People with myasthenia gravis can develop psychiatric symptoms, including depression and insomnia. However, recommendations regarding safe medication are insufficient.
In this case study, clinicians suggest that alpha-blockers are a potential safe therapeutic option for relieving insomnia and anxiety in a female myasthenia gravis patient.
The case report, “Management of Insomnia and Anxiety in Myasthenia Gravis,” was published in the Journal of Neuropsychiatry and Clinical Neurosciences.
People with myasthenia gravis are often burdened with stress that ultimately leads to the development of psychiatric conditions, such as anxiety, insomnia, and depression. Some studies estimate that up to 45 percent of patients with myasthenia gravis are diagnosed with anxiety and 58 percent with depression.
However, because of the clinical features of myasthenia gravis, selecting medications suitable for the treatment of psychiatric conditions in these patients can be challenging.
In this work, two clinicians from Philadelphia’s Lewis Katz School of Medicine at Temple University reported a case of a 31-year-old woman with myasthenia gravis who was admitted for a psychiatric consultation.
The patient had a history of myasthenia gravis and reported anxiety, depression, attention deficit hyperactivity, and post-traumatic stress disorder. She had a history of drug use and sleep deprivation, which may have precipitated the myasthenia gravis crisis that preceded her hospital admission.
Her initial symptoms included weakness, shortness of breath, difficulty in swallowing (dysphagia), and muscle spasms. These symptoms improved with Solu-Medrol, a corticosteroid that works as an immune suppressor. But anxiety and insomnia were not allowing the patient to fully recover.
Clinicians gave her the sedative zolpidem (sold under the brand name Ambien, among others) to treat her insomnia, and the antidepressant trazodone (sold as Desyrel, among other names), but these were not effective.
The patient had used bupropion (sold as Wellbutrin) for her depression and alprazolam (sold as Xanax, among other names) for anxiety for 11 years. Alprazolam belongs to the family of benzodiazepines, medicines that act on the central nervous system (brain and spinal cord) to produce a calming effect.
She used doxazosin (sold under the brand name Cardura, among others) for a brief period. This medicine belongs to the family of alpha-blockers used in treating anxiety and post-traumatic stress disorder.
The team was not able to assess whether anxiety and insomnia symptoms were due to benzodiazepines withdrawal or a psychiatric condition. However, because she had responded to prior treatment with an alpha-blocker, clinicians administered her the alpha-1 blocker prazosin (1 milligram at bedtime). This significantly improved the patient’s sleep.
“The following morning, she reported significant improvement in sleep and mood. She was able to be discharged on this regimen after medical stabilization and reported continued adherence at the time of outpatient follow-up per records,” they stated.
The medical team’s major concerns regarding sleep and anxiety medication were related to the possibility of substances causing respiratory depression, severe reduction in blood pressure, and interaction with myasthenia gravis medication.
They discarded medicines linked with respiratory insufficiency, such as benzodiazepines, and therapies that could worsen myasthenia gravis symptoms.
“Given a history of prior success with an [alpha 1]-blocker, we attempted a trial of prazosin with good relief of symptoms,” the study concluded.
Other antidepressants, like mirtazapine (sold under the brand name Remeron), or the so-called tricyclic antidepressants and ramelteon (sold as Rozerem), used to treat insomnia, were also considered relatively safe to use in myasthenia gravis patients.