Overview
· There is no cure, but complete remission is possible
· Symptoms may include the following: dyphasia, frequent gagging or choking, difficulty chewing, also affects the muscles involved in talking and breathing, posterior swallowing time is effected the most.  These symptoms worsen with use (eating, talking) and improve with rest.

Treatment--Medical

• Anticholinesterates
• They block the enzymes (acetylcholinesterase) that normally break up acetylcholine and they also allow acetylcholine to stay present for longer.  Shown to improve muscle conctraction.  Should be given at least 30 minutes before meals to maximize the ability to eat and swallow foods.
• Corticosteroid Therapy
• Lowers the antibody production to the cholinergic  receptors that block the receptor.  This increases the number of available receptors to interact with acetylcholine and improves muscle strength.
• Thymectomy
• Surgical removal of the thymus gland. This procedure takes years to have an effect and is used for long-term control of MG and can result in complete remission.
• *  Occasionally, a tumor of the thymus gland can cause MG symptoms.  A thymectomy will alleviate the symptoms.
• Azathioprine
• Is being used increasingly in the U.S. since the mid-eighties.  Long-term immunosuppressive treatment that acts as an inhibitor of purine biosynthesis and induces both B and T cell lymphopenia.
• Cyclosporine-A
• Another immunosuppressive drug, which is a third choice because of its multiple and part-serious side effects.
• Plasmapharesis
• Plasma exchange therapy typically involving 3 to 5 exchanges of 1 or 1.5 volumes per week until the patient shows satisfactory improvement.  Usually combined with immunosuppressive treatment.

Compensatory strategies/ Swallowing therapy

• Reduced lip and tongue strength
• Exercises exist for these symptoms, but not recommended due to energy expenditure
• Reduced Pharyngeal contraction bilaterally
• Turn head sideways: best strategy to allow throat to become   narrower and compensate for lack of muscle constriction
• Masako exercise treats this symptom, but again is an exercise that can induce extra fatigue
• Diet:
• 1. Alternate liquid/ (semi)solid swallows to wash thicker material down.
• 2. Limit only to liquid/ thin paste.
• 3. Follow each swallow w/ several dry swallows.
• **Series of repetitive swallows may be too fatiguing.
• Reduced laryngeal elevation
• Mendelsohn maneuver designed to this symptom, but requires patients to hold muscles for several seconds in contracted position.
• Risk of silent aspiration after swallow
• Some patients use coughing after swallow to compensate for choking, but may be ineffective due to possible exhaustion of respiratory muscles.

Therefore, not many therapy procedures are recommended due to fatigue factor.  Diet changes and head turning may be the best compensation.  However, limiting diet in those patients who already find eating to be a chore, may lead to more negative reactions toward food.  Eating more small meals per day instead of 3 large ones is highly recommended.  Potassium-rich foods may be important in the diet if a deficiency is the source of muscle weakness.