Historical note and terminology
The beneficial effect of physostigmine, a cholinesterase inhibitor, on myasthenia gravis was first described by Mary Broadfoot Walker in 1934 (Walker 1934). Physostigmine was soon replaced by prostigmine because of its side effects (Walker 1935). Prostigmine remained the primary drug for myasthenia gravis until the 1950s when it was replaced by its analog, pyridostigmine. Pyridostigmine has a longer duration of action and fewer muscarinic side effects than does prostigmine. It is marketed for the treatment of myasthenia gravis. Even though data from well controlled clinical trials to support its clinical use are lacking, pyridostigmine is the most commonly used first-line therapy for myasthenia gravis based on its use in practice for over 50 years (Maggi and Mantegazza 2011). In 2003, the FDA approved pyridostigmine for use by the military for increasing troops' chances of surviving exposure to the nerve gas soman. Because no human trials have been done, the approval was based on reviewing effectiveness studies in animals.
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