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Drugs that may unmask or worsen myasthenia gravis

Drugs that may unmask or worsen myasthenia gravis
Drugs that may unmask or worsen myasthenia gravis
Anesthetic agents
Neuromuscular blocking agents
Antibiotics
Aminoglycosides (eg, gentamicin, neomycin, tobramycin)
Fluoroquinolones (eg, ciprofloxacin, levofloxacin, norfloxacin)
Ketolides◊ (eg, telithromycin)
Macrolides (eg, azithromycin, clarithromycin, erythromycin)
Cardiovascular drugs
Beta blockers (eg, atenolol, labetalol, metoprolol, propranolol)
Procainamide
Quinidine
Other drugs
Anti-PD-1 monoclonal antibodies (eg, nivolumab and pembrolizumab)
Botulinum toxin
Chloroquine
Hydroxychloroquine
Magnesium
Penicillamine
Quinine
Drugs usually well tolerated in myasthenia gravis but occasionally associated with an exacerbation*
Anesthetic agents
Inhalation anesthetics (eg, isoflurane, halothane)
Local anestheticsΔ (eg, lidocaine, procaine)
Antibiotics and antiviral agents
Antiretroviral agents (eg, ritonavir)
Clindamycin
Metronidazole
Nitrofurantoin
Tetracyclines (eg, doxycycline, tetracycline)
Vancomycin
Antiseizure medications
Carbamazepine
Ethosuximide
Gabapentin
Phenobarbital
Phenytoin
Antipsychotics and other psychiatric drugs
Butyrophenones (eg, haloperidol)
Lithium
Phenothiazines§ (eg, chlorpromazine, prochlorperazine)
Glucocorticoids¥
Dexamethasone
Methylprednisolone
Prednisone
Ophthalmic drugs
Betaxolol
Echothiophate
Proparacaine
Timolol
Tropicamide
Other drugs
Cisplatinum
Emetine (Ipecac syrup)
Fludarabine
Glatiramer acetate
HMG CoA reductase inhibitors (statins)
Interferon alpha
Interleukin-2
Iodinated contrast agents
Riluzole
PD-1: programmed death receptor-1; HMG CoA: hydroxymethylglutaryl coenzyme A; IVIG: intravenous immune globulin.
* This is not a complete list of all drugs that may, in individual patients, adversely affect neuromuscular transmission. Refer to UpToDate topics for further information.
¶ Only when necessary in hospitalized patients and with caution for respiratory muscle weakness.
Δ When administered intravenously.
◊ Contraindicated in myasthenia gravis.
§ Also used as antiemetics.
¥ Although glucocorticoids are a common treatment for myasthenia gravis, at high doses they may cause a significant exacerbation of myasthenia gravis symptoms during early stages of treatment. For this reason, glucocorticoids should be started in high doses only in hospitalized patients who are receiving concurrent plasmapheresis or IVIG for myasthenic crisis.
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