To pool randomized and observational evidence on B-cell depletion therapies in generalized myasthenia gravis using empirical Bayesian methods, and to characterize the comparative signal between B-cell depletion and complement inhibition in long-standing refractory disease.

Two randomized trials of rituximab in generalized myasthenia gravis (gMG) reached divergent conclusions and a phase 3 trial of inebilizumab was reported in 2025. No prior synthesis has pooled these data using empirical Bayesian methods or has structured a comparison between B-cell depletion and complement inhibition.

PubMed, Embase, and Scopus were searched through 2026 for studies of rituximab or inebilizumab in adults with gMG. Bayesian random-effects pairwise meta-analyses with Turner empirical log-normal priors on between-study heterogeneity were performed for continuous outcomes; pooled proportions were estimated for dichotomous outcomes. Reporting followed PRISMA 2020.

Twenty-two studies (n = 919) were included; 16 contributed to the primary analysis. Rituximab was associated with a greater reduction in QMG score at 12 months than placebo (mean difference, −2.85; 95% credible interval, −4.54 to −1.15; k = 2 RCTs; τ posterior median, 0.20). Inebilizumab versus placebo from the MINT trial yielded mean differences of −1.87 on MG-ADL and −2.28 on QMG at 26 weeks. Eculizumab was favored over rituximab in long-standing refractory disease in two observational studies (Durmus MG-ADL mean difference +4.60; Nelke QMG mean difference +5.30). Pooled minimal-manifestations-or-better rate was 65.7% at the last follow-up and 39.8% at 12 months. Pooled all-cause mortality was 4.2%, and progressive multifocal leukoencephalopathy was 1.7%.

B-cell depletion was associated with greater clinical improvement than placebo in randomized trials of generalized myasthenia gravis. The direction and magnitude of benefit appeared to depend on disease stage and antibody subtype.