MG Crisis – Pyridostigmine Management — SCE Neurology MCQ

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HardPeripheral Neuropathy & NeuromuscularMG Crisis – Pyridostigmine ManagementSCE Neurology

A 40-year-old woman with myasthenia gravis on pyridostigmine and prednisolone develops acute respiratory failure with FVC of 0.8 L. She is intubated. While in the ICU, what important medication adjustment should be made regarding pyridostigmine?

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Correct answer: A — Temporarily withhold pyridostigmine during mechanical ventilation

During myasthenic crisis requiring mechanical ventilation, pyridostigmine is often temporarily withheld ('drug holiday') for several reasons: (1) it can increase bronchial secretions, complicating ventilator management; (2) it may contribute to a depolarising block at the NMJ ('cholinergic crisis'); (3) the patient is mechanically ventilated so immediate symptom relief is not needed. Once the underlying crisis is treated (with IVIg or PLEX) and extubation is planned, pyridostigmine can be cautiously reintroduced. A: Increasing dose during ventilation risks secretion problems. B: Continuing may worsen secretions. D: IV neostigmine is not preferred. E: Atropine may be used for excess secretions but the primary action is withholding pyridostigmine.

Reference: ABN MG Guidelines (2025); MGFA International Consensus Guidance (2020)