{
  "abstract": "Background Myasthenia gravis (MG) is a rare condition of the neuromuscular junction (BMJ Best Practice. Myasthenia Gravis. [internet]. 2025), posing unique challenges for palliative care patients and clinicians with few published cases. Opioids, benzodiazepines and high dose steroids are commonly used for palliation but can theoretically pose a high risk for patients with MG, with potential to cause myasthenic crisis involving respiratory failure and arrest (Sheikh, Alvi, Soliven, et al. J Clin Med. 2021 Apr 6;10(7):1537). There is further risk of deterioration in MG symptoms and myasthenic crisis if these patients cannot take their oral acetylcholinesterase inhibitors (Hindmarsh, Woods, Lee, et al. J Palliat Care. 2019;35(2):78-81).Case presentation We discuss a patient in her fifties with MG and metastatic sigmoid adenocarcinoma receiving end of life care. She was fearful of the feeling of suffocation she had experienced during prior myasthenic crises, and her priority was avoiding this symptom. Patient-centred discussions revolved around potential dangers of medications relating to her MG. Oral morphine at admission to the hospice was 320 mg over 24 hours and dexamethasone 16 mg daily was needed for several weeks. However, she was benzodiazepine naïve. We agreed that if midazolam was required for symptoms, we would trial 1.25 mg first and up-titrate if required. Through joint decision making we agreed a plan to replace her oral pyridostigmine with subcutaneous neostigmine infusion if not managing oral medications.Case outcome This patient deteriorated and died comfortably four days after stopping pyridostigmine, deciding against a neostigmine infusion as she no longer wished to prolong her life. Her medication was titrated, and symptoms were controlled with oxycodone 420 mg and midazolam 30 mg subcutaneously over 24 hours. Opiate toxicity occurred from reduced renal function on morphine therefore oxycodone was commenced with resolution.Conclusion This patient with MG had no adverse effects with high dose steroids, opioids and benzodiazepines. The patient’s decision not to have acetylcholinesterase inhibitor subcutaneously did not appear to hasten death or affect symptom management.",
  "authors": [
    {
      "affiliations": [
        "Addenbrooke’s Hospital, Cambridge, UK"
      ],
      "name": "Danielle Durant"
    },
    {
      "affiliations": [
        "Mid and South Essex NHS Trust, Southend, UK"
      ],
      "name": "Jennifer Balls"
    }
  ],
  "title": "P-57 A case of myasthenia gravis and the challenges in end of life care",
  "uid": "62af0a97-aca6-5cbf-97a0-ab1b6823754b"
}