title: IVIG Versus PLEX in the Treatment of Worsening Myasthenia Gravis: What is the Evidence?: A Critically Appraised Topic.
abstract: BACKGROUND
  Immune therapies such as intravenous immunoglobulin (IVIG) and plasma exchange (PLEX) are first line in the treatment of worsening myasthenia gravis. Although PLEX is favored in myasthenic crisis, IVIG is increasingly used in exacerbations due to cost and ease of administration.
  
  
  OBJECTIVE
  To review and critically assess current evidence on the effects of IVIG and PLEX on functional outcomes in patients with worsening myasthenia gravis.
  
  
  METHODS
  A structured critical appraisal was conducted on the objective topic. This included a creation of a structured question based on a clinical scenario, comprehensive literature search, selection of evidence for review, and critical appraisal of selected evidence. Evidence was summarized and commentary provided. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of neuromuscular neurology.
  
  
  RESULTS
  A single-blinded, randomized-controlled trial that compared IVIG and PLEX in 84 patients with worsening myasthenia gravis was selected for review. Primary outcome measure was functional status at 14 days after treatment, as assessed by the Quantitative Myasthenia Gravis Score. Change in Quantitative Myasthenia Gravis Score at day 14 for all subjects was 4.0, without statistically significant differences between IVIG and PLEX groups.
  
  
  CONCLUSIONS
  IVIG and PLEX are equally effective in worsening myasthenia gravis. Treatment decisions may depend on several variables, including presence of respiratory distress, medical comorbidities, access to medication, and cost. PLEX will likely remain the treatment of choice in true myasthenic crisis.
authors.affiliation: *Department of Neurology, Mayo Clinic ‡Department of Library service, Division of Education Administration, Mayo Clinic, Scottsdale §Department of Neurology, Mayo Clinic, Phoenix, AZ †Department of Neurology, Mayo Clinic, Rochester, NY.
authors.forename: Priya S
authors.initials: PS
authors.lastname: Dhawan
authors.forename: Brent P
authors.initials: BP
authors.lastname: Goodman
authors.forename: Charles M
authors.initials: CM
authors.lastname: Harper
authors.forename: Peter E
authors.initials: PE
authors.lastname: Bosch
authors.forename: Charlene R
authors.initials: CR
authors.lastname: Hoffman-Snyder
authors.forename: Kay E
authors.initials: KE
authors.lastname: Wellik
authors.forename: Dean M
authors.initials: DM
authors.lastname: Wingerchuk
authors.forename: Bart M
authors.initials: BM
authors.lastname: Demaerschalk
mesh_terms: D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D000906:Antibodies / Q000097:blood; D004576:Electromyography; D005260:Female; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use*; D007155:Immunologic Factors / Q000627:therapeutic use*; D016239:MEDLINE / Q000706:statistics & numerical data; D008875:Middle Aged; D009157:Myasthenia Gravis / Q000503:physiopathology / Q000628:therapy*; D010951:Plasma Exchange / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D011950:Receptors, Cholinergic / Q000276:immunology; D016037:Single-Blind Method; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000906:Antibodies; D016756:Immunoglobulins, Intravenous; D007155:Immunologic Factors; D011950:Receptors, Cholinergic