Use of neuromuscular blocking agents for patients with myasthenia gravis: a  literature review

Martynas Zaremba1, Valdonė Ališkevičiūtė1, Vykinta Zeleckytė1

1Medical Academy of the Lithuanian University of Health Sciences


Myasthenia gravis is an autoimmune disease which affects neuromuscular junction and as a result leads to muscle weakness. The pathogenesis of this disease is the formation of antibodies against acetylcholine receptors which are located at the postsynaptic neuromuscular junction. Neuromuscular blocking agents, which are often used during anesthesia, act by similar mechanism, therefore it is very important to know, what medication and their doses to choose and what side effects should be expected. We analyzed medical publications using international databases like UpToDate, PubMed, Cohrane, MedScape. Certain keywords and their combinations were used to find specific medical articles. Conclusions: 1. Myasthenia gravis is caused by antibodies which formed against postsynaptic nicotinic acetylcholine receptors or antibodies which formed against muscle-specific kinase (MuSK), which is essential for the development and maintenance of the acetylcholine receptors. 2. There are two types of neuromuscular blockers: depolarizing, which act as acetylcholine receptor agonists and non-depolarizing, acting as acetylcholine receptor antagonists. 3. Neuromuscular blocking agents should be avoided in patients with myasthenia gravis, but short- or moderate-acting non-depolarizing muscular blockers should be chosen if it is unavoidable. 4. To reverse neuromuscular blockade, sugammadex should be chosen over neostigmine to avoid possible side effects such as cholinergic crisis. 5. The main symptoms of a cholinergic crisis are cramps, increased salivation, tearing, muscle weakness, paralysis, muscle fasciculations, diarrhea and blurred vision, and the first-line treatment for it is atropine.

Keywords: neuromuscular blocking agents, neuromuscular, neuromuscular junction, myasthenia gravis, anesthesia.