National guidelines for diagnosis, treatment, and management of myasthenia gravis in Israel.

Abstract

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disorder characterized primarily by fluctuating skeletal muscle weakness affecting ocular, bulbar, truncal, limb, and respiratory muscles. The disease is typically mediated by anti-acetylcholine receptor (AChR) antibodies, and less commonly by anti-muscle-specific kinase) or anti-low-density lipoprotein receptor-related protein 4 antibodies. Despite significant advancements in diagnostics and immunotherapy, disparities in treatment access and practice variability remain prevalent in Israel. To address these gaps, updated national guidelines have been developed, integrating the latest international evidence and adapting it to the local healthcare landscape, regulation, and population diversity. This national guideline emphasizes precise diagnostic evaluation through comprehensive clinical assessment, standardized antibody testing, neurophysiological studies, and mediastinal imaging for thymic pathology assessment. Utilizing standardized scales, including MG activities of daily living, quantitative MG score, and MG Foundation of America post-intervention status, is crucial for disease staging and therapeutic decision-making. Therapeutic goals prioritize achieving full remission or a state of minimal manifestations of disease with negligible treatment-related side effects. Guidelines for treatment strategies are based on antibody status, disease severity, patient age, and comorbidities. Thymectomy is recommended for patients with generalized AChR antibody-positive MG, ideally within 2 years of disease onset. Pregnant women, older adults, children, and patients with cancer need specific immunotherapy approaches. Multidisciplinary care, structured patient education, and psychosocial support are integral to managing MG effectively. These national guidelines aim to standardize clinical practices, enhance patient outcomes, and reduce healthcare disparities in the management of MG across Israel.