Pyridostigmine improves hand grip strength in patients with myalgic encephalomyelitis/chronic fatigue syndrome

Schlömer, Ella; Stein, Elisa; Kedor, Claudia; Rust, Rebekka; Brock, Anna; Wittke, Kirsten; Scheibenbogen, Carmen; Kim, Laura

Pyridostigmine improves hand grip strength in patients with myalgic encephalomyelitis/chronic fatigue syndrome

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Item Type:	Article
Title:	Pyridostigmine improves hand grip strength in patients with myalgic encephalomyelitis/chronic fatigue syndrome
Creators Name:	Schlömer, Ella, Stein, Elisa, Kedor, Claudia, Rust, Rebekka, Brock, Anna, Wittke, Kirsten, Scheibenbogen, Carmen and Kim, Laura
Abstract:	BACKGROUND: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a multisystemic disease characterized by exertional intolerance and fatigue which is often accompanied by muscle weakness and fatiguability. A study showed efficacy of the acetylcholinesterase inhibitor pyridostigmine on cardiac output in ME/CFS patients. Pyridostigmine is currently used off-label in ME/CFS and postural orthostatic tachycardia syndrome. METHODS: We evaluated the effect of pyridostigmine on hand grip strength in 20 patients with post-infectious ME/CFS. Hand grip strength testing was performed ten times using an electric dynamometer and was repeated after 1 h. In a second test, 30 mg of pyridostigmine was given immediately after the first measurement. Orthostatic function was assessed using a passive standing test. Neurological examination and autoantibody testing were performed to rule out a diagnosis of myasthenia gravis. RESULTS: All patients had reduced maximum hand grip strength with a median of 16.45 kg (IQR: 11.45 kg–22.8 kg). Hand grip strength was diminished by a median of 4.65 kg after 1 h. In contrast, 1 h after pyridostigmine administration, patients showed an improvement in maximum hand grip strength with a median increase of 2.6 kg. The maximum hand grip strength after exertion was about 1.5-fold higher with then without pyridostigmine (p = 0.01). The increase in heart rate from lying to standing was median 17 beats per minute without pyridostigmine (IQR: 13 beats per minute – 23 beats per minute) and 13 beats per minute (IQR: 9 beats per minute – 20 beats per minute) (p = 0.017) with pyridostigmine. None of the patients tested positive for myasthenia gravis specific autoantibodies. CONCLUSION: Pyridostigmine exerts an immediate effect on muscle strength and orthostatic function. This may be attributed to increased acetylcholine availability at neuromuscular junctions, and its augmentation of parasympathetic tone.
Keywords:	Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, Post-COVID Syndrome, Hand Grip Strength, Orthostatic Intolerance, Myasthenia Gravis, COVID-19, Pyridostigmine
Source:	Frontiers in Neuroscience
ISSN:	1662-453X
Publisher:	Frontiers Media SA
Volume:	19
Page Range:	1637838
Date:	3 September 2025
Official Publication:	https://doi.org/10.3389/fnins.2025.1637838
PubMed:	View item in PubMed

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