NR 571 Week 4 Competing Treatment Analysis Example

Competing Treatment Analysis: Raising Prednisone for a Myasthenic Worsening Against Protecting Glucose and Infection Control, and Why Immune Globulin Fits the Clock This Week

Student Name

College of Nursing, Chamberlain University

NR 571: Complex Diagnosis and Management in Acute Care Practicum

Instructor Name

Month Day, Year

Competing Treatment Analysis: Raising Prednisone for a Myasthenic Worsening Against Protecting Glucose and Infection Control, and Why Immune Globulin Fits the Clock This Week

The Two Recommendations, as Written

The first recommendation comes from the international consensus guidance on myasthenia gravis, updated in 2020 and published in 2021 by a task force convened by the Myasthenia Gravis Foundation of America (Narayanaswami et al., 2021). In its own terms, corticosteroids are a mainstay of immunotherapy for generalized myasthenia, and for a patient who is worsening, treatment can be escalated; intravenous immune globulin and plasma exchange are named as short-term treatments for patients with impending or manifest crisis, or when a rapid response is needed.

The second recommendation comes from the Endocrine Society guideline on hyperglycemia in hospitalized patients outside intensive care (Umpierrez et al., 2012). In its own terms, it recommends keeping glucose below about 140 mg/dL before meals and below 180 mg/dL at random checks for most patients, and it identifies glucocorticoid therapy as a common cause of hospital hyperglycemia that needs a planned insulin response.

Where They Collide

For the 72-year-old with generalized myasthenia and pneumonia, whose bedside breathing numbers fell overnight, the most familiar way to treat the worsening is to raise the prednisone dose from 10 mg to a higher daily amount. That move would push a glucose that is already running between 198 and 262 higher during an active infection, and it would not begin to help the myasthenia for weeks.

Which Clock the Patient Is On

The patient is on a short clock. Over 12 hours the count on a single breath went from 22 to 17, and the measured vital capacity lost 400 mL. If the decline continues at that pace, the patient could need ventilatory support within two or three days. Whatever is done for the myasthenia has to work inside that window.

Prednisone does not work inside that window. In myasthenia, the benefit of corticosteroids usually begins after weeks, not days, and starting or sharply raising the dose can cause a temporary worsening in the first one to two weeks (Gilhus, 2016). A higher dose started today would bring its costs immediately, higher glucose, possibly slower infection control and the early dip in strength, and its benefit after the patient has either recovered or been intubated.

Immune globulin and plasma exchange do work inside the window. In a randomized trial in patients with moderate to severe worsening myasthenia, immune globulin given over two days and a course of five plasma exchanges were similarly effective, with about two thirds of patients in each group improving (Barth et al., 2011). Either one brings benefit in days.

So the question is not whether to treat the myasthenia, which is not in doubt, but which tool matches the clock. Raising prednisone answers a long-term question, how to keep the disease controlled over months, at the moment when the short-term question, how to get through this week without a breathing tube, is the one that matters.

What Is Being Accepted

Choosing immune globulin over a prednisone increase is not free. Immune globulin can cause kidney injury, particularly with products that contain sucrose, and it can increase the risk of blood clots (Orbach et al., 2005). This patient has stage 3a kidney disease and atrial fibrillation. The price is managed rather than avoided: a sucrose-free product, a slow infusion rate, hydration, creatinine checked daily, and the patient's apixaban continued, which offers some protection against clots.

Plasma exchange was the alternative. It works as fast and avoids the kidney concern, but it needs large-bore venous access, it can lower blood pressure in a patient with an infection and a fast heart rate, and on this unit it would mean transfer to intensive care for the procedure. Neurology preferred immune globulin, and I agree with that choice for this patient.

Keeping prednisone at 10 mg also means accepting that the patient's long-term control is not being strengthened this week. That decision is deferred, not abandoned, and the deferral is written into the plan so that it is not lost at discharge.

Why Not Do Both

One option would be to give immune globulin now and raise the prednisone at the same time, so that long-term control starts building while the short-term treatment works. The neurology consultant advised against it this week, and the argument holds for this patient. A steroid increase in the first days can deepen weakness at the very time the team is trying to keep the breathing numbers from falling, which would muddy the reading of whether immune globulin is working. The glucose would rise during an active infection. And the long-term benefit would arrive at about the same time whether the dose is raised today or in a week, once the infection has resolved, so waiting costs little on the long clock and avoids harm on the short one.

What Happens to the Glucose

With prednisone unchanged, the glucose plan stays as it is: basal insulin with correction doses, aiming below 180 mg/dL at random checks, in line with the guideline (Umpierrez et al., 2012). If neurology later raises the prednisone, the insulin plan will need to rise with it, most often with additional insulin timed to the morning steroid dose, since prednisone given in the morning raises glucose mostly in the afternoon and evening. The current pattern already shows this, with the highest readings before the evening meal. Writing the conditional plan now means the team will not have to work it out under pressure if the dose changes on a weekend.

The Period, the Review Point and the Decision Left Open

The plan runs for five days. Immune globulin is given over two days starting today. Bedside breathing numbers are checked every four hours, and a capacity under roughly 1.2 L or a weakening cough brings an intensive care review at once. On day 5 the neurology team will decide, with the patient, whether the long-term regimen needs a higher prednisone dose or a change to the steroid-sparing drug, once the pneumonia has resolved and the glucose question is no longer complicated by infection.

Left open is the question of whether this episode shows that the current long-term regimen is not enough. That is a real question, and it belongs to the outpatient neurologist with the patient, not to a decision made at the worst moment of an infection.

References

Barth, D., Nabavi Nouri, M., Ng, E., Nwe, P., & Bril, V. (2011). Comparison of IVIg and PLEX in patients with myasthenia gravis. Neurology, 76(23), 2017-2023. https://doi.org/10.1212/WNL.0b013e31821e5505

Gilhus, N. E. (2016). Myasthenia gravis. New England Journal of Medicine, 375(26), 2570-2581. https://doi.org/10.1056/NEJMra1602678

Narayanaswami, P., Sanders, D. B., Wolfe, G., Benatar, M., Cea, G., Evoli, A., Gilhus, N. E., Illa, I., Kuntz, N. L., Massey, J., Melms, A., Murai, H., Nicolle, M., Palace, J., Richman, D., & Verschuuren, J. (2021). International consensus guidance for management of myasthenia gravis: 2020 update. Neurology, 96(3), 114-122. https://doi.org/10.1212/WNL.0000000000011124

Orbach, H., Katz, U., Sherer, Y., & Shoenfeld, Y. (2005). Intravenous immunoglobulin: Adverse effects and safe administration. Clinical Reviews in Allergy & Immunology, 29(3), 173-184. https://doi.org/10.1385/CRIAI:29:3:173

Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G. A., Montori, V. M., Seley, J. J., & Van den Berghe, G. (2012). Management of hyperglycemia in hospitalized patients in non-critical care setting: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 97(1), 16-38. https://doi.org/10.1210/jc.2011-2098