  To evaluate the efficacy of acetylcholinesterase inhibitors in all forms of myasthenia gravis.
  
  
  METHODS
  We searched The Cochrane Neuromuscular Disease Group Specialized Register (5 October 2009), The Cochrane Central Register of Controlled Trials CENTRAL) (The Cochrane Library Issue 3, 2009), MEDLINE (January 1966 to September 2009), EMBASE (January 1980 to September 2009) for randomised controlled trials and quasi-randomised controlled trials regarding usage of acetylcholinesterase inhibitors in myasthenia gravis. Two authors scanned the articles for any study eligible for inclusion. We also contacted the authors and known experts in the field to identify additional published or unpublished data.
  
  
  METHODS
  Types of studies: all randomised or quasi-randomised trials.
  
  
  METHODS
  all myasthenia gravis patients diagnosed by an internationally accepted definition.Types of interventions: treatment with any form of acetylcholinesterase inhibitor.Types of outcome measuresPrimary outcome measureImprovement in the presenting symptoms within 1 to 14 days of the start of treatment.Secondary outcome measures(1) Improvement in the presenting symptoms more than 14 days after the start of treatment.(2) Change in impairment measured by a recognised and preferably validated scale, such as the quantitative myasthenia gravis score within 1 to 14 days and more than 14 days after the start of treatment.(3) Myasthenia Gravis Association of America post-intervention status more than 14 days after start of treatment.(4) Adverse events: muscarinic side effects.
  
  
  METHODS
  One author (MMM) extracted the data, which were checked by a second author. We contacted study authors for extra information and collected data on adverse effects from the trials.
  
  
  RESULTS
  We did not find any large randomised or quasi-randomised trials of acetylcholinesterase inhibitors in generalised myasthenia gravis. One cross-over randomised trial using intranasal neostigmine in a total of 10 subjects was only available as an abstract.
  
  
  CONCLUSIONS
  Except for one small and inconclusive trial of intranasal neostigmine, no randomised controlled trial has been conducted on the use of acetylcholinesterase inhibitors in myasthenia gravis. Response to acetylcholinesterase inhibitors in observational studies is so clear that a randomised controlled trial depriving participants in the placebo arm of treatment would be difficult to justify.
authors.affiliation: Department of Neurology, G.B. Pant Hospital, #502, Academic Block, New Delhi, India, 110002.
authors.forename: Man Mohan
authors.initials: MM
authors.lastname: Mehndiratta
authors.forename: Sanjay
authors.initials: S
authors.lastname: Pandey
authors.forename: Thierry
authors.initials: T
authors.lastname: Kuntzer
mesh_terms: D002800:Cholinesterase Inhibitors / Q000627:therapeutic use*; D006801:Humans; D009157:Myasthenia Gravis / Q000188:drug therapy*; D009388:Neostigmine / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic
chemical_list: D002800:Cholinesterase Inhibitors; D009388:Neostigmine