Intravenous Efgartigimod Alfa as Initial Monotherapy for Disabling Ocular Myasthenia in an Elderly Patient with Multiple Comorbidities

Abstract

Myasthenia gravis (MG) is one of the most common neuromuscular disorders. It is an antibody-mediated autoimmune disease affecting the neuromuscular junction, presenting with fluctuating muscle weakness that commonly affects the ocular, bulbar, proximal, and respiratory muscles. Treating MG in the older population with preexisting comorbidities can be challenging. Intravenous efgartigimod alfa (EA) was successfully used as an initial monotherapy for a 90-year-old woman with acetylcholine receptor seropositive MG and stage IV colon adenocarcinoma who was referred for visually disabling bilateral eyelid ptosis. Standard MG therapy was considered but not chosen due to relative contraindications and anticipated adverse effects. EA infusions were well tolerated and corrected her ptosis after two weeks of treatment. EA infusion may be considered the first-line therapy for selected patients with seropositive generalized MG who have disabling ocular symptoms.

Keywords: autoimmune disease; efgartigimod alfa; ocular myasthenia; older population; positive antibodies; ptosis.

Figure 1. After two weeks of treatment, residual left ptosis was relieved, improving visual obstruction.

*The picture was obtained with permission from the patient.

Figure 2. After one cycle of treatment (four weeks).

*The picture was obtained with permission from the patient.

Figure 3. Efgartigimod alfa decreases circulating pathogenic IgG by blocking the release from lysosomal degradation.

Image credit: Octavio Carranza Renteria. Made in BioRender (https://www.biorender.com).