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There is a risk of steroid induced deterioration in patients with exacerbation of myasthenia gravis, possibly reduced if the steroid dose is increased slowly. However, there is limited evidence for this and individual practice varies. We aimed to determine if a slow steroid dose escalation reduced the risk of respiratory failure in our hospital.We retrospectively analysed the clinical records of all patients admitted to our hospital with an exacerbation of myasthenia gravis between January 2010 and December 2014.69 patients were admitted with an exacerbation of myasthenia gravis. 51 patients were treated with a slowly increasing dose and 18 patients immediately with a high dose of steroids. There was a no significant increase in ITU admission in the high dose group (27.78% vs 17.65% p:0.4957) nor any difference in FVC trend, readmission rate, mortality, or treatment with IVIG or PLEX. Length of stay was longer in the patients treated with a slowly escalating dose of steroids (mean number of days 17.8 vs 15.22, p:0.1687).We did not find a significant deterioration in patients treated with a high dose of steroids. Given most patients are treated with an escalating steroid dose (that requires a longer hospital stay) there is need for a randomised trial to determine if this is required.