Liječenje bolesnika oboljelih od mijastenije gravis s COVID-19: pregled literature

Coronavirus disease 2019 (COVID-19), caused by the late 2019 outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes a respiratory disease which could put myasthenia gravis (MG) patients at a greater risk of developing severe disease course, since infections and some drugs are a well-recognized trigger of symptom exacerbation in MG patients. Out of ten most commonly used past and present drugs used in COVID-19 treatment, two (quinolone derivatives and azithromycin) are known to worsen MG symptoms, whereas another two (tocilizumab and eculizumab) might have positive effect on MG symptoms. Colchicine, remdesivir, lopinavir, ritonavir and favipiravir seem to be safe to use, while data are insufficient for bamlanivimab, although it is also probably safe to use. Considering MG treatment options in patients infected with SARS-CoV-2, acetylcholine esterase inhibitors are generally safe to use with some preliminary studies even demonstrating therapeutic properties in regard to COVID-19. Corticosteroids are in general safe to use, even recommended in specific circumstances, whereas other immunosuppressive medications (mycophenolate mofetil, azathioprine, cyclosporine, methotrexate) are probably safe to use. The only exception is rituximab since the resulting B cell depletion can lead to more severe COVID-19 disease. Concerning plasmapheresis and intravenous immunoglobulins, both can be used in COVID- 19 while taking into consideration thromboembolic properties of the former and hemodynamic disturbances of the latter. As current data suggest, all known COVID-19 vaccines are safe to use in MG patients.Koronavirusna bolest 2019 (COVID-19) uzrokovana širenjem virusa SARS-CoV-2 izaziva respiracijsku bolest koja potencijalno može dodatno ugroziti pacijente koji boluju od mijastenije gravis. Uz infekcije, egzacerbaciju simptoma mijastenije gravis mogu uzrokovati i neki lijekovi. Od deset najčešće primjenjivanih skupina lijekova za liječenje COVID-19, dvije skupine lijekova (kinoloni i azitromicin) mogu uzrokovati pogoršanje simptoma mijastenije gravis, a dvije skupine lijekova (tocilizumab i ekulizumab) imaju pozitivne učinke na simptome mijastenije gravis. Kolhicin, remdesivir, lopinavir, ritonavir i favipiravir nemaju učinka na simptome mijastenije gravis, dok su podatci za bamlanivimab nedostatni, no isti je vjerojatno siguran za upotrebu u bolesnika s mijastenijom gravis. Što se tiče primjene lijekova za mijasteniju gravis kod bolesnika zaraženih virusom SARS-CoV-2, inhibitori acetilkolinestaraze su u pravilu sigurni za primjenu; neke studije su čak dokazale i terapijske mogućnosti navedenih lijekova u liječenju COVID-19. Kortikosteroidi su uglavnom sigurni za primjenu, a čak se i preporučaju u određenim okolnostima, dok su ostali imunosupresivi (mikofenolat mofetil, azatioprin, ciklosporin i metotreksat) sigurni za primjenu. Jedina iznimka je rituksimab učinak kojega na B-staničnu imunost može rezultirati težom kliničkom slikom bolesti COVID-19. Plazmafereza i intravenski imunoglobulini, dvije najčešće primjenjivane terapijske opcije liječenja akutnih egzacerbacija mijastenije gravis, mogu se primijeniti kod bolesnika s COVID-19 uzimajući u obzir tromboembolijske učinke intravenskih imunoglobulina, odnosno hemodinamske učinke plazmafereze. Sva cjepiva COVID-19, koliko je poznato, sigurna su za primjenu u bolesnika s mijastenijom gravis