A Case Study of a Patient With Generalized Myasthenia Gravis That Transitioned From Eculizumab to Ravulizumab Following Severe SARS-CoV-2 Infection


Clinical Management

Poster Number: 29


Deena Rodney, APRN, Neurology Associates, PA, Maitland, FL, Arnaldo Isa, MD, Neurology Associates, PA, Maitland, FL

Anti-acetylcholine receptor antibody-positive generalized myasthenia gravis (anti-AChR Ab+ gMG) is difficult to manage in some patients. Here, we report the case of a 68-year-old male with anti-AChR Ab+ gMG that was placed on intravenous immunoglobulin (IVIg) with oral immunosuppression following discontinuation of TAK-079 due to inadequate disease control after 32 weeks in a clinical trial (NCT04159805). The patient had a score of 8 on the myasthenia gravis activities of daily living scale (MG-ADL; max score, 24) and a score of 15 on the myasthenia gravis quality of life 15 item revised scale (MG-QoL15r; max score, 30) when eculizumab was started with concomitant oral therapy (prednisone 35 mg/d, pyridostigmine 60 mg q6H, mycophenolate mofetil 500 mg BID). The patient had a clinical response on eculizumab; however, eculizumab was paused while the patient was hospitalized for 39 days with a SARS-CoV-2 infection. After discharge, eculizumab and prednisone taper were resumed with his ongoing concomitant oral regimen, and the patient reported clinical response within 2 months (MG-ADL, 2; MG-QoL15r, 2). Over the next 5 months, the patient was affected by sequelae of SARS-CoV-2 infection and MG symptoms, including shortness of breath, mild ptosis, dysphagia, and difficulty walking, along with depression and frustration that MG was affecting his social engagements (MG-ADL, 3; MG-QoL15r, 7). At that point, the patient transitioned to ravulizumab due to preference for Q8W dosing and continued the prednisone taper. In less than 3 weeks, the patient resumed his twice-daily walks (MG-ADL, 1; MG-QoL15r, 4); pyridostigmine was reduced to 60 mg TID. Following a third ravulizumab maintenance dose, MG-ADL and MG-QoL15r scores were both 0. These findings demonstrate maintained efficacy of C5 inhibition with steroid taper and with transition from eculizumab to ravulizumab. This case shares valuable information on patient-reported improvement on complement inhibitor therapy during recovery from severe SARS-CoV-2 infection.