The therapy of congenital myasthenic syndromes

Congenital myasthenic syndromes (CMSs) are heterogeneous disorders in which the safety margin of neuromuscular transmission is compromised by one or more mechanisms. Specific diagnosis of a CMS is important as some medications that benefit one type of CMS can be detrimental in another type. In some CMSs, strong clinical clues point to a specific diagnosis. In other CMSs, morphologic and in vitro electrophysiologic studies of the neuromuscular junction, determination of the number of acetylcholine receptors (AchRs) perjunction, and molecular genetic studies may be required for a specific diagnosis. Strategies for therapy are based on whether a given CMS decreases or increases the synaptic response to acetylcholine (ACh). Cholinesterase inhibitors that increase the synaptic response to ACh and 3,4-diaminopyridine, which increases ACh release, are useful when the synaptic response to ACh is attenuated. Long-lived open-channel blockers of the AChR, quinidine, and fluoxetine, are useful when the synaptic response is increased by abnormally prolonged opening episodes of the AChR channel. Ephedrine has beneficial effects in some CMSs but its mechanism of action is not understood.