To Treat (an MS relapse) or Not to Treat with Steroids

To treat [a relapse] or not to treat [a relapse]...that is the question.

This is a question that has vexed neurologists and patients for decades. Although there is still no consensus based on evidence, there is a pattern of advice provided by most MS specialists that is generally consistent.

First, some definitions and information regarding relapses and new lesions on MRI: a relapse is the development of new or worsening neurological symptoms in an MS patient, usually with confirmatory findings on examination, that lasts for more than 48 hours and is NOT caused by a fever, medication or another medical problem. Relapses can last for less than 48 hours but do not require any intervention. A relapse typically continues to worsen over several days if not weeks before stabilizing and improving. In fact the initial stage of MS is called relapsing remitting because following a relapse a patient normally recovers without treatment, although the extent of recovery varies from patient to patient and relapse to relapse. The rule of thumb regarding relapse recovery is that it takes longer to recover from relapses that develop over a longer period of time. Patients who awaken with the sudden onset of symptoms at their worst point, such as being blind in one eye, often recover faster and more completely than a person who develops lesser symptoms over an interval of weeks.

Relapses DO NOT require the presence of Gadolinium-enhancing lesions on MRI. In fact some of the worst relapses I have observed occurred in patients with large new areas of involvement on MRI that did not enhance following the administration of contrast. Similarly, the presence of gadolinium enhancing lesions (contrast enhancement) on MRI does not mean you are having a relapse. In short, relapses are only defined by symptoms and findings determined by an expert evaluator (often this is the patient after years of experience) to be caused by new or worsening areas of inflammatory demyelination in the CNS.

The mainstay of treatment for relapses continues to be corticosteroids or adrenocorticotropin (ACTH), collectively called steroids.  For patients who continue to worsen with severe relapses despite treatment with high doses of steroids, we often treat with plasma exchange. The decision to treat and how to treat depends on a number of individual circumstances and often the preferences of both the physician and the patient. Many many studies have demonstrated that different formulations of corticosteroids (most commonly methylprednisolone or solumedrol, prednisone or dexamethasone) or ACTH in high doses are effective at speeding up the recovery rate from relapses without significantly affecting the amount of long term recovery that would have occurred without treatment 6 months after the relapse. Some studies have demonstrated other long term benefits of steroid treatments but not an effect on clinical recovery. When treatment is considered it is usually best to initiate treatment within 2 weeks of onset of symptoms, although later treatment may be beneficial as well.

Steroid treatments are often associated with mild side effects, although some people experience quite severe side effects that must be managed by a physician with considerable experience. The potential physical side effects are too numerous to mention but include flushing and a metallic taste in the tongue during IV infusion, increased appetite, weight gain, elevated blood sugar, hypertension and upset stomach.  Psychiatric side effects include insomnia, hyperactivity or even mania with psychosis, depression, and cognitive slowing. Rare side effects include refractory hiccups, pancreatitis, severe bradycardia during IV infusion and avascular necrosis of the hip. All side effects tend to be manageable and short lived.

With this totality of information in mind, here are my personal thoughts on treatment of relapses with steroids.

1.    Mild relapses require either no treatment or relatively low dose oral treatment. I find that those patients who know they tolerate steroids well and want to feel better quickly usually prefer treatment with steroids.

2.    Moderate relapse are those that result in changes on examination and a significant alteration of daily activities but do not result in a significant decline in activities of daily living or require hospitalization. Treatment regimens for moderate relapses include 1000 mg of methylprednisolone IV for 3 days with or without an oral prednisone taper, IM ACTH 80 units for 5 days or high dose oral steroids depending on the circumstances and prior experience. Given the extreme cost of ACTH and the demonstrated benefits of other formulations, this treatment is used far less often than other types of steroids. There are those who believe that ACTH has a unique mechanism of action distinct from its corticosteroid effects but this remains mere speculation in MS despite years of research. Patients who continue to worsen over 2 weeks despite treatment with high dose corticosteroids are usually considered good candidates for plasma exchange

3.    Severe relapses are those that result in significant functional impairment impairing several activities of daily living and often requiring hospitalization. These are usually treated with very high doses of methylprednisolone (1000 to 2000 mg per day for 5 to 7 days) often with a prednisone taper. Failure to respond quickly may require the use of plasma exchange to speed recovery.

Please Note:  The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.  Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.