Relapsed MS: The Role of Corticosteroids

Thomas P. Leist, MD, PhD: MS [multiple sclerosis] relapses very often occur at the time when the patient presents with new symptoms. It is important, if we entertain an MS relapse, to ensure that the patient doesn’t have a pseudorelapse or a worsening of neurological functioning in the context of another illness, such as an infection. Once we arrive at the conclusion that the patient has had a relapse, we normally entertain a short course of steroids. In recalcitrant patients, we also have other interventions, such as plasma exchange or ACTH [adrenocorticotropic hormone], that can be considered depending on local availability.

The goal of steroid treatment is to interrupt the worsening process. Whether steroid treatment leads to a long-term benefit is questionable. In general, we can reduce the nadir and hopefully, in the short term, we can return the patient to earlier functioning.

How long should we treat with corticosteroids in the context of a relapse? Should we consider a taper or not? In general, all of us have slightly different approaches to this in the field. In my practice, I use a 3-day approach using 1 g of methylprednisolone per day.

I do also use an alternate approach, and this is particularly important for patients who don’t have home infusion or other benefits. I use 650 mg of prednisone 2 times a day for 3 days. This is normally well tolerated. The 1.3 g of prednisone per day equates to 1 g of methylprednisolone in its dose equivalency. Obviously, this would need to be done in a patient who is known to tolerate steroids because, as always with steroids, there is an ultimate risk for psychosis associated with treatment, particularly in patients whose tolerance for steroids is unknown.

A lot of patients inquire about alternate and nonstandard treatments when faced with a diagnosis of multiple sclerosis. One of the treatments that is considered very often is bone marrow transplant, for example.

This is a treatment that certainly may have its benefits. At this point in time, the long-term negative consequences are not as well-understood than with other therapies. In a patient with highly aggressive multiple sclerosis, this is certainly something that could be considered in an experimental setting, in the hands of an appropriate transplant center.

A few years ago, there was consideration of whether veins to the brain had any contribution to the pathology of multiple sclerosis, and at that point in time, venous dilation and the whole concept of CCSVI [chronic cerebrospinal venous insufficiency] was being discussed. It was brought forward by an Italian research group. Over the years, research by both the National Multiple Sclerosis Society and that sponsored by the Multiple Sclerosis Society of Canada has significantly discredited the theory, and at this point in time, such approaches should not be used in patients with MS. I think there is enough evidence to not use these approaches.

Generally, regarding alternative and complementary therapy with supplements, it’s important to keep in mind that some supplements may actually be immune-stimulating. They may not necessarily be indicated in a disease state like multiple sclerosis, where the immune system is not underactive but actually overactive. Whenever one considers such alternative approaches, it’s important not to set aside the proved therapies and the proved benefits of medications that have undergone phase 3 trials and been studied, and to help up to regulatory review.