Neuromuscular blockers in myasthenia gravis and LambertEaton

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This is a review of how neuromuscular blocking agents (both depolarizing like succinylcholine and non-depolarizing like rocuronium) might behave in patients that have neuromuscular disorders, myasthenia gravis and Lambert-Eaton. • Images adapted from Wikimedia Commons. • ADDITIONAL TAGS: • Neuromuscular blockers in myasthenia gravis and Lambert-Eaton • Myasthenia gravis: Autoimmune loss of postsynaptic proteins (nicotinic AchR) of NMJ • Generally avoid NMBA in MG, unless ndNMBA and sugammadex available • MG has ↓ Ach receptors → resistant to depolarizing NMBAs • 2.6-fold ↑ in ED95 of succ • Tx with anticholinesterase meds (-stigmines, donepezil, galantamine) may ↑ effects of succ • MG: very sensitive to ndNMBA • Administer ndNMBA in small doses (0.1*ED95) w ToF monitor • Reverse with sugammadex; anticholinesterase reversal (neostigmine) can induce a cholinergic crisis • Lambert-Eaton myasthenic syndrome: Autoimm destruction of presynaptic voltage-gated Ca_v → ↓ Ach release at NMJ • Sensitive to both dNMBA and ndNMBA: Requires ↓ succ or roc • Patients with LEMS are more sensitive to ndNMBAs than patients with MG • Reversal with neostigmine might be ineffective • Only use ndNMBAs if sugammadex is available: admin small titrated doses and monitor • Condition sensitivity to: • dNMBA (succ) • ndNMBA (roc) • MG: • ↓ • ↑ • LEMS: • ↑ • ↑ • If the goal is surgical paralysis … • Amnt drug required in: • dNMBA (succ) • ndNMBA (roc) • MG: • ↑ • ↓ • LEMS: • ↓ • ↓ • Normal neuromuscular junction: • O = acetylcholine (ACh) • Lambert-Eaton myasthenic syndrome: Autoimmune destruction of presynaptic voltage-gated Ca_v → ↓ Ach release at NMJ • Myasthenia gravis: Autoimmune loss of postsynaptic nicotinic AchR of NMJ • Depolarizing neuromuscular blocking agent (dNMBA = O) mimics acetylcholine, causing initial twitch then blocks further muscle action. • Nondepolarizing neuromuscular blocking agent (ndNMBA = X) competes with acetylcholine for receptor sites, preventing muscle activation. • Adapted from TrueLearn, Wikipedia, UpToDate. By Paul Hege - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index...

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