Long-term Efficacy of Modified Guilu Erxian Glue in Treating Patients With Myasthenia Gravis: A Retrospective Cohort Study
Conditions: Myasthenia Gravis (MG)
Sponsor: Beijing University of Chinese Medicine

2023.07.01
Long-term Efficacy of Modified Guilu Erxian Jiao Formula in
the Treatment of Patients with Myasthenia Gravis: A
Retrospective Cohort Study
Clinical Study Protocol
1 Study Subjects
A retrospective analysis was performed on the medical records of patients with myasthenia gravis
(MG) who attended the First Affiliated Hospital of Henan University of Chinese Medicine and Henan
Academy of Medical and Pharmaceutical Sciences from January 2020 to January 2024. The final
on-site or telephone follow-up for the outcomes of the enrolled cases was completed by July 31,
2024.
2 Diagnostic Criteria
2.1 Western Medicine Diagnostic Criteria
The criteria were formulated in accordance with the Guidelines for the Diagnosis and Treatment of
Myasthenia Gravis in China (2020 Edition) issued by the Chinese Society of Neuroimmunology,
Chinese Society for Immunology. A clinical diagnosis of MG can be made if the patient presents
with typical clinical manifestations of MG, supported by any one of the neostigmine test,
neuroelectrophysiological assessment, or serum specific antibody detection, and other diseases
are excluded (Table 1).
Table 1 Western Medicine Diagnostic Criteria for Myasthenia Gravis
Item
Description
Clinical Manifestations
Any skeletal muscle throughout the body can be affected, presenting with
fluctuating weakness and fatigability. Symptoms follow a pattern of "worse
in the evening and better in the morning", aggravated after activity and
relieved after rest. The extraocular muscles are the most commonly
affected, presenting with symmetric or asymmetric ptosis and/or binocular
diplopia, which are the most common initial symptoms of MG.
Pharmacological
Findings
Positive neostigmine test.
Neuroelectrophysiology A decrement of more than 10% in wave amplitude with low-frequency
stimulation on repetitive nerve stimulation (RNS) examination.
Antibodies
Acetylcholine receptor (AChR) antibodies can be detected in the blood of
most patients with generalized MG. A small number of patients with AChR
antibody-negative MG can be tested positive for muscle-specific kinase
(MuSK) antibodies, low-density lipoprotein receptor-related protein 4
(LRP4) antibodies, or titin antibodies.
2.2 Western Medicine Classification Criteria
The criteria were formulated in accordance with the Myasthenia Gravis Foundation of America
(MGFA) Clinical Classification (2000) (Table 2).
Table 2 MGFA Clinical Classification Criteria

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Classification
Symptom Manifestation
Type I
Any ocular muscle weakness, may be accompanied by weak eyelid closure, with
normal muscle strength in other muscle groups.
Type II
Mild weakness in muscle groups other than the ocular muscles, may be
accompanied by ocular muscle weakness.
Type IIa
Mainly affecting limb muscles and/or trunk muscles, with or without lesser degree of
bulbar muscle involvement.
Type IIb
Mainly affecting bulbar muscles and/or respiratory muscles, with or without lesser
degree of limb and/or trunk muscle involvement.
Type III
Moderate weakness in other muscle groups regardless of the degree of ocular
muscle weakness.
Type IIIa
Mainly affecting limb muscles and/or trunk muscles, with or without lesser degree of
bulbar muscle involvement.
Type IIIb
Mainly affecting bulbar muscles and/or respiratory muscles, with or without lesser
degree of limb and/or trunk muscle involvement.
Type IV
Severe weakness in other muscle groups regardless of the degree of ocular muscle
weakness.
Type IVa
Mainly affecting limb muscles and/or trunk muscles, with or without lesser degree of
bulbar muscle involvement.
Type IVb
Mainly affecting bulbar muscles and/or respiratory muscles, with or without lesser
degree of limb and/or trunk muscle involvement.
Type V
Endotracheal intubation with or without mechanical ventilation (excluding routine
postoperative use). Cases receiving only nasogastric feeding without endotracheal
intubation are classified as Type IVb.
3 Case Selection Criteria
3.1 Inclusion Criteria
(1) Meeting the diagnostic criteria of the Chinese Medical Association, with MGFA classification
Type I-IV;(2) Meeting the diagnostic criteria of the China Association of Chinese Medicine, with
TCM syndrome differentiation of spleen and kidney deficiency;(3) No age or gender restrictions;(4)
Received conventional western medicine treatment for ≥1 month (pyridostigmine bromide tablets
combined with prednisone acetate tablets);(5) Complete medical records.
Only patients who met all the above criteria were included in this study.
3.2 Exclusion Criteria
(1) Patients with concurrent other severe systemic diseases, severe impairment of heart, liver,
kidney or other organ functions, or history of psychiatric disorders;(2) Patients with incomplete
medical records.
Patients who met any of the above criteria were excluded.
4 Grouping Method
All enrolled patients received conventional western medicine treatment, and were grouped as
follows:(1) Treatment Group: Patients who took the modified Guilu Erxian Jiao formula for a
cumulative duration of ≥1 month per year(2) Control Group: Patients who only received
conventional western medicine treatment
The conventional western medicine regimen consisted of pyridostigmine bromide tablets combined
with prednisone acetate tablets. The modified Guilu Erxian Jiao formula was composed of Colla
Carapacis et Plastri Testudinis 10g, Colla Cornus Cervi 10g, Ginseng Radix et Rhizoma 10g, Lycii
Fructus 10g, and Astragali Radix 30g, with the dosage halved for minor patients.
5 Data Collection
5.1 Baseline Information
General information including name, gender, age, body mass index (BMI); medical history
information including age at onset, disease duration, initial affected muscle groups, involved muscle

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groups; auxiliary examination results including serum autoantibody levels, thymus status,
neostigmine test, RNS and other information were extracted from the patients' medical records and
filled in the relevant sections of the Case Report Form (CRF). On-site or telephone follow-up was
conducted on the outcome events of the patients, including the occurrence of relapse, time and
cause of relapse, and medication tapering status, to further supplement and improve the CRF.
5.2 Primary Outcome Measure
(1) Relapse RateRelapse was defined as recurrence of MG symptoms or a significant increase in
MG medications after the patient achieved Minimal Manifestation Status (MMS) or better. The
overall relapse rate and relapse rates at different time points (within 6 months, 6-12 months, 12-24
months, 24-36 months, and 36-48 months after treatment) were calculated.
5.3 Secondary Outcome Measures
(1) Time to First Dose Reduction of Conventional Western MedicineTime to first dose reduction was
defined as the interval between the date of the first dose reduction and the initial consultation,
measured in months. The time to first dose reduction of pyridostigmine bromide tablets and
prednisone acetate tablets was calculated for both groups respectively.
(2) TCM Syndrome Score ScaleThe TCM syndrome score was formulated with reference to the
Guiding Principles for Clinical Research of New Traditional Chinese Medicines issued by the
Ministry of Health of the People's Republic of China in 2002 (Appendix 1). The total TCM syndrome
score and scores of each individual symptom were calculated.
(3) Myasthenia Gravis-Activities of Daily Living (MG-ADL) ProfileThe core function of the MG-ADL
is to quantitatively analyze the correlation between the patient's clinical manifestations and daily
functional status to reflect the severity of the disease, which includes 8 items (Appendix 2).
(4) Incidence of Myasthenic CrisisMyasthenic crisis was defined as rapid deterioration of MG
condition requiring immediate airway opening and assisted ventilation, or MGFA classification Type
V.
(5) MGFA Clinical ClassificationThe Myasthenia Gravis Foundation of America (MGFA) Clinical
Classification (2000) was adopted, including Type I, Type IIa, Type IIb, Type IIIa, Type IIIb, Type
IVa, Type IVb, and Type V.
(6) Hamilton Anxiety Rating Scale (HAMA)The HAMA is a clinical scale used for the diagnosis and
severity grading of anxiety states (Appendix 3).
(7) MGFA Post-Intervention Status (MGFA-PIS)The MGFA-PIS was developed by the Myasthenia
Gravis Foundation of America (Table 3). A favorable outcome was defined as achieving any of
Complete Stable Remission (CSR), Pharmacologic Remission (PR), or Minimal Manifestation
Status (MMS).
Table 3 MGFA Post-Intervention Status (MGFA-PIS)
Grade
Description of Post-Intervention Status
Complete Stable
Remission (CSR)
No symptoms or signs of myasthenia for at least 1 year, during which no MG
medications were received; no evidence of muscle weakness found on
examination by a professional neurologist, with minimal weak eyelid closure
allowed.
Pharmacologic
Remission (PR)
The criteria are the same as CSR, except that the above state is achieved
through medication (excluding cholinesterase inhibitors).
Minimal
Manifestation Status
(MMS)
No functional limitation caused by myasthenia, with certain muscle weakness
detected on examination by a professional neuromyopathy physician.
Improved (I)
Significant reduction in clinical symptoms of myasthenia or significant
decrease in the dosage of MG treatment medications compared with baseline.

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Grade
Description of Post-Intervention Status
Unchanged (U)
No significant change in clinical symptoms and dosage of MG treatment
medications compared with baseline.
Worse (W)
Significant aggravation of clinical symptoms of myasthenia or significant
increase in the dosage of MG treatment medications compared with baseline.
Exacerbation (E)
New clinical symptoms appear after CSR, PR or MMS has been achieved.
Died Of MG (D)
Death from MG or complications of MG treatment, or death within 30 days
after thymectomy.
6 Autoantibody Detection
Acetylcholine receptor antibody (AChR-Ab) was detected using an enzyme-linked immunosorbent
assay (ELISA) kit from RSR Ltd. (UK), and titin antibody (Titin-Ab) was detected using an ELISA kit
from DLD Diagnostika GmbH (Germany). The cut-off values for positive AChR-Ab and Titin-Ab
were 0.45 nmol/L and 1, respectively.
7 Statistical Analysis
Medical records and follow-up data were entered into a database using Microsoft Excel software,
followed by double review and verification. Incorrect information was rechecked against the original
medical records, and the verified data were imported into SPSS 26.0 software for statistical
analysis.
Measurement data conforming to normal distribution were expressed as mean ± standard deviation
(x̄ ± SD) and analyzed by independent samples t-test; those not conforming to normal distribution
were expressed as median and interquartile range [M(P25, P75)] and analyzed by rank sum test.
Enumeration data were expressed as number of cases (n) and rate (%), and analyzed by
chi-square (χ²) test. A P-value < 0.05 was considered statistically significant.
Kaplan-Meier (K-M) survival analysis was used to plot the cumulative relapse probability risk curve,
and the Log-Rank test was performed for hypothesis testing. Cox multivariate regression analysis
was conducted to identify statistically significant variables associated with relapse, and to screen
out relevant protective and risk factors for MG relapse.
Appendix 1: TCM Syndrome Score Scale
Table A1 TCM Syndrome Score Scale
Symptom
Mild (1 point)
Moderate (2 points)
Severe (3 points)
Score
Sallow
Complexion
Pale yellow without dirt,
with luster
Slightly dull and sallow,
with faint luster
Dull sallow complexion
with dirt, no luster
Shortness of
Breath and
Reluctance to
Speak
Speaks little only when
asked repeatedly
Does not speak unless
asked
Unwilling to speak at all
Chest Distress Mild chest distress
Obvious chest distress
with frequent deep sighs
Feeling of chest
oppression as if stuffed
Epigastric
Distension
Epigastric distension
after meals, resolves
spontaneously within
30 minutes
Epigastric distension
after meals, resolves
spontaneously within 2
hours
Persistent epigastric
distension and
abdominal bloating
Reduced Food
Intake
Slight decrease in food
intake
Decreased food intake
Markedly reduced food
intake
Loose Stools
Unformed stool
Loose stools 2-3 times a
day
Watery loose stools
more than 4 times a day
Soreness and
Weakness of
Loin and Knees
Intermittent soreness
and weakness of the
waist and knees
Dull aching pain,
requiring frequent
postural changes
Severe lumbago as if
broken, persistent and
unrelieved, only relieved
by medication

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Symptom
Mild (1 point)
Moderate (2 points)
Severe (3 points)
Score
Cold Intolerance
and Cold Limbs
Subjective feeling of
cold
Frequent cold
intolerance or cold
hands and feet in winter,
requiring extra clothing
Body temperature often
fails to reach normal
level, cold hands and
feet in both winter and
summer
Frequent
Nocturia
Nocturia 2 times
Nocturia 3 times
Nocturia 4 times or more
Total Score
-
-
-
Note: 0 points for absence of the above symptoms; 1 point for mild symptoms; 2 points for
moderate symptoms; 3 points for severe symptoms.
Appendix 2: Myasthenia Gravis-Activities of Daily Living (MG-ADL) Profile
Table A2 Myasthenia Gravis-Activities of Daily Living (MG-ADL) Profile
No.
Item
0 points
1 point
2 points
3 points
Score
1
Speech
Normal
Intermittent
hyponasality or
nasal twang
Continuous
hyponasality or nasal
twang, but intelligible
Speech is
unintelligible
2
Chewing
Normal
Fatigue when
eating hard food
Fatigue when eating
soft food
Nasogastric tube
feeding with liquid
diet
3
Swallowing
Normal
Occasional choking
Frequent choking
leading to dietary
changes
Nasogastric tube
feeding with liquid
diet
4
Breathing
Normal
Shortness of breath
after exertion
Shortness of breath at
rest
Mechanical
ventilation support
5
Impaired ability
to brush teeth or
comb hair
None
Strenuous, but can
be completed
without rest
Requires rest midway Complete loss of
these abilities
6
Impaired ability
to stand up from
a chair
None
Mild, sometimes
requires hand
support
Moderate, often
requires hand support
Severe, requires
assistance from
others
7
Diplopia
None
Occasional, not
daily
Daily, but not
persistent
Persistent
8
Ptosis
None
Occasional, not
daily
Daily, but not
persistent
Persistent
-
Total MG-ADL
Score (0-24)
-
-
-
-
Appendix 3: Hamilton Anxiety Rating Scale (HAMA)
Table A3 Hamilton Anxiety Rating Scale (HAMA)
Symptom
Score
(0-4 points)
Anxiety: Worry, preoccupation, feeling that the worst is going to happen, irritability.
0 1 2 3 4
Tension: Feelings of tension, fatigability, inability to relax, emotional reactions, easy
crying, tremors, feelings of restlessness.
0 1 2 3 4
Fears: Fear of the dark, strangers, being alone, animals, travel by car or bus,
crowds.
0 1 2 3 4
Insomnia: Difficulty falling asleep, frequent awakening, light sleep, excessive
dreaming, night terrors, fatigue on waking.
0 1 2 3 4
Cognitive Function: Or memory and attention disorders. Inability to concentrate,
poor memory.
0 1 2 3 4
Depressed Mood: Loss of interest, lack of pleasure in previous hobbies, depression,
early morning awakening, diurnal variation (worse in the morning and lighter in the
evening).
0 1 2 3 4
Musculoskeletal System: Muscle soreness, inflexibility of movement, muscle
0 1 2 3 4

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Symptom
Score
(0-4 points)
twitching, limb twitching, chattering of teeth, trembling of voice.
Sensory System: Blurred vision, chills and hot flushes, feelings of weakness,
tingling all over the body.
0 1 2 3 4
Cardiovascular System: Tachycardia, palpitations, chest pain, throbbing of blood
vessels, feeling of fainting, missed heart beats.
0 1 2 3 4
Respiratory System: Chest tightness, feeling of suffocation, sighing, difficulty
breathing.
0 1 2 3 4
Gastrointestinal Tract: Difficulty swallowing, belching, indigestion (postprandial
abdominal pain, burning sensation in the stomach, abdominal distension, nausea,
fullness in the stomach), borborygmus, diarrhea, weight loss, constipation.
0 1 2 3 4
Genitourinary System: Frequent urination, urgent urination, amenorrhea, frigidity,
premature ejaculation, erectile dysfunction, impotence.
0 1 2 3 4
Autonomic Nervous System: Dry mouth, flushing, pallor, easy sweating, goose
bumps, tension headache, piloerection.
0 1 2 3 4
Behavior at Interview: (1) General manifestations: Tension, inability to relax,
fidgeting, finger biting, clenched fists, fidgeting with handkerchief, facial muscle
twitching, constant foot tapping, hand tremors, frowning, stiff facial expression,
sighing respiration, pallor; (2) Physiological manifestations: Swallowing, hiccups,
rapid heart rate at rest, tachypnea (more than 20 breaths per minute), hyperactive
tendon reflexes, tremors, dilated pupils, eyelid twitching, excessive sweating,
exophthalmos.
0 1 2 3 4
Note: A score ≥29 indicates severe anxiety; a score of 21 indicates marked anxiety; a score ≥14
indicates definite anxiety; a score >7 indicates possible anxiety; a score <7 indicates no anxiety.