What is your step-wise approach to treating worsening ocular myasthenia gravis symptoms?

I will assume that the patient is AChR antibody positive or seronegative (MuSK is a different discussion).

Usually, I start with pyridostigmine, with gradual titration of dose up to approximately 240 mg (60 mg 4 times a day). Higher doses are not likely to provide additional benefit, and cholinergic side effects will get worse. If not sufficiently effective, I will add prednisone. I try to avoid pushing the daily dose to more than 20-25 mg, although some patients need more.

As a third step, if a patient has good response to oral prednisone, but ocular symptoms consistently relapse every time the dose is tapered to 15 mg daily or below, or the patient develops intolerable steroid side effects, azathioprine or MMF can be added.

The most challeng...