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Hi there. Removing the thymus gland can be very helpful for those 10 to 15 percent of patients with MG associated with thymoma. There are risks associated with surgery, of course, so thymectomy should be managed by the surgeon in close collaboration with anesthesiology and a neurologist.
Studies do suggest that Rituximab treatment offers some benefit for adult patients with MG, and that quality of life measures improve overall.
It also tends to reduce the need for prednisone.
In general, side effects were few in the studies but more studies are underway to look at this with larger populations.
These would be the main considerations in those that do not tolerate or do not benefit from IVIG and/or plasma exchange.
Have they tried pulsed intravenous methylprednisolone? That would be another option for moderate exacerbations. This is typically followed by oral prednisone to keep symptoms under control.
Average duration of improvement with this option is about 8 weeks.
Surgery is indicated in about 10-15% of those with MG associated with a thymoma. If she falls into this sub-classification, according to her neurologist, then it would make sense. They might want to obtain a tissue sample via biopsy to make a definitive diagnosis prior to surgery. One study with 200 patients who underwent thymectomy found that less than 10% were in remission after a mean follow up of 10 years, and about 80% were still requiring immunosuppression.
She had IVIG prior to the plasma exchange, so it would be hard to say which one worked. The beneficial effects of IVIG can take up to 5 weeks to kick in. Either way, if she does respond well, and the response is sustained, one could argue this should be done with each flare. The Rituximab may not be necessary. On the other hand, a trial would be reasonable as IVIG and plasma exchange are expensive and inconvenient (and somewhat invasive). And yes, the thymectomy is a call best made by her neurologist after considering all the various factors in her clinical situation and all the risks and potential benefits.