30 60 mg PO every 4 6 hr initially with a maximum daily dose of 360 mg ii

30 60 mg po every 4 6 hr initially with a maximum

  • Walden University
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i. 30-60 mg PO every 4-6 hr initially, with a maximum daily dose of 360 mg ii. Average daily dose: 600 mg/day iii. Mild MG: 60-360 mg/day iv. Severe MG: maximum daily dose as high as 1500 mg d. Onset of effect is 30 minutes, duration 4 hr e. Longer-acting preparation is available for patients on stable dosing.
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f. Monitor patient for cholinergic adverse effects, such as nausea, vomiting, diarrhea, increased salivation, bronchial secretions, and cramps. These adverse effects can be controlled with propantheline (15 mg may be given 15-30 minutes prior to administration of pyridostigmine). 2. Drugs to try to avoid in patients with MG include: a. Ketolides b. Aminoglycosides c. Polypeptides (when not used topically) d. Glycopeptides e. Lincosamide f. Class 1 antiarrhythmics E. Immunomodulating therapy: necessary for patients with MG and may require lifelong therapy (IVIG and plasmapheresis for rapid immunomodulating therapies, see myasthenic crisis) 1. Prednisone a. Should be administered to those who have responded poorly to anticholinesterase drugs and, if indicated, have already undergone thymectomy b. Dose is determined on an individual basis c. High initial dose can gradually be tapered to a lower maintenance dose d. Continue to taper very slowly, attempting to establish the minimum dosage necessary to maintain remission 2. Azathioprine a. Widely used as a nonsteroidal immunosuppressant and can be used as monotherapy b. Dose is started at 50 mg/day, titrated up to 2-3 mg/kg PO per day if well tolerated c. May cause macrocytosis and lymphopenia (drug should not be discontinued for this effect) d. If remission not achieved, refer to specialist for other immune modulating therapies (e.g., methotrexate, cyclosporin, mycophenolate, or tacrolimus) E. Management of impending myasthenic crisis 1. Airway and ventilatory management a. Patients with bulbar weakness, declining vital capacity (less than 20 ml/kg), maximal inspiratory force of negative 30 cm H2O, or weak or ineffective cough that increases work of breathing, should be admitted to an intensive care unit to monitor for possible intubation and mechanical ventilation. b. Vital capacity may not be reliable in patients having difficulty maintaining a seal around a spirometer mouthpiece. 2. Rapid immunomodulating therapies (IVIG and plasmapheresis are equivocal in efficacy in myasthenic crisis) a. IVIG i. Therapy that has been used traditionally as an alternative to plasmapheresis ii. Dosing: 1 gram/kg/day IV for 2 days or 400 mg/kg/day IV for 5 days, for a total of 1-2 grams/kg IV for 2-5 days iii. Major component is IgG molecule and is derived from healthy donated blood neutralizing pathogenic antibodies and limiting activation of the complement system iv. Decision to use over plasmapheresis usually determined by available resources and comorbidities increasing potential complications, such as heart disease, renal insufficiency, and IgA deficiency b. Plasmapheresis i. Mechanically removes antibodies and activated complements from the blood ii. Routine frequency is five times
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