Efficacy and safety of non-steroidal immunosuppressive treatments in Generalized Myasthenia Gravis patients. A systematic review and meta-analysis

Background and aims: Myasthenia Gravis (MG) treatment consists of the use of acetylcholinesterase inhibitors, corticosteroids and, in cases of insufficient response, immunosuppressive treatments. Our aim is to evaluate the efficacy and safety of immunosuppressive drugs in generalized MG through a systematic review and metaanalysis. Methods: We performed a systematic review (PUBMED, EMBASE and Clinical trials gov, 2 January to 1 February 2019) to identify all the randomized clinical trials and cohort studies evaluating the effects of adding immunosuppressive drugs to the treatment of patients with generalized MG. Data analysis was performed using Review Manager 5 software and results were summarized as odds ratio (OR), mean difference and 95% confidence intervals (CI). We evaluated: (1) change in the Quantitative Myasthenia Gravis (QMG) score at the end of the study from baseline and (2) number of dropouts due to adverse events (AE). Results: A total of 323 manuscript were retrieved in the systematic review. We selected 22 articles. Treatment with tacrolimus, cyclosporine, cyclophosphamide, rituximab and eculizumab showed significant effects on the QMG score. There were more dropouts in the experimental groups compared to placebo, with statistically significant differences (OR 1.74, 95%CI 1.03-2.95). Forest plot of meta-analysis of EA in all the studies, odds ratios, overall odds ratios and 95% CI related to each categorical outcome measure Conclusion: Tacrolimus, rituximab and eculizumab stand out as the treatments with better efficacy and safety profile in generalized MG resistant to 1st-line treatments, although more studies with greater homogeneity are needed to draw conclusions that lead to algorithms of therapeutic decision. (Figure Presented).