Dr. Edmundson: 
This is CE on ReachMD, and I'm Dr. Christyn Edmundson.

When treating generalized myasthenia gravis, we can't only rely on what our patients tell us or even on what we observe. We need tools that bring structure, objectivity, and trendability to our decisions. Today, I'll walk you through how to use several core scales, the MG-ADL, QMG, MG-MMT, and MG-QoL15r. We'll look at them not just individually, but together to see how they guide gMG treatment over time.

First, let's talk about the MG-ADL score. The MG-ADL score is a disease severity score that's based on multiple symptoms that patients categorize in severity. It's a quick patient-reported scale that is fairly easy to do, either at a clinic visit or even by telephone or e-mail. There are 8 items that are assessed with scores of 0 in each item reflecting no symptoms at all and scores of 3 in each item reflecting the worst possible symptoms. So overall, it's graded 0 to 24 with lower scores reflecting less disease burden and higher scores reflecting more disease burden.

Now, an important point is that this assesses a patient's symptoms over the past week. We consider a significant change in the score usually around 2 points or more.

I really like the MG-ADL score. As I said, it's something I do for every patient at every visit. And if a patient is having significant changes in their disease severity between visits, it's something that I like to use to help quantify that. The MG-ADL can also be filled out by a patient during check-in, but it's something that I like to then go through and double-check myself to make sure that a patient is properly answering the questions

Next is the QMG score. This is a clinician-rated 13-item score that looks at bedside strength and endurance. This is a really useful score for clinical trial outcomes, but it's a pretty cumbersome test to do, and it's not something that I do in routine clinical practice. So, the times that I am performing this, it's usually as part of an assessment for a clinical trial. That's partly because it can take a while. It typically takes somewhere between 15 and 30 minutes to complete, in my experience. And it also requires some additional equipment to complete. So, part of the QMG score includes a forced vital capacity, so you need a machine in order to perform that. It also looks at grip strength, so you would need a dynamometer. It also looks at things like a patient's ability to swallow water, to count up to 50. It looks at ocular and limb strength on exam, as well. A change in the score of 3 points or more is typically considered significant, and it's graded on a scale of 0 to 39.

Third is the MG-MMT score. And this is actually sort of a quick, easy summation of the motor exam that I also typically do at each visit. So, it isn't the same as the QMG at all, but it’s similar to the QMG in that the MG-MMT score is based on physical exam findings of a patient. In contrast to the QMG, where there are these really routinized ways that you have to do the physical examination in order to grade it, the MG-MMT score basically looks at mild, moderate, or severe weakness in a variety of different muscles that are routinely tested in clinical practice in the care of myasthenia gravis patients. So, I also really like this as a bedside test that I do at each in-person visit with the patient.

Last is the MG-QoL15r. This is a 15-item patient quality of life assessment that looks at multiple domains. So, this is really useful in capturing the impact of a patient's myasthenia gravis on their general life and function. In this score, as well, lower numbers reflect lower burden of disease and higher numbers reflect a worse burden of disease. And whereas the MGL really looks at sort of specific symptoms, like do you have ptosis every day, some days but not others, or constantly, the MG-QoL looks more at how are your myasthenia symptoms impacting your life? Do you find them burdensome? Are you refraining from doing things that you would typically enjoy doing because of your myasthenia symptoms? So, this captures the impact that symptoms and myasthenia in general are having on a patient's day-to-day life.

It's also interesting to see when one score changes but another doesn't. So, for instance, someone's MG-ADL is really jumping, or the MG-QoL is really jumping, indicating that they're experiencing more symptoms or they're having more of an impact on their sort of day-to-day life and function, but their MG-MMT is staying the same.

And so, figuring out there, is that because the myasthenia is worsening? Or are there such big fluctuations that maybe I'm not capturing on my physical exam, the impact of symptoms that patients are having at other times? Or are there other things going on? Right? Is there depression? Are there other diseases that are worsening that might impact a patient's sort of quality of life or experience symptoms, but their physical exam isn't really changing?

By making these part of your routine, you not only improve how you assess and manage generalized myasthenia, but you can also give your patients a clearer path forward towards sort of meaning and measurable progress.

With this, my time is up. Thank you so much for listening, and I hope this overview will be helpful in your clinical practice.