Miscellaneous And Unknown Mechanisms
A certain range of drugs have been associated with myasthenic side effects, but details regarding the underlying mechanisms are lacking in the literature. Hence, it can only be assumed based on pharmacological properties and the time course of neuromuscular manifestations, whether the effects relate to NMJ function or the immune system. Since the present article focuses on the underlying mechanisms of medication-associated myasthenia, such treatments with poorly characterized or unknown mechanisms will only be mentioned briefly, focusing on clinical aspects.
What Medications Should Be Avoided
Certain medications can worsen the symptoms of myasthenia and should be avoided. These medications include specific antibiotics , beta-blockers, calcium channel blockers, and phenytoin . If a patient with myasthenia gravis requires a surgical procedure, the anesthesiologist should be aware and in order to use the proper medications.
Antibiotics Myasthenia Gravis And Risk Of Weakness
A 71 year old female presents to the ED with lethargy, fever , and tachypnea . She has a long-standing history of myasthenia gravis for which she receives periodic IVIG infusions. She is accompanied by her son, who informs you that she had a recent 10-day hospital stay for weakness. A CXR reveals an infiltrate in the left lower lobe.
The decision is made to initiate antimicrobial therapy for presumed healthcare-associated pneumonia. But, which antibiotics are safe to use in a patient with severe MG?
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Risk Of Increased Weakness12
Based on reported literature, these antibiotics seem to have at least some likelihood of exacerbating underlying MG. The risk of increased weakness is reported.
* Not an all-inclusive list, but includes most that have been reported
** Risk is based on estimated prevalence and severity of effect
*** Note that the fluoroquinolones have a black-box warning against using them in patients with MG
Why Is This Medication Prescribed
Levofloxacin is used to treat certain infections such as pneumonia, and kidney, prostate , and skin infections. Levofloxacin is also used to prevent anthrax in people who may have been exposed to anthrax germs in the air, and treat and prevent plague (a serious infection that may be spread on purpose as part of a bioterror attack. Levofloxacin may also be used to treat bronchitis, sinus infections, or urinary tract infections but should not be used for bronchitis and certain types of urinary tract infections if there are other treatment options available. Levofloxacin is in a class of antibiotics called fluoroquinolones. It works by killing bacteria that cause infections.
Antibiotics such as levofloxacin will not work for colds, flu, or other viral infections. Using antibiotics when they are not needed increases your risk of getting an infection later that resists antibiotic treatment.
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Episode : Medications That May Increase Weakness And Impair Neuromuscular Transmission In Patients With Myasthenia Gravis
Myasthenia Gravis is a neuromuscular junction disease that results from the production of autoantibodies directed against the nicotinic acetylcholine receptor.
The Myasthenia Gravis Foundation of America keeps a list of medications that may potentially exacerbate myasthenia symptoms on their website, myasthenia.org. This type of document is a pattern that follows for many other relatively rare conditions I always look for a foundation website with resources for healthcare professionals when I encounter a patient with a rare medical condition.
Some of the medication classes that are of potential concern in patients with myasthenia gravis are antimicrobials, cardiovascular drugs, antiepileptic drugs, hormonal medications, ophthalmic medications, psychoactive medications.
The classes of medications that have the most well-established reasons for avoiding use in patients with myasthenia gravis are magnesium, aminoglycosides and neuromuscular blocking agents.
Magnesium inhibits release of acetylcholine thus interfering with neuromuscular transmission. Increased myasthenia symptoms occur more often with parenteral magnesium, but oral magnesium has also been reported to be problematic. For this reason, parenteral magnesium is relatively contraindicated in patients with myasthenia gravis.
There are case reports and in vitro data implicating virtual every class of antibiotic in causing weakness or neuromuscular transmission dysfunction.
How To Take Cipro
Take Cipro exactly according to your doctors instructions. You might start to feel better before you finish your entire Cipro treatment. Even if you start to feel better, dont stop taking Cipro. In many cases, its important to finish the entire treatment to make sure the infection doesnt come back.
If youre feeling better and want to stop Cipro early, be sure to talk with your doctor first to make sure its safe to do so.
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Immunological Mechanisms In Drug
As opposed to the delineated NMJ-related drug effects, some medical treatments are known or presumed to set in motion a de novo immunological process, thus initiating new-onset autoimmune phenomena that may clinically resemble acquired conditions such as MG. This pathophysiological concept is in line with new-onset diseases in previously healthy individuals rather than a transient aggravation of a pre-existing disorder. However, also previous autoimmunological conditions may be more likely to flare up as a consequence of immune-modulatory treatments.
How Long Does It Take To Work
Cipro begins to work against bacterial infections within hours of when you take it. However, you may not notice improvement in your symptoms for a few days.
The Cipro dosage your doctor prescribes will depend on several factors. These include:
- the type and severity of the condition youre using Cipro to treat
- your age
- the form of Cipro you take
- other medical conditions you may have, such as kidney disease
Typically, your doctor will start you on a low dosage and adjust it over time to reach the dosage thats right for you. Theyll ultimately prescribe the smallest dosage that provides the desired effect.
The following information describes dosages that are commonly used or recommended. However, be sure to take the dosage your doctor prescribes for you. Your doctor will determine the best dosage to suit your needs.
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Drugs And Vaccines To Avoid In Myasthenia Gravis
- Reactions 0 reactions
If you have myasthenia gravis , you are likely aware that there are a number of prescription and over-the-counter drugs that you should avoid. Some of these medications are known to worsen MG symptoms, however, it doesnt necessarily mean that you will never be prescribed one of these therapies.
In some cases, your doctor may opt to prescribe these drugs if the potential benefits outweigh the risks. Nevertheless, tell your physicians, dentists, and pharmacists that you have MG so that these drugs can be avoided when possible.
Cipro And Other Medications
Below is a list of medications that can interact with Cipro. This list does not contain all drugs that may interact with Cipro.
Before taking Cipro, be sure to tell your doctor and pharmacist about all prescription, over-the-counter, and other drugs you take. Also tell them about any vitamins, herbs, and supplements you use. Sharing this information can help you avoid potential interactions.
If you have questions about drug interactions that may affect you, ask your doctor or pharmacist.
Many antacids contain calcium carbonate, magnesium hydroxide, and aluminum hydroxide. These ingredients can bind to Cipro and prevent your body from absorbing it. This can decrease how well Cipro works.
To avoid this interaction, take Cipro at least two hours before taking an antacid, or six hours afterward.
Taking Cipro with oral anticoagulant drugs such as warfarin might increase the anticoagulant effects. This might result in increased bleeding. If you take an anticoagulant, your doctor may need to monitor your bleeding risk more frequently if you take Cipro.
Drugs that prolong the QT interval
Certain medications prolong your QT interval, which means they might affect the rhythm of your heartbeat. Taking Cipro with these drugs can increase the risk of having a dangerous irregular heartbeat. Cipro should be avoided or used very carefully with these medications.
Examples of these medications include:
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Guidance For Antibiotic Use In Myasthenia Gravis
All prescribers should be aware of the range of possible adverse effects associated with antibiotics. Though perhaps less well recognized than other adverse effects, various neurotoxicities including seizure, optic neuropathy, encephalopathy, peripheral neuropathy, and exacerbation of myasthenia gravis may result from antibiotic use.1 This risk is increased in older patients, patients with impaired renal function, and patients with preexisting neurologic conditions.1
Safe prescribing practices can be particularly difficult in patients with MG due to myriad medications that can interfere with neuromuscular transmission. While the mechanism by which drugs affect the neuromuscular junction varies, medications commonly known to cause drug-induced neuromuscular blockade include certain antibiotics, anticonvulsants such as phenytoin, antirheumatic drugs such as penicillamine and chloroquine, cardiovascular drugs such as calcium channel blockers and -blockers, and psychotropic drugs such as lithium.1,2
Infection and Myasthenia Gravis
Although vaccines are generally recommended for patients with MG, live-attenuated vaccines should be avoided in those who are immunosuppressed, and vaccination should be avoided during an acute exacerbation.3 If vaccination with live-attenuated doses is necessary, it is ideal to do so before immunosuppressive therapy is started.3
Antibiotics and Myasthenia Gravis
Approved Uses For Cipro
Cipro is FDA-approved for treating many different types of infections in adults. Examples of these FDA-approved uses include:
- Abdominal infections such as:
Less common FDA-approved uses include:
- typhoid fever
Cipro XR extended-release tablets are only approved for treating urinary tract infections .
Although Cipro is effective, the FDA has recommended that Cipro and other fluoroquinolone antibiotics should not be used as a first-choice antibiotic for certain infections, such as:
- sinus infections
- urinary tract infections
For these conditions, the risk of serious side effects caused by Cipro outweigh the benefits. Other antibiotics should be used as a first choice.
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How Can Double Vision Be Treated
Double vision that results from myasthenia gravis is most often treated by blocking the vision from one eye. Either an eye patch can be worn or scotch tape can be placed over one lens in the eyeglasses. If one eyelid is very droopy and blocks the vision in that eye, the double vision will not require a separate treatment. Usually special glasses with prisms are not helpful because of the considerable fluctuation in the amount of double vision in patients with myasthenia gravis.
Cipro In Dogs And Cats
Cipro is sometimes prescribed by veterinarians to treat infections in dogs and cats. Its commonly used for urinary tract infections, and may also be used for other kinds of infections.
If you think your dog or cat has an infection, see your veterinarian for an evaluation and treatment. Different doses are used for animals than humans, so dont try to treat your pet with a Cipro prescription intended for humans.
If you think your pet has eaten your prescription of Cipro, call your veterinarian right away.
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Taking Cipro With Food
Cipro can be taken with or without food. Either way you take it, be sure to consume plenty of fluids while taking Cipro.
Cipro shouldnt be taken along with dairy products or calcium-fortified juices. It should be taken at least two hours before or after consuming these products. However, Cipro can be taken along with a meal that contains dairy products or calcium-fortified foods or drinks.
How Often Does Myasthenia Gravis Only Affect The Eyes
For about one half of patients with myasthenia gravis, the first symptoms are visual. About 15% of these patients will remain only having visual symptoms, even years after their diagnosis. In the other 85% of patients, however, symptoms of weakness will develop in another part of the body, usually within the next three years. At that time, these patients are considered to have generalized myasthenia gravis.
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Other Uses For This Medicine
Levofloxacin is also sometimes used to treat endocarditis , certain sexually transmitted diseases, salmonella , shigella , inhalation anthrax , and tuberculosis . Levofloxacin is also sometimes used to prevent or treat traveler’s diarrhea. Talk to your doctor about the risks of using this medication for your condition.
This medication may be prescribed for other uses ask your doctor or pharmacist for more information.
Blockade Of Acetylcholine Receptors
The plant-derived toxin curare is a historical example for neuromuscular blockade, acting by a competitive inhibition of the nicotinic AChR at the postsynaptic membrane. Functionally similar mechanisms have also been proposed for various drugs.
A broad range of antibiotics have already been associated with clinical worsening in patients with MG. This is particularly relevant, since many patients with MG are under immunosuppressive treatment, partly suffering from recurrent respiratory symptoms and requiring antimicrobial treatment. Yet, the exact mechanisms underlying neuromuscular blockade are diverse and often poorly understood.
First, Telithromycin, a relatively new ketolide antibiotic, is known to induce myasthenia or lead to severe symptom exacerbations including fatal respiratory failure and death . In vitro studies substantiated these observations by showing that telithromycin inhibits nicotinic AChRs and blocks neuromuscular transmission . A case series comprising 10 affected individuals highlights the potential to aggravate and unmask MG, also reporting that most patients develop symptoms within 2 h after the first administration of telithromycin, which is in line with the aforementioned mechanism . The drug has already been withdrawn from the market due to its severe side effects.
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Pathomechanisms And Clinical Implications Of Myasthenic Syndromes Exacerbated And Induced By Medical Treatments
- 1Department of Neurology, Medical University of Vienna, Vienna, Austria
- 2Division of Blood and Marrow Transplantation, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- 3Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
What Other Information Should I Know
Keep all appointments with your doctor and the laboratory. Your doctor may order certain lab tests to check your body’s response to levofloxacin. If you have diabetes, your doctor may ask you to check your blood sugar more often while taking levofloxacin.
Before having any laboratory test, tell your doctor and the laboratory personnel that you are taking levofloxacin.
Do not let anyone else take your medication. Your prescription is probably not refillable. If you still have symptoms of infection after you finish taking levofloxacin, call your doctor.
It is important for you to keep a written list of all of the prescription and nonprescription medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.
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Cipro And Herbs And Supplements
Some vitamin and supplement products can bind to Cipro and prevent your body from absorbing it. This can decrease how well Cipro works. These supplements include:
To avoid this interaction, you should take Cipro at least two hours before you take these supplements, or at least six hours afterward.
More Common Side Effects
The more common side effects of Cipro include:
Also, results from a liver function test can be higher than normal. This is usually temporary, but can also be a sign of liver damage.
Most of these side effects may go away within a few days or a couple of weeks. If theyre more severe or dont go away, talk to your doctor or pharmacist.
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Allogeneic Hematopoietic Stem Cell Transplantation
Allogeneic HSCT is a standard treatment for a variety of hematological malignancies involving the transfer of a donorâs hematopoietic and immune system to a host. Graft-versus-host disease is one of the major complications of the procedure and summarizes host end-organ damage due to alloreactivity of the donorâs immune system. T-cell infiltration and epithelial damage to the skin, gut and liver are the hallmarks of acute GVHD, usually occurring within the first 100 days after HSCT . Chronic GVHD typically develops 3â12 months after HSCT and resembles a spectrum of autoimmune-related diseases through combined pathomechanisms of cellular and humoral alloreactivity .
Myasthenia Gravis Meds To Avoid
Myasthenia Gravis Meds to Avoid
Myasthenia Gravis is a chronic autoimmune disease that causes weakness in muscles. Some symptoms include slurred speech, drooped eyelids, dysphagia chewing difficulties, weakness in arms, and/or weakness in legs .
In MG there is a reduction in the number of receptor sites due to certain abnormal antibodies made in MG patients. The receptor sites send a signal to the muscle by a chemical called Acetylcholine. This chemical tells the muscle to contract. The antibodies made in a patient with MG, actually attack these receptor sites and may block or destroy them. This in turn stops the activation for muscle contraction .
Certain medications may actually worsen the symptoms of myasthenia gravis. Below is a list of some meds that should be avoided if possible.
MED TO AVOID- LIST
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How Is Ocular Myasthenia Gravis Different From Generalized Myasthenia Gravis
Ocular myasthenia gravis only affects the muscles that move the eyes and eyelids. The symptoms of ocular myasthenia gravis include double vision , trouble focusing, and drooping eyelids. On the other hand, generalized myasthenia gravis affects muscles throughout the body. In addition to visual symptoms, generalized myasthenia gravis may cause trouble speaking, trouble swallowing, and weakness in the arms or legs.
What Are The Treatments For Myasthenia Gravis
One of the medications that is commonly used to treat myasthenia gravis is called pyridostigmine . This medication helps build higher levels of the chemical acetylcholine, which is the signal that tells a muscle to move. The side effects of pyridostigmine can include diarrhea, abdominal cramps, nausea, and vomiting. Another medication called glycopyrrolate can be used to reduce these effects.
Corticosteroid medications, such as prednisone, can also be used to help patients with myasthenia gravis. These medicines can be very effective at controlling the immune response that causes myasthenia. Unfortunately, long-term use of steroids is also associated with side effects that include osteoporosis , diabetes, high blood pressure, sleep disturbance, and emotional changes. In some cases, other medications can be used to help control the immune system and lower the dosage of prednisone. These medications include azathioprine , cyclosporine, and mycophenolate mofetil . Intravenous immunoglobulin is another medication that can be used intermittently and can be very effective.
If myasthenia gravis is diagnosed, a CT scan of the chest should be performed in order to look for a type of benign tumor called a thymoma. Many experts believe that if the thymus is enlarged, removing it can improve the symptoms of myasthenia. Thymomas are present more often in patients with generalized myasthenia gravis compared to those with ocular myasthenia gravis.
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