Myasthenia Gravis (MG) presents a unique challenge for nurses due to its variable and often subtle clinical features. It is characterised by fluctuating skeletal muscle weakness that typically worsens with sustained activity and improves with rest. The underlying pathology involves autoantibodies that impair neuromuscular transmission, resulting in a distinctive pattern of muscle fatigability rather than generalised tiredness (Narayanaswami et al., 2021). Nurses play a vital role in recognising early signs of MG, educating patients, families, care providers, and managing symptoms to prevent complications, including myasthenic crisis.
While MG is a rare disease, its management is complex, often requiring a combination of symptomatic therapy, immunosuppression, rescue treatments, and in some cases surgical or biologic interventions.
In Australia, treatment pathways are guided not only by international consensus recommendations but also by the regulatory and funding environment, including the Therapeutic Goods Administration (TGA), the Pharmaceutical Benefits Scheme (PBS), and the National Blood Authority (NBA). Nurses in neurology clinics, inpatient wards, medical infusion units and intensive care units play an essential role in care delivery, monitoring, and patient education. Their role has expanded further with the introduction of new biologic therapies, which bring both new opportunities and new safety responsibilities.
Myasthenia gravis (MG) is an autoimmune disorder in which the immune system mistakenly targets components of the neuromuscular junction, disrupting communication between motor nerves and skeletal muscles. In most cases, this process is driven by antibodies directed against acetylcholine receptors (AChR), which are essential for normal muscle contraction. These antibodies block receptor function, accelerate receptor degradation, and reduce the overall number of available receptors at the postsynaptic membrane. As a result, neuromuscular transmission becomes inefficient, leading to the characteristic fatigable muscle weakness that worsens with repeated activity (Gilhus et al., 2019).
In a subset of patients, MG is associated with antibodies against other proteins involved in neuromuscular junction integrity, most notably muscle-specific kinase (MuSK). MuSK plays a critical role in the clustering and maintenance of acetylcholine receptors at the synapse. Antibodies targeting MuSK interfere with these processes, impairing receptor organisation and stability and further reducing the muscle’s ability to respond effectively to nerve impulses (Dalakas, 2015; Zhang et al., 2012). A smaller proportion of individuals have no detectable antibodies using standard assays and are classified as having seronegative MG, although immune-mediated mechanisms are still believed to underlie their disease.
The thymus gland has a central role in the pathogenesis of MG, particularly in AChR-positive disease. Many patients exhibit thymic hyperplasia or develop thymomas, both of which are thought to contribute to abnormal immune education and the production of autoreactive immune cells. Surgical removal of the thymus (thymectomy) has been shown to improve clinical outcomes in selected patients, supporting the thymus as a key driver of disease activity (Wolfe et al., 2016). In addition to antibody-mediated mechanisms, T cells play an important contributory role by promoting and sustaining autoantibody production. MG frequently coexists with other autoimmune conditions, further emphasising its systemic immune basis (Evoli & Padua, 2013).
A clear understanding of MG pathogenesis is essential for nursing practice, as it underpins many therapeutic strategies, including immunosuppressive therapies, targeted biological agents, and surgical interventions. This knowledge also informs patient education, clinical monitoring, and long-term support, enabling nurses to anticipate complications, explain treatment rationales, and provide holistic, evidence-based care.
MG is characterised by skeletal muscle weakness that typically worsens with activity and improves with rest. The presentation is highly variable, ranging from isolated ocular symptoms to generalised weakness involving bulbar, limb, and respiratory muscles. Symptom severity may fluctuate within a single day or across time, contributing to diagnostic delays and inconsistent clinical presentation (Howard et al., 2022).
The cardinal feature of MG is skeletal muscle weakness that increases with exertion, a phenomenon known as fatigability. Unlike general fatigue, which is a subjective feeling, MG presents with objective, reproducible muscle fatigue: a progressive reduction in contractile strength with continued use. This often affects specific muscle groups rather than presenting as generalised fatigue (Howard et al., 2022). Patients typically report functional limitations, such as difficulty holding up the head, chewing, speaking, or maintaining upward gaze, that worsen with prolonged activity.
Ocular symptoms are the most common initial presentation of MG and occur in up to two-thirds of cases (Gilhus et al., 2019). These include ptosis due to weakness in the levator palpebrae muscles, and diplopia resulting from weakness of the extraocular muscles. Symptoms are often asymmetric and fluctuate throughout the day.
Ptosis may vary significantly, often worsening toward the end of the day. It may present unilaterally or become bilateral. Clinical examination may reveal ptosis after sustained upward gaze or a positive “curtain sign,” where lifting one eyelid causes the other to droop. Diplopia can be elicited during sustained lateral gaze or identified by noting extraocular misalignment that does not conform to single nerve involvement. Weakness in orbicularis oculi muscles may be noted when patients struggle to keep their eyes closed against resistance.
Approximately 15% of patients present with bulbar symptoms, including dysarthria, dysphagia, and facial muscle weakness. These are significant not only due to their impact on communication and nutrition but also because of the increased risk of aspiration and respiratory compromise (Narayanaswami et al., 2021).
Dysarthria may be nasal or hypophonic, worsening with prolonged speech. Dysphagia can lead to difficulty swallowing tablets or food, sometimes manifesting as nasal regurgitation due to palatal muscle weakness. Jaw muscle fatigue becomes apparent during prolonged chewing, particularly with tough foods, and patients may subconsciously support their jaw with their hands.
Facial muscle weakness contributes to an expressionless appearance. A hallmark sign is the “myasthenic sneer,” where only the mid-line of the upper lip rises during an attempted smile.
Generalised MG often involves the neck and limbs, though they are less commonly initial symptoms. Weakness tends to be proximal, affecting shoulder and hip girdles, with upper limbs more frequently involved than lower limbs (Howard et al., 2022). In some cases, neck extensor weakness leads to a “dropped head syndrome,” particularly later in the day. Examination may reveal weakness when patients attempt to hold their head upright or lift their arms or legs against gravity.
Respiratory muscle involvement is the most life-threatening complication of MG. Although it is rarely the initial symptom, respiratory compromise may develop during exacerbations, known as myasthenic crisis. This condition requires immediate intervention and can be precipitated by infections, medications, surgery, or tapering of immunosuppressive therapy (Narayanaswami et al., 2021).
Symptoms include dyspnoea on exertion or orthopnoea. Nurses should monitor respiratory status closely in at-risk patients using objective measures such as forced vital capacity (FVC) and maximal inspiratory pressure. Early signs of deterioration should prompt urgent medical review.
A hallmark feature of MG is symptom fluctuation, often with worsening later in the day or after physical activity. Early in the disease, patients may feel normal in the morning, with symptoms appearing only in the evening. As the disease progresses, symptom-free periods become shorter or absent altogether. Recognising this fluctuation is critical for diagnosis, as it distinguishes MG from other neurological or muscular conditions such as myopathies or motor neuron disease (Gilhus et al., 2019).
Classification systems in myasthenia gravis are essential for guiding treatment decisions, monitoring disease progression, and supporting consistent communication within multidisciplinary teams. MG is recognised as a heterogeneous autoimmune disorder and is commonly categorised using several key domains: clinical subtype, autoantibody status, age of onset, thymic pathology, and overall disease severity. Clinically, MG is divided into ocular MG, where weakness is confined to the extra-ocular muscles, and generalised MG, which involves limb, bulbar, axial, and respiratory muscles.
MG is also classified by age of onset; early, late, or juvenile, which correlates with sex distribution, thymic pathology, and comorbidity burden. Thymic abnormalities, including thymic hyperplasia and thymoma, are particularly relevant in AChR-positive disease and influence management decisions such as thymectomy. (Gilhus et al., 2019; Sanders et al., 2016).
The mainstay of symptomatic management is pyridostigmine, an anticholinesterase agent that increases the availability of acetylcholine at the neuromuscular junction. It can improve ptosis, bulbar weakness, and fatigability, but it does not alter disease progression. Nurses support patients in optimising dosage schedules, particularly for those with swallowing difficulties who benefit from timing medication before meals. Monitoring for gastrointestinal side effects, bradycardia, and secretions is also part of routine nursing care (Narayanaswami et al., 2021).
Most patients with generalised MG require immunosuppressive therapy. Corticosteroids such as prednisone remain highly effective but need cautious titration, as high starting doses can paradoxically worsen weakness. Long-term adverse effects such as osteoporosis, diabetes, weight gain, and infection necessitate early introduction of steroid-sparing agents such as azathioprine, or mycophenolate. Nurses are frequently involved in monitoring blood counts, liver function, and counselling on infection precautions, vaccination, and bone health (Narayanaswami et al., 2021).
For acute deterioration, intravenous immunoglobulin (IVIg) and plasma exchange (PLEX) are rapid-acting options. In Australia, IVIg access is managed through the NBA’s Blood-STAR system, which requires clinicians to record outcome measures such as the MG Activities of Daily Living (MG-ADL) or the MG Composite Score. Nurses are central to this process, both in administering therapy and in ensuring accurate assessment and documentation (National Blood Authority, 2024). Monitoring for infusion reactions, haemodynamic changes, and renal function is a core nursing responsibility.
Thymectomy remains an important treatment option in younger patients with AChR antibody–positive, non-thymomatous MG. The MGTX trial demonstrated that thymectomy in combination with prednisone improved clinical outcomes and reduced steroid use, with benefits persisting on long-term follow-up (Wolfe et al., 2016). For nurses, peri-operative management involves close respiratory observation, support with early mobilisation, and education on long-term treatment expectations. Assessment tools in myasthenia gravis Structured assessment is essential in MG to guide therapy, monitor disease progression, and document treatment response. The Myasthenia Gravis Activities of Daily Living (MGADL) scale is a patient-reported measure assessing the functional impact of MG on speech, swallowing, respiratory function, and limb activities. Scores range from 0 to 24, with higher scores reflecting greater disability. MGADL is routinely used in clinical practice and is required documentation for IVIg access under NBA criteria (National Blood Authority, 2024). The Myasthenia Gravis Composite (MGC) score combines patient-reported symptoms and clinician-assessed signs, including ocular, bulbar, respiratory, and limb function. Scores range from 0 to 50, with higher scores indicating more severe disease. MGC is recommended for tracking disease progression and evaluating response to therapy (Narayanaswami et al., 2021).
The Quantitative Myasthenia Gravis (QMG) score is a clinician-administered tool incorporating timed tests, grip strength, and respiratory measures such as forced vital capacity (FVC). While primarily used in research, it provides objective measurement of disease severity, particularly in patients receiving IVIg, plasma exchange, or biologic therapies (Narayanaswami et al., 2021).
Nurses also use bedside measures such as FVC to monitor respiratory function, especially in patients with bulbar or generalised weakness. Regular assessment with these tools supports early recognition of deterioration and guides escalation of care, including ICU referral or initiation of rescue therapies.
Recently, the treatment landscape for MG has been transformed by the introduction of targeted biologics. These therapies provide alternatives for patients with moderate to severe disease who are unresponsive to conventional immunosuppression.
FcRn inhibitors such as efgartigimod and rozanolixizumab reduce pathogenic IgG levels by blocking the neonatal Fc receptor. Both received TGA approval in early 2025. Efgartigimod is administered intravenously, while rozanolixizumab is delivered subcutaneously, offering greater convenience for some patients. Although both have been recommended by the Pharmaceutical Benefits Advisory Committee (PBAC), final PBS listing is pending. Nurses caring for patients on FcRn inhibitors must monitor for infections, ensure vaccination status is up to date, and educate patients about potential side effects such as headache and nausea (TGA, 2025; PBAC, 2025).
Complement inhibitors block the terminal complement cascade, preventing antibody-mediated damage at the neuromuscular junction. Ravulizumab, offers the advantage of long-interval intravenous dosing, while zilucoplan, can be self-administered by subcutaneous injection. These drugs significantly improve muscle strength and reduce the risk of crisis, but they carry a serious risk of meningococcal infection. Nurses play a critical role in ensuring patients are vaccinated with both MenACWY and MenB vaccines, receive antibiotic prophylaxis if indicated, and are educated to seek urgent medical attention if symptoms of meningococcal disease develop (TGA, 2023; 2025).
Across all treatment modalities, nurses are central to both safety and patient experience. Vigilance for red flags of impending crisis—including dysphagia, weak cough, orthopnoea, and declining respiratory function—is essential in both inpatient and community settings. Nurses also act as advocates, ensuring timely escalation of care and coordination with intensive care services when necessary. Medication safety is another vital area. Nurses must be alert to potential drug interactions and advocate for safe prescribing practices.
Importantly, nurses play a role in psychosocial support. Living with MG’s fluctuating and often invisible symptoms can impact mental health and quality of life. Compassionate, informed nursing care is essential to empower patients and promote self-efficacy.
Effective patient education is a cornerstone of managing Myasthenia Gravis (MG), as it empowers individuals to participate actively in their care and recognise early signs of exacerbation. Patient education is ongoing and multi-faceted. Nurses play a critical role in providing tailored education that supports treatment adherence, lifestyle adaptation, and symptom monitoring.
Patients should be educated on the autoimmune nature of MG, the typical fluctuating pattern of muscle weakness, and the specific muscles it may affect (Gilhus, 2016). Clarifying that MG is not caused by general fatigue but by a neuromuscular transmission failure can help reduce misconceptions and stigma. Adherence to prescribed medications is essential for symptom control. Patients should be instructed on the timing and potential side effects of medications, including the importance of not abruptly stopping immunosuppressive therapy (Sanders et al., 2016).
With biologics now available, education also extends to vaccination schedules, recognition of infection symptoms, and navigating access through PBS or hospital-based funding. For many patients, the nurse is the consistent point of contact who provides reassurance, answers questions, and helps integrate complex treatments into daily life.
Due to fatigable muscle weakness, patients benefit from learning how to pace activities and incorporate rest periods into their day.
Energy conservation strategies help prevent symptom exacerbation and maintain independence in daily living (Rowland & Pedley, 2010).
Patients and caregivers must be educated to identify early signs of exacerbation, such as increased dysphagia, ptosis, limb weakness, or shortness of breath. Prompt recognition is critical, as severe exacerbations can lead to respiratory failure requiring emergency intervention (Meuth et al., 2022).
Patients should be advised to avoid known exacerbating factors, such as infections, stress, and medications that can worsen MG. Seasonal vaccinations and infection prevention strategies are also recommended (Sanders et al., 2016).
For patients with thymoma or generalised MG, understanding the role and outcomes of thymectomy is essential. Education should include realistic expectations about disease progression, potential remission, and the need for ongoing neurological follow-up (Wolfe et al., 2016).
Access to support groups, educational materials, and counselling should be encouraged. The emotional burden of MG can be significant, and social support improves coping and quality of life (Gilhus et al., 2019).
The clinical course of Myasthenia Gravis is complex and highly individualised, marked by initial symptom fluctuation, potential generalisation, and variable outcomes. With knowledge of common patterns and risk factors, nurses can anticipate complications, contribute to accurate diagnosis, and advocate for timely interventions.
Myasthenia gravis treatment in Australia now encompasses a wide spectrum, from established symptomatic and immunosuppressive therapies to innovative biologics that offer new hope for refractory disease. This evolving landscape requires nurses to maintain up-to-date knowledge of treatment pathways, safety considerations, and funding systems. Whether in outpatient clinics, infusion centres, or intensive care units, nurses remain central to the safe delivery of therapy, early detection of complications, and support of patients navigating the challenges of living with MG. An understanding of disease trajectory not only informs nursing assessment but also enhances patient education and holistic care throughout the MG journey.