Cyclophosphamide for myasthenia gravis: a comeback?

https://jnnp.bmj.com/content/early/2024/07/04/jnnp-2024-333920

this study shows that lower doses of cyclophosphamide can be effective and safe in people with MG, including older age. Clinicians may consider low-dose cyclophosphamide as a safe and cost-effective intervention in carefully selected patients, especially when novel treatments are inaccessible. Further studies are needed to understand the effect of timing of cyclophosphamide, as well as efficacy in other MG subtypes (eg, MuSK). This study also shows that the ongoing research and approvals of novel therapeutics in MG should not deter researchers from looking at older interventions, as these still play an important role in the treatment of MG.


Links to this paywalled article

https://jnnp.bmj.com/content/early/2024/07/04/jnnp-2023-333189

 

This seems to be just a retrospective study with no controls. And a tiny group so serious adverse reactions might not be picked up (they occur very long term). There was a death from opportunist pneumonia it seems even so.

I don't see the point in this.

My experience from talking to people involved in treating MG with anti-B cell therapies has been that they do not really understand the pharmacodynamics that you need to understand in order to use the treatments sensibly. In fact the same applies to rheumatoid and lupus but at least for RA the disease forces you to use fairly practical regimens. But complaints that things like rituximab are no good for MG are usually based on the physician not understanding how to use it. The drug companies do not understand so provide no guidance.

B cell depletion with biologics is still a long way from optimal in practical terms but at least people are looking at unpicking the dynamics with plasma cell targeting etc. Going back to cycle seems to me just giving up.

 

So really the message from them should have been more general to ‘include’ the new in being persistent and methodical at looking at the how to use them well ?