Hi everyone, I'd really appreciate your constructive advice.

A close friend is currently being treated with Pyridostigmine / Mestinon. She was originally on a generic brand but is now using name-brand Mestinon with generally positive effects.

Her current regimen is to take 1/2 a tablet every 3 hours. At or around the 3 hour mark, the improvement often has a sudden dropoff. The effictiveness during the ~3-hour period with name-brand Mestinon appears better but this sudden falloff in efficacy is even more pronounced.

This is generally effective and works well. However, in a work environment one can't always excuse themselves from a slightly extended business meeting or videoconference when the effects suddenly drop off and another dose is required. Additionally, it can be uncomfortable to communicate this need since the onset is sudden and can affect speech.

I understand that MG and the treatment thereof can vary widely from person to person and be trial-and-error, but with this situation in mind, I was wondering whether anyone had any similar experience, and I also had an idea that I suspect may be effective, and would like to know whether anyone has tried something similar or knows of a good reason why this should not be done.

The idea I had is that instead of taking 1/2 a tablet every 3 hours, to divide that dose again and simultaneously take:
- 1/4 a tablet
- 1/4 a tablet inside a do-it-yourself vegetarian cellulose capsule

My understanding is that the it takes 20-30 minutes for the cellulose capsules to dissolve (vs. 2-5 minutes for a gelatin capsule), so my instinct is that this would extend some of the positive effect for another 20 minutes. So, instead of being faced with an "oh no - it completely stopped working - and it's now uncomfortable to speak to communicate this" situation, she might have 10 minutes of feeling a more gradual dropoff and be able to excuse herself to take the next dose.

Reasons that I think this might work are:
- No change in schedule and no chance of forgetting to take an additional part-tablet
- The dosage rate itself (in mg / hour) is not changing
- It should be a minimal change to what we know is a generally effective regimen
- Some of the dose is still absorbed pretty much immediately and should hopefully start being effective quickly
- Sustained release versions of Mestinon exist, indicating that it is OK for it to be absorbed in the small intestine
- The time to dissolve the cellulose capsule (about 30 minutes according to what sources I could find) seems to be long enough to make a difference. According to simulations using a 1.75hr half-life, the concentration normally hit at ~3hrs is extended to ~3hrs15min. Other options to play with this delay period might be to use gelatin capsules and/or cellulose capsules in a Babushka doll/Nesting doll fashion.

I appreciate your advice and help!

Aaron