What are the recommended first-line treatment options for managing myasthenia gravis in adults?

First-line treatment options for managing myasthenia gravis (MG) in adults primarily include symptomatic therapy with acetylcholinesterase inhibitors, such as pyridostigmine, which improve neuromuscular transmission and provide symptomatic relief.

In addition to symptomatic treatment, immunosuppressive therapy is recommended early in the disease course to control the autoimmune process. Oral corticosteroids, typically prednisolone, are considered first-line immunosuppressants to reduce antibody-mediated damage to the neuromuscular junction.

For patients who cannot tolerate corticosteroids or require steroid-sparing strategies, other immunosuppressive agents such as azathioprine may be introduced as adjunctive therapy.

In cases of more severe or refractory disease, or when rapid control is needed, short-term treatments like intravenous immunoglobulin (IVIg) or plasma exchange can be used, but these are generally not first-line maintenance therapies.

Recent literature also highlights the emerging role of biologic therapies such as rituximab, especially in refractory MG or in patients with MuSK antibody-positive disease, but these are not yet standard first-line treatments and are reserved for specific cases.

Overall, the UK and international guidelines recommend starting with acetylcholinesterase inhibitors and corticosteroids, with immunosuppressants added as needed, tailoring treatment to disease severity and patient tolerance.

References: ¹; (Melzer et al., 2016); (Shelly et al., 2025); (Dodd et al., 2025)