ACTH and adrenal corticosteroids are effective in the treatment of myasthenia gravis. However, increased weakness may occur early in treatment, posing a considerable risk for the patient. To determine whether the early weakening could be avoided by use of a gradually increasing dosage schedule, we started treatment with 25 mg of prednisone on alternate days, and gradually increased the dose to 100 mg on alternate days. Anticholinesterase medication was maintained. No increased weakness developed in any of 12 patients on this regimen. Seven patients had good to excellent improvement in strength, returning to normal activity. Four patients had moderate improvement, and one did not benefit. The greater safety of this treatment regimen extends the usefulness of steroid therapy to a larger group of myasthenic patients than would otherwise be feasible. (N Engl J Med 290:81–84, 1974), ACTH and adrenal corticosteroids have recently been found to be effective in the treatment of many patients with myasthenia gravis. However, increased weakness often occurs early in the course of steroid treatment, requiring hospitalization and sometimes intensive medical care with respiratory support. The risk of precipitating a steroid-induced crisis has limited the practical usefulness of this mode of therapy in the management of myasthenic patients, and steroid treatment has been reserved for especially difficult or refractory cases. In the past, treatment has usually been initiated with large doses of ACTH or glucocorticoids. We wondered whether we could avoid the early.
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