Using ACTH and IV Ig for MS Relapses

• Q:  When should drugs (like ACTH or IV Ig) be given for relapses? How is it decided whether the relapse should "run its course", or be managed with these drugs?

The answer to this question depends upon whether the IV Ig or ACTH (acthar gel) is being used to treat an acute relapse, to reduce the chance of future relapses in patients with relapsing remitting multiple sclerosis or to prevent the accumulation of disability in any patient, particularly progressive patients:

Treatment of Acute Relapses:

1. ACTH was actually the first drug approved specifically to hasten recovery from MS relapses. It does not require an infusion and is generally as well tolerated as IV methylprednisolone (Solumedrol). There is no class I evidence to suggest one is better than the other at treating acute relapses. ACT is very expensive and there may be problems getting insurance to cover the treatment.
2. The evidence to support IV Ig for the treatment of acute relapses is probably class III (minimal). There are few well designed studies for this indication although it remains a popular treatment for MS relapses in the Pediatric population. It is primarily used to treat relapses in patients totally unable to tolerate corticosteroids or with a contraindication to corticosteroid usage. When a single dose of IV Ig is given with a regular three day course of IV methylprednisolone for acute relapses, it does not appear to add any benefit to the steroid treatment. It is sometimes used in patients who continue to worsen over 2 weeks despite treatment with high dose methylprednisolone, although plasma exchange is the preferred treatment for this scenario. Again, this is a very expensive treatment costing more than $5,000 per infusion and usually given for 3 to 5 days to treat a relapse.
   

Prevention of relapses in patients currently stable:

1. There is no good evidence to support the use of ACTH for this indication. Even though some neurologists prescribe regular injections of ACTH to manage MS symptoms, the use of regular injections (weekly, every two weeks or monthly) must be weighted against to the costs and potential long term side effects.
2. IV Ig has been shown to reduce the risk of relapses when given regularly, usually 400 mg/kg, once monthly. Due to cost, modest benefits and the availability of other agents ,this is usually not a first line treatment of relapsing MS. It has been shown to reduce the risk of postpartum relapses in one study where woman took IV Ig for 5 consecutive days in the first week after delivery and then in a single dose given 6 and 12 weeks later. This is a reasonable indication particularly in those women with a high risk of post partum relapse.
   

Prevention of the accumulation of disability in relapsing or progressive MS:

• ACTH has never been tested for this indication

• Although slightly controversial in some quarters, IV Ig does not appear to be beneficial as mono therapy for this indication. Whether it would be beneficial in combination with other treatments is unknown.