Myastenia management

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"myasthenia gravis" AND treatment

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Myasthenia Gravis: Management

Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction, most commonly caused by antibodies against the acetylcholine receptor (AChR), with smaller subsets having anti-MuSK or anti-LRP4 antibodies. Management is individualized based on subtype (ocular vs. generalized), severity, antibody status, and presence of thymoma, with the treatment goal being "no symptoms or functional limitations from MG, with no more than mild side effects" (Sanders et al. 2016 MG Foundation of America consensus, cited in Bradley and Daroff's Neurology in Clinical Practice).

1. Symptomatic Treatment: Cholinesterase Inhibitors (First-line)

Pyridostigmine bromide is the most commonly used agent and part of initial treatment for most patients.
Adult starting dose: 30-60 mg every 4-8 hours; titrated to the muscle groups causing the most disability (not to exceed ~480 mg/day).
A timed-release 180 mg tablet can be used at bedtime for patients too weak to swallow in the morning, though absorption is erratic.
Side effects are cholinergic (muscarinic): nausea, cramps, diarrhea, salivation, increased secretions — can be managed with glycopyrrolate, hyoscyamine, or loperamide.
Caution: patients with anti-MuSK MG may worsen with cholinesterase inhibitors.
Cholinesterase inhibitors control symptoms but do not alter the underlying autoimmune process — most patients with generalized disease ultimately need immunotherapy.

2. Chronic Immunotherapy

Corticosteroids (e.g., prednisone) are typically first-line immunosuppression, often started at lower doses with slow up-titration to avoid an early steroid-induced exacerbation (or given after/with PLEX bridging in severe cases).
Steroid-sparing immunosuppressants: azathioprine, mycophenolate mofetil, cyclosporine, tacrolimus — used for long-term control, allowing steroid dose reduction. Onset of benefit is slow (months).
Rituximab (anti-CD20) is increasingly used, particularly in anti-MuSK MG and refractory disease.
Long-term principle: use the lowest effective dose, since chronic immunosuppression carries unclear but real long-term risks of infection and malignancy.

3. Rapid-Onset (Short-Term) Therapies — for Crisis or Severe Exacerbation

Plasma exchange (PLEX): removes circulating antibodies; improvement within days. Typical course is 5-6 exchanges every other day. Used for myasthenic crisis, severe MG, or pre-thymectomy preparation. Benefit wanes after ~4 weeks (up to 3 months); not used as chronic maintenance.
IVIG: alternative rapid-acting option with a similar role to PLEX in crisis/exacerbation management.
These bridge patients until slower-acting chronic immunotherapies take effect.

4. Newer Biologic Agents

Complement inhibitors (e.g., eculizumab) and anti-neonatal Fc receptor antibodies (e.g., efgartigimod, which accelerates IgG degradation) are approved/emerging targeted therapies for refractory generalized AChR-antibody-positive MG.
Amifampridine has shown benefit particularly in anti-MuSK MG.
A 2025 systematic review and network meta-analysis (PMID: 40346603) compared novel biologics (complement inhibitors, FcRn antagonists) for efficacy and acceptability in MG — supporting their growing role as add-on/refractory-disease options. This is worth discussing with a treating neurologist if standard immunotherapy fails.

5. Thymectomy

Recommended in most AChR-antibody-positive generalized MG patients, especially with thymoma (10-15% of MG patients have a thymoma).
Nearly all thymoma patients should undergo surgical resection regardless of age; advanced-stage or higher-grade tumors also need radiation therapy.

6. Precipitants and Drugs to Avoid

Treat concurrent thyroid disease aggressively (both hyper- and hypothyroidism worsen MG).
Treat infections promptly — they can precipitate myasthenic crisis, especially in immunosuppressed patients.
Certain drugs (e.g., some aminoglycosides, fluoroquinolones, magnesium, certain anesthetics/neuromuscular blockers) can worsen neuromuscular transmission and should be used cautiously (Bradley and Daroff's Neurology, Box 108.2).

Myasthenic Crisis (brief note)

Life-threatening respiratory/bulbar weakness requiring ICU-level care, airway monitoring (vital capacity/negative inspiratory force), and rapid-onset therapy (PLEX or IVIG) plus initiation/escalation of chronic immunotherapy.

Sources: Treatment of Myasthenia Gravis, Treatment Plan for Myasthenia Gravis - Bradley and Daroff's Neurology in Clinical Practice; supplemented by International Consensus Guidance for Management of Myasthenia Gravis (2020 update, Neurology 2021;96:114-122) as referenced across Goldman-Cecil Medicine and Harrison's Principles of Internal Medicine.

Recent evidence note: A 2025 network meta-analysis (PMID: 40346603) on novel biologics in MG treatment may refine relative positioning of newer agents (complement inhibitors vs. FcRn antagonists) beyond what's captured in current textbook editions - worth checking if considering biologic therapy for refractory disease.

Prescription

Asking for Preferences

What kind of prescription info do you need, following up on the myasthenia gravis discussion?

Myasthenia Gravis: Management

1. Symptomatic Treatment: Cholinesterase Inhibitors (First-line)

Pyridostigmine bromide is the most commonly used agent and part of initial treatment for most patients.
Adult starting dose: 30-60 mg every 4-8 hours; titrated to the muscle groups causing the most disability (not to exceed ~480 mg/day).
A timed-release 180 mg tablet can be used at bedtime for patients too weak to swallow in the morning, though absorption is erratic.
Side effects are cholinergic (muscarinic): nausea, cramps, diarrhea, salivation, increased secretions — can be managed with glycopyrrolate, hyoscyamine, or loperamide.
Caution: patients with anti-MuSK MG may worsen with cholinesterase inhibitors.
Cholinesterase inhibitors control symptoms but do not alter the underlying autoimmune process — most patients with generalized disease ultimately need immunotherapy.

2. Chronic Immunotherapy

Corticosteroids (e.g., prednisone) are typically first-line immunosuppression, often started at lower doses with slow up-titration to avoid an early steroid-induced exacerbation (or given after/with PLEX bridging in severe cases).
Steroid-sparing immunosuppressants: azathioprine, mycophenolate mofetil, cyclosporine, tacrolimus — used for long-term control, allowing steroid dose reduction. Onset of benefit is slow (months).
Rituximab (anti-CD20) is increasingly used, particularly in anti-MuSK MG and refractory disease.
Long-term principle: use the lowest effective dose, since chronic immunosuppression carries unclear but real long-term risks of infection and malignancy.

3. Rapid-Onset (Short-Term) Therapies — for Crisis or Severe Exacerbation

Plasma exchange (PLEX): removes circulating antibodies; improvement within days. Typical course is 5-6 exchanges every other day. Used for myasthenic crisis, severe MG, or pre-thymectomy preparation. Benefit wanes after ~4 weeks (up to 3 months); not used as chronic maintenance.
IVIG: alternative rapid-acting option with a similar role to PLEX in crisis/exacerbation management.
These bridge patients until slower-acting chronic immunotherapies take effect.

4. Newer Biologic Agents

Complement inhibitors (e.g., eculizumab) and anti-neonatal Fc receptor antibodies (e.g., efgartigimod, which accelerates IgG degradation) are approved/emerging targeted therapies for refractory generalized AChR-antibody-positive MG.
Amifampridine has shown benefit particularly in anti-MuSK MG.
A 2025 systematic review and network meta-analysis (PMID: 40346603) compared novel biologics (complement inhibitors, FcRn antagonists) for efficacy and acceptability in MG — supporting their growing role as add-on/refractory-disease options. This is worth discussing with a treating neurologist if standard immunotherapy fails.

5. Thymectomy

Recommended in most AChR-antibody-positive generalized MG patients, especially with thymoma (10-15% of MG patients have a thymoma).
Nearly all thymoma patients should undergo surgical resection regardless of age; advanced-stage or higher-grade tumors also need radiation therapy.

6. Precipitants and Drugs to Avoid

Treat concurrent thyroid disease aggressively (both hyper- and hypothyroidism worsen MG).
Treat infections promptly — they can precipitate myasthenic crisis, especially in immunosuppressed patients.
Certain drugs (e.g., some aminoglycosides, fluoroquinolones, magnesium, certain anesthetics/neuromuscular blockers) can worsen neuromuscular transmission and should be used cautiously (Bradley and Daroff's Neurology, Box 108.2).

Myasthenic Crisis (brief note)

If you'd like, I can go deeper into any specific area - e.g., myasthenic crisis management, ocular MG-specific approach, MuSK-antibody MG peculiarities, pregnancy considerations, or the newer biologics (efgartigimod/eculizumab) in detail.Since the clarification request didn't go through, here's a practical prescription reference for myasthenia gravis based on the management plan discussed — covering the most common first-line and escalation therapies. Adjust doses to the individual patient under a treating physician's supervision.

Sample Prescription — Ocular / Mild Generalized MG (First-Line)

Rx: Pyridostigmine bromide (Mestinon)

Tablet 60 mg
Sig: Take 1 tablet (60 mg) by mouth every 6 hours, 4 times daily
Titrate: may increase to 60-120 mg every 3-4 hours based on symptom response, not to exceed 480 mg/day
Dispense: 30-day supply
Notes: take ~30-45 min before meals if oropharyngeal/bulbar weakness present; take with food if GI upset occurs

If GI side effects (cramping, diarrhea) limit titration, add:

Glycopyrrolate 1 mg PO BID-TID as needed, or
Loperamide 2 mg PO PRN for diarrhea

Sample Prescription — Generalized MG Requiring Immunosuppression

Rx: Prednisone

Start low to avoid steroid-induced exacerbation: 10-20 mg PO daily (or alternate-day dosing), titrate up over 1-2 weeks to 1 mg/kg/day (max ~60-80 mg/day) as tolerated
Once clinical improvement is stable (usually 1-3 months), taper slowly to lowest effective dose
Co-prescribe: calcium + vitamin D, consider bisphosphonate for bone protection; monitor glucose, blood pressure

Steroid-sparing agent (added for long-term control), e.g.:

Azathioprine 50 mg PO daily, titrate to 2-3 mg/kg/day over several weeks (check TPMT/NUDT15 status first; monitor CBC and LFTs)
or Mycophenolate mofetil 500 mg PO BID, titrate to 1000 mg PO BID (monitor CBC)

For Myasthenic Crisis / Severe Exacerbation (inpatient)

IVIG 0.4 g/kg/day IV for 5 days, or
Plasma exchange: 5-6 exchanges over 10-14 days
Continue/initiate corticosteroids concurrently; monitor respiratory status (vital capacity, NIF) closely, ICU-level care if bulbar/respiratory compromise

Important Prescribing Cautions

Avoid or use cautiously: aminoglycosides, fluoroquinolones, magnesium salts, certain beta-blockers, neuromuscular blocking agents, and telithromycin — all can worsen MG.
Anti-MuSK MG patients may respond poorly to cholinesterase inhibitors — favor immunotherapy/rituximab-based approach.
Always screen for thymoma (chest CT/MRI) before or shortly after starting immunosuppression, and check TB/hepatitis status if immunosuppression is planned.

This is a general reference framework, not a specific prescription for an actual patient — actual dosing must be individualized by the treating physician based on antibody subtype, severity, comorbidities, renal/hepatic function, and response to therapy. Let me know if you want this tailored to a specific patient scenario (e.g., pregnant patient, pediatric case, or MuSK-antibody positive disease) or formatted as a downloadable document.

Create a quick reference PDF guide for MG prescribing protocols

Reading File

Running Command

mkdir -p /tmp/workspace/mg-prescribing-guide && ls -la /tmp/workspace/

Writing File

~/mg-prescribing-guide/build_pdf.py

#!/usr/bin/env python3
"""Build a Myasthenia Gravis Prescribing Quick Reference PDF."""

from reportlab.lib.pagesizes import letter
from reportlab.lib.units import inch
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, ListFlowable, ListItem
)
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT

OUT = "/tmp/workspace/mg-prescribing-guide/MG_Prescribing_Quick_Reference.pdf"

styles = getSampleStyleSheet()

title_style = ParagraphStyle(
    "TitleStyle", parent=styles["Title"], fontSize=20, textColor=colors.HexColor("#1a3c6e"),
    spaceAfter=4, alignment=TA_CENTER
)
subtitle_style = ParagraphStyle(
    "SubtitleStyle", parent=styles["Normal"], fontSize=10.5, textColor=colors.HexColor("#555555"),
    alignment=TA_CENTER, spaceAfter=14
)
h1 = ParagraphStyle(
    "H1", parent=styles["Heading1"], fontSize=14, textColor=colors.white,
    backColor=colors.HexColor("#1a3c6e"), spaceBefore=14, spaceAfter=8,
    leftIndent=6, borderPadding=(6, 6, 6, 6)
)
h2 = ParagraphStyle(
    "H2", parent=styles["Heading2"], fontSize=11.5, textColor=colors.HexColor("#1a3c6e"),
    spaceBefore=10, spaceAfter=4
)
body = ParagraphStyle(
    "Body", parent=styles["Normal"], fontSize=9.3, leading=13, spaceAfter=4
)
bullet_style = ParagraphStyle(
    "Bullet", parent=body, leftIndent=12, bulletIndent=2, spaceAfter=3
)
warn_style = ParagraphStyle(
    "Warn", parent=body, textColor=colors.HexColor("#7a1f1f"), backColor=colors.HexColor("#fdecea"),
    borderPadding=(6, 6, 6, 6), spaceAfter=6
)
note_style = ParagraphStyle(
    "Note", parent=body, textColor=colors.HexColor("#1a3c6e"), backColor=colors.HexColor("#eaf1fb"),
    borderPadding=(6, 6, 6, 6), spaceAfter=6
)
footer_style = ParagraphStyle(
    "Footer", parent=styles["Normal"], fontSize=7.5, textColor=colors.HexColor("#888888"), alignment=TA_CENTER
)

TABLE_HEAD_BG = colors.HexColor("#1a3c6e")
TABLE_ALT_BG = colors.HexColor("#f2f5fa")


def std_table(data, col_widths, font_size=8.3):
    t = Table(data, colWidths=col_widths, repeatRows=1)
    style = [
        ("BACKGROUND", (0, 0), (-1, 0), TABLE_HEAD_BG),
        ("TEXTCOLOR", (0, 0), (-1, 0), colors.white),
        ("FONTNAME", (0, 0), (-1, 0), "Helvetica-Bold"),
        ("FONTSIZE", (0, 0), (-1, -1), font_size),
        ("GRID", (0, 0), (-1, -1), 0.5, colors.HexColor("#c9c9c9")),
        ("VALIGN", (0, 0), (-1, -1), "TOP"),
        ("LEFTPADDING", (0, 0), (-1, -1), 5),
        ("RIGHTPADDING", (0, 0), (-1, -1), 5),
        ("TOPPADDING", (0, 0), (-1, -1), 4),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 4),
    ]
    for i in range(1, len(data)):
        if i % 2 == 0:
            style.append(("BACKGROUND", (0, i), (-1, i), TABLE_ALT_BG))
    t.setStyle(TableStyle(style))
    return t


def p(text, style=body):
    return Paragraph(text, style)


def bullets(items, style=bullet_style):
    return ListFlowable(
        [ListItem(Paragraph(it, style), bulletColor=colors.HexColor("#1a3c6e")) for it in items],
        bulletType="bullet", start="circle", leftIndent=14
    )


elements = []

# ---------- TITLE ----------
elements.append(Paragraph("Myasthenia Gravis", title_style))
elements.append(Paragraph("Prescribing Quick Reference Guide", ParagraphStyle(
    "Sub2", parent=title_style, fontSize=13, spaceAfter=2)))
elements.append(Paragraph(
    "For clinician reference only &mdash; individualize therapy per patient antibody subtype, severity, and comorbidities",
    subtitle_style))
elements.append(HRFlowable(width="100%", thickness=1.2, color=colors.HexColor("#1a3c6e"), spaceAfter=10))

elements.append(p(
    "<b>Goal of therapy:</b> No symptoms/functional limitation from MG, with no more than mild, "
    "non-intervention-requiring side effects (MGFA consensus).", note_style))

# ---------- SECTION 1: First-line symptomatic ----------
elements.append(Paragraph("1. First-Line Symptomatic Therapy &mdash; Cholinesterase Inhibitor", h1))

data1 = [
    ["Drug", "Starting Dose", "Titration / Max", "Key Points"],
    ["Pyridostigmine\nbromide (Mestinon)",
     "60 mg PO q6h\n(adult)",
     "60&ndash;120 mg q3&ndash;4h\nMax 480 mg/day",
     "Time dose ~30&ndash;45 min before meals if bulbar weakness. "
     "Timed-release 180 mg tab useful at bedtime. Caution: erratic absorption."],
    ["Pyridostigmine\n(pediatric)", "1 mg/kg PO", "Titrate to response",
     "Syrup 60 mg/5 mL available for NG/impaired swallowing."],
]
elements.append(std_table(data1, [1.15*inch, 1.1*inch, 1.25*inch, 2.5*inch]))
elements.append(Spacer(1, 6))

elements.append(Paragraph("Managing cholinergic (muscarinic) side effects:", h2))
elements.append(bullets([
    "Glycopyrrolate 1 mg PO BID&ndash;TID PRN for secretions/cramping",
    "Loperamide 2 mg PO PRN for diarrhea",
    "Hyoscyamine or propantheline as alternatives",
]))
elements.append(p(
    "<b>Caution:</b> Anti-MuSK antibody-positive MG may worsen with cholinesterase inhibitors &mdash; "
    "favor early immunotherapy in this subgroup.", warn_style))

# ---------- SECTION 2: Chronic immunotherapy ----------
elements.append(Paragraph("2. Chronic Immunotherapy (Generalized / ChEI-Refractory MG)", h1))

data2 = [
    ["Agent", "Induction", "Maintenance / Taper", "Monitoring"],
    ["Prednisone",
     "10&ndash;20 mg/day,\nup-titrate over 1&ndash;2 wks",
     "Up to 1 mg/kg/day (max ~60&ndash;80 mg/day);\ntaper to lowest effective dose once stable (1&ndash;3 mo)",
     "Glucose, BP, bone density; co-Rx calcium + vit D \u00b1 bisphosphonate"],
    ["Azathioprine",
     "50 mg/day",
     "Titrate to 2&ndash;3 mg/kg/day over several weeks",
     "Check TPMT/NUDT15 first; CBC + LFTs q1&ndash;2 wks initially, then q1&ndash;3 mo"],
    ["Mycophenolate\nmofetil",
     "500 mg PO BID",
     "Titrate to 1000 mg PO BID",
     "CBC periodically; teratogenic &mdash; avoid in pregnancy"],
    ["Rituximab",
     "Per protocol\n(e.g., 375 mg/m\u00b2 or\nfixed-dose regimens)",
     "Repeat per B-cell repletion / clinical relapse",
     "Preferred in refractory anti-MuSK MG; screen HBV before use"],
]
elements.append(std_table(data2, [1.0*inch, 1.15*inch, 1.85*inch, 2.0*inch], font_size=8.0))
elements.append(Spacer(1, 6))
elements.append(p(
    "<b>Pre-immunosuppression screening:</b> chest CT/MRI for thymoma, TB test "
    "(skin test or QuantiFERON-TB Gold), hepatitis B/C serology.", note_style))
elements.append(p(
    "<b>Principle:</b> use the lowest effective dose long-term &mdash; chronic risks of infection "
    "and malignancy, while not precisely quantified, are associated with these agents.", body))

# ---------- SECTION 3: Rapid-onset / crisis ----------
elements.append(Paragraph("3. Rapid-Onset Therapy &mdash; Severe Exacerbation / Myasthenic Crisis", h1))

data3 = [
    ["Modality", "Regimen", "Onset / Duration", "Notes"],
    ["IVIG", "0.4 g/kg/day IV \u00d7 5 days",
     "Onset days; benefit\nlasts weeks&ndash;months",
     "Preferred if venous access difficult or renal/cardiac fluid-shift risk with PLEX"],
    ["Plasma exchange\n(PLEX)", "5&ndash;6 exchanges,\nevery other day\n(2&ndash;3 L/exchange)",
     "Onset days; wears off\n~4 wks, up to 3 mo",
     "Used pre-thymectomy, crisis, or to prevent steroid-induced flare. Not for chronic maintenance."],
]
elements.append(std_table(data3, [1.05*inch, 1.55*inch, 1.4*inch, 2.0*inch], font_size=8.2))
elements.append(Spacer(1, 6))
elements.append(p(
    "<b>Myasthenic crisis:</b> ICU-level monitoring, serial vital capacity / negative inspiratory "
    "force, early airway support if bulbar/respiratory compromise. Continue or initiate chronic "
    "immunotherapy concurrently.", warn_style))

# ---------- SECTION 4: Biologics ----------
elements.append(Paragraph("4. Targeted Biologic Agents (Refractory Generalized MG)", h1))
elements.append(bullets([
    "<b>Complement (C5) inhibitors</b> (e.g., eculizumab) &mdash; for refractory AChR-antibody-positive generalized MG",
    "<b>Anti-FcRn agents</b> (e.g., efgartigimod) &mdash; accelerate IgG degradation, reduce pathogenic antibody levels",
    "<b>Amifampridine</b> &mdash; symptomatic benefit reported particularly in anti-MuSK MG",
]))
elements.append(p(
    "A 2025 systematic review / network meta-analysis of novel biologics in MG "
    "(PMID: 40346603) supports growing evidence for these agents as add-on/refractory-disease "
    "options &mdash; discuss with a treating neurologist before initiating.", note_style))

elements.append(PageBreak())

# ---------- SECTION 5: Thymectomy ----------
elements.append(Paragraph("5. Thymectomy", h1))
elements.append(bullets([
    "Recommended for most AChR-antibody-positive generalized MG patients, especially with thymoma "
    "(present in 10&ndash;15% of MG patients)",
    "Nearly all thymoma patients should undergo surgical resection regardless of age",
    "Advanced-stage / higher WHO grade tumors (Stage II&ndash;IV, B2/B3) require adjunctive radiation therapy",
    "Elderly/multimorbid patients with small tumors may be followed with periodic imaging instead",
]))

# ---------- SECTION 6: Drugs to avoid ----------
elements.append(Paragraph("6. Drugs to Avoid or Use with Caution in MG", h1))

data6 = [
    ["Category", "Examples"],
    ["Antibiotics", "Aminoglycosides, fluoroquinolones, telithromycin, macrolides (high dose)"],
    ["Cardiovascular", "Beta-blockers, some calcium channel blockers, procainamide, quinidine"],
    ["Anesthesia-related", "Neuromuscular blocking agents (non-depolarizing/depolarizing), high-dose local anesthetics"],
    ["Electrolytes", "Magnesium salts (IV magnesium especially)"],
    ["Rheumatologic", "Penicillamine, chloroquine/hydroxychloroquine"],
    ["Psychiatric", "Lithium, high-dose benzodiazepines/phenothiazines"],
]
elements.append(std_table(data6, [1.5*inch, 4.5*inch], font_size=8.3))
elements.append(Spacer(1, 6))
elements.append(p(
    "Clinical judgment applies &mdash; associations are often based on case reports; weigh "
    "risk/benefit rather than treating this as an absolute contraindication list.", body))

# ---------- SECTION 7: Comorbidity management ----------
elements.append(Paragraph("7. Managing Concurrent Conditions", h1))
elements.append(bullets([
    "<b>Thyroid disease:</b> treat vigorously &mdash; both hyper- and hypothyroidism worsen myasthenic weakness",
    "<b>Infections:</b> treat immediately &mdash; can precipitate crisis, especially in immunosuppressed patients",
    "<b>Pregnancy:</b> avoid mycophenolate and methotrexate (teratogenic); pyridostigmine and prednisone "
    "are generally considered compatible &mdash; manage with maternal-fetal medicine and neurology co-input",
]))

# ---------- SECTION 8: Quick decision snapshot ----------
elements.append(Paragraph("8. Quick Decision Snapshot", h1))
data8 = [
    ["Presentation", "First Choice"],
    ["Ocular / mild generalized MG", "Pyridostigmine \u00b1 low-dose steroid"],
    ["Moderate-severe generalized MG", "Pyridostigmine + corticosteroid + steroid-sparing agent"],
    ["Anti-MuSK MG", "Immunotherapy-focused (rituximab); ChEIs may worsen symptoms; consider amifampridine"],
    ["Thymoma present", "Surgical thymectomy \u00b1 radiation, regardless of MG severity"],
    ["Myasthenic crisis", "ICU + IVIG or PLEX + continue/escalate chronic immunotherapy"],
    ["Refractory to conventional therapy", "Consider complement inhibitor / FcRn antagonist / rituximab"],
]
elements.append(std_table(data8, [2.2*inch, 3.8*inch], font_size=8.3))

elements.append(Spacer(1, 14))
elements.append(HRFlowable(width="100%", thickness=0.8, color=colors.HexColor("#c9c9c9")))
elements.append(Spacer(1, 6))
elements.append(Paragraph(
    "This guide is a general clinical reference synthesized from Bradley and Daroff's Neurology in "
    "Clinical Practice, International Consensus Guidance for Management of Myasthenia Gravis (2020 "
    "update, Neurology 2021;96:114&ndash;122), and current systematic review literature (e.g., PMID: "
    "40346603). It is NOT a substitute for individualized clinical judgment, institutional protocols, "
    "or current prescribing information. Always verify doses, contraindications, and monitoring "
    "requirements against current package inserts and specialist guidance before prescribing.",
    footer_style
))

doc = SimpleDocTemplate(
    OUT, pagesize=letter,
    topMargin=0.55*inch, bottomMargin=0.55*inch,
    leftMargin=0.6*inch, rightMargin=0.6*inch,
    title="MG Prescribing Quick Reference"
)
doc.build(elements)
print("Saved:", OUT)

Running Command

cd /tmp/workspace/mg-prescribing-guide && python3 build_pdf.py

Running Command

cd /tmp/workspace/mg-prescribing-guide && python3 -c " from pypdf import PdfReader r = PdfReader('MG_Prescribing_Quick_Reference.pdf') print('Pages:', len(r.pages)) print('Size KB:', __import__('os').path.getsize('MG_Prescribing_Quick_Reference.pdf')/1024) " ls -la /tmp/workspace/mg-prescribing-guide/

PDF built successfully - 3 pages, covers all prescribing protocols.

MG Prescribing Quick Reference

PDF Document · PDF

Contents:

First-line symptomatic therapy (pyridostigmine dosing, side-effect management)
Chronic immunotherapy (prednisone, azathioprine, mycophenolate, rituximab dosing/monitoring tables)
Rapid-onset therapy for crisis (IVIG vs. PLEX)
Targeted biologics (complement inhibitors, anti-FcRn agents, amifampridine)
Thymectomy indications
Drugs to avoid/use with caution
Managing concurrent conditions (thyroid, infection, pregnancy)
Quick decision snapshot table by clinical scenario

It's formatted as a clinician reference with color-coded warning/note boxes and tables for fast bedside/clinic lookup, and includes a footer disclaimer noting it's a general reference (not a substitute for individualized judgment) sourced from Bradley and Daroff's Neurology in Clinical Practice, the 2020 International Consensus Guidance for MG Management, and current systematic review literature (PMID: 40346603).

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