Efficacy of Pyridostigmine in Myasthenia Gravis: A Randomized, Double-Blind, Placebo-Controlled Crossover Trial

Clinical Snapshot

Key Findings

• P Value: p = 0.004 for primary outcome

• Effect Size: Moderate to large effect size across all outcome measures

• Primary Outcome: MGII score mean difference of 5.3 points favoring pyridostigmine over placebo

• Nnt Or Sensitivity: Cost savings of €6,565 annually with 0.106 QALY improvement per patient

• Confidence Interval: 95% CI 1.9-8.7 for primary outcome

Clinical Application

Highly feasible - pyridostigmine is readily available, well-established dosing protocols, and requires minimal monitoring Pyridostigmine is PBS-listed for myasthenia gravis (Authority Required). Results support current RACGP and specialist neurological practice guidelines recommending pyridostigmine as first-line symptomatic therapy Adults with AChR-positive myasthenia gravis on stable immunosuppressive therapy who are candidates for symptomatic treatment

Abstract

BACKGROUND AND OBJECTIVES: Pyridostigmine, an acetylcholinesterase inhibitor, is a symptomatic drug approved for the treatment of myasthenia gravis (MG), but no randomized controlled trials substantiate its widespread use. We aimed to assess the efficacy and cost utility of pyridostigmine in patients with anti-acetylcholine receptor-positive MG (AChR MG). METHODS: A randomized, double-blind, placebo-controlled crossover trial was conducted at Leiden University Medical Center, a tertiary center for the treatment of MG in the Netherlands. Main eligibility criteria were current use of pyridostigmine and a stable dose of other MG treatments. Participants were assigned to a sequence of 2 treatment periods for 5 days separated by a 2-day washout, in which patients either first received placebo and then pyridostigmine, or vice versa. Pyridostigmine dosing matched each participant's prestudy regimen. The primary outcome was change in the Myasthenia Gravis Impairment Index (MGII) score. Secondary efficacy outcome measures included the Myasthenia Gravis Activities of Daily Living (MG-ADL) scale, the Quantitative Myasthenia Gravis (QMG) score, and the revised 15-item Myasthenia Gravis Quality of Life (MG-QOL15r) questionnaire. For the post hoc cost-utility analysis, a mathematical model was developed to translate the observed study results into long-term annual effect on societal costs and quality-adjusted life years (QALYs). RESULTS: A total of 19 patients (median age 59 years, 58% female) were recruited between March 23, 2023, and February 21, 2024. The estimated mean difference in the MGII score between pyridostigmine and placebo interventions was 5.3 (95% CI 1.9-8.7, p = 0.004). Secondary efficacy outcome measures showed estimated mean differences of 1.4 (95% CI 0.5-2.3) for the QMG score, 1.2 (95% CI 0.5-1.8) for the MG-ADL score, and 2.0 (95% CI 0.03-3.91) for the MG-QoL15r score. The post hoc cost-utility analysis showed lower annual societal costs (€6,565, 95% CI €328-€15,945) and annual improved QALYs (0.106, 95% CI 0.019-0.210) for patients using pyridostigmine. DISCUSSION: This trial showed that, in patients with AChR MG chronically treated with pyridostigmine, pyridostigmine demonstrated benefit over placebo across all efficacy outcome measures and substantially reduced societal costs. TRIAL REGISTRATION INFORMATION: The trial was registered at EudraCT (2021-004110-20, registration date: July 12, 2022) and ClinicalTrials.gov (NCT05919407, registration date: June 16, 2023). First patient enrolled: March 23, 2023. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that, in adults with AChR ab-positive ocular or generalized MG on stable standard-of-care therapy and currently using pyridostigmine, pyridostigmine improves MG symptoms compared with placebo.

References

1. 1.Remijn-Nelissen, L., Bakker, W. R., van den Hout, W. B., van Gelder, T., Ruiter, A. M., Campman, Y. J. M., Badrising, U. A., Straathof, C. S. M., Verschuuren, J. J. G. M., & Tannemaat, M. R. (2026). Efficacy of Pyridostigmine in Myasthenia Gravis: A Randomized, Double-Blind, Placebo-Controlled Crossover Trial. Neurology. https://doi.org/10.1212/WNL.0000000000214865