“The study below mirrors my clinical experience that steroid treatment for relapses is unpredictable and at worst dangerous. Clinicians have a ‘must treat worldview‘ and have developed a culture that favors treatment over no treatment. When someone comes in with a relapse we tend to reach for the prescription pad and prescribe steroids. The data favoring steroid treatment of relapses is weak and if anything marginal. Firstly, the outcome at 6 months after a relapse is independent of whether, or not, you receive steroids. All that steroids do is speed up your rate of recovery from a relapse by about two weeks; in other words you get back to you old baseline, or new baseline, 2 weeks earlier if you have steroid treatment. Secondly, the evidence that steroids makes a difference when given 5 weeks after the onset of a relapse is non-existent; in other words if you are going to be treated with steroid you need to receive them as soon as possible after the onset of an attack. Thirdly, the dose counts; most studies of low dose oral have not shown a benefit. Therefore you need high intravenous or oral steroids. I would recommend the following protocols only:
- 1g or 1,000mg methylprednisolone intravenously for 3 days
- 500mg methylprednisolone intravenously for 5 days
- 500mg methylprednisolone orally for 5 days
- Increased appetite, weight gain
- Water retention with leg swelling or a swollen, “puffy” face
- Nervousness, restlessness
- Sudden mood swings (happiness and sadness)
- Hypomania (persistent euphoria or extreme happiness) and rarely acute psychosis
- Avascular necrosis of the hip and other bones
- Thrombosus or clots
- Allergic reactions; this is not an allergic reaction to steroids, but to the incipients in the solution. If you are allergic to the IV formulation you can still take high-dose oral steroids.
- Muscle weakness
- Blurred vision
- Increased growth of body hair
- Easy bruising
- Lower resistance to infection
- Osteoporosis (bone thinning)
- Diabetes or worsening of diabetes
- High blood pressure
- Stomach irritation
- Cataracts or glaucoma
As I have stated many times before on this blog, avascular necrosis and psychosis are the side effects that worry me the most. As with all treatments there is a risk:benefit ratio and in my opinion the risks of steroids outweigh the benefits for mild and sometimes moderate attacks. Obviously if your relapse is preventing you from functioning normally then speeding up the recovery is worthwhile.
Some neurologists still use an oral taper; i.e. after the pulse of high-dose steroids is finished you go onto oral steroids that are then weaned over a 4-8 week period. There is no evidence that a taper makes any difference to the rate of recovery. I don’t use it as it causes a large number of side effects. My only exception to this rule is rebound after the Lazarus effect. The Lazarus effect this is when MSers with a severe relapse, which renders them bed-bound, respond dramatically to a pulse of steroids; they literally get up and start walking 24-48 hours after starting steroids. If they then deteriorate after the pulse of steroids is finished and respond to a second course of steroids I will prescribe a taper to try and prevent a further deterioration. The latter presumably occurs from swelling of the a lesion in the spinal cord and a taper prevents this from reoccurring. Please note that since the wide-spread use of DMTs the number of severe spinal relapses has plummeted and hence I have not seen a Lazarus effect in years. Since we have started using DMTs for treating RRMS not only has the number of relapses plummeted, but also the severity. Another reason for neurologists to use DMTs liberally.
Another trend that has taken off in recent times is the use of monthly pulsed steroids as a DMT; typically 1g or 1,000 mg methylprednisolone intravenously monthly. In my opinion the evidence supporting this treatment is poor and hence I don’t use it personally. The exception being is that if someone is referred to me on this treatment I tend to let them decide whether or not they want to continue, or not, with their monthly infusions after I have explained my position. In general, most MSers stop after hearing about the side effects. I have had one MSer referred to me with such bad osteoporosis from pulsed monthly steroids that she developed a spontaneous vertebral compression fracture. Hence the need to have a baseline bone density scan and to be put on osteoporosis prophylaxis if you are going to stay on steroids long-term.”
The following is a short survey I would like you to complete on steroid use in MS:
Epub: Nickerson M, Marrie RA.The multiple sclerosis relapse experience: patient-reported outcomes from the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry. BMC Neurol. 2013 Sep;13(1):119.
BACKGROUND: Among MSers with relapsing-remitting multiple sclerosis, relapses are associated with increased disability and decreased quality of life. Relapses are commonly treated with corticosteroids or left untreated. They aimed to better understand MSer perceptions of the adequacy of corticosteroids in resolving relapse symptoms.
METHODS: They examined self-reported data from 4482 participants in the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry regarding evaluation, treatment, and recovery from relapses.
RESULTS: Forty percent (1775/4482) of respondents were simply observed for disease worsening, whereas 25% (1133/4482) were treated with intravenous methylprednisolone (IVMP) and 20% (923/4482) with oral corticosteroids; additional treatments included adrenocorticotropic hormone, plasmapheresis, intravenous immunoglobulin, and others. Among MSers who responded to questions about their most recent relapse, 32% (363/1123) of IVMP-treated and 34% (301/895) of oral corticosteroid-treated MSers indicated their symptoms were worse one month after treatment than pre-relapse, as did 39% (612/1574) of observation-only MSers; 30% (335/1122) of IVMP-treated MSers indicated their treatment made relapse symptoms worse (13% [145/1122]) or had no effect (17% [190/1122]), as did 38% (340/894) of oral corticosteroid-treated MSers (worse, 13% [116/894]; no effect, 25% [224/894]) and 76% (1162/1514) of observation-only MSers (worse, 17% [264/1514]; no change, 59% [898/1514]).
CONCLUSIONS: Overall, MSers with relapsing multiple sclerosis who receive treatment report better outcomes than those who are simply observed. However, a sizeable percentage of MSers feel that their symptoms following corticosteroid treatment are worse than pre-relapse symptoms and that treatment had no effect or worsened symptoms. MSer perceptions of relapse treatment deserve more attention, and more effective treatment options are needed.