Use treatment options for refractory myasthenia gravis, ocular or bulbar weakness differential, and How does myasthenia gravis and pregnancy to frame the working diagnosis and next step; let it drive treatment choice rather than habit. Make ocular or bulbar weakness differential the checkpoint that determines whether you escalate testing, narrow the differential, or change treatment.

Oral Mestinon, or pyridostigmine, remains your absolute go to for first-line symptomatic management; On the flip side, teratogenic immunosuppressants like azathioprine or mycophenolate are unsafe and must be discontinued; For cases that prove truly stubborn, options include putting the individual on a chronic IVIG or chronic plasma exchange schedule; Prednisone and pyridostigmine are generally safe options to maintain; You might also think about utilizing cyclophosphamide, and there is a decent body of evidence supporting the use of rituximab as well