What is the treatment (Tx) for an acute multiple sclerosis (MS) flare?

Treatment for Acute Multiple Sclerosis Flares

High-dose corticosteroids are the first-line treatment for acute multiple sclerosis (MS) flares, with intravenous methylprednisolone 1000mg daily for 3-5 days or oral prednisone 1250mg daily for 3-5 days being equally effective options. 1, 2, 3

First-Line Treatment Options

Intravenous Methylprednisolone

• Dosage: 1000mg daily for 3-5 days
• Administration: Intravenous infusion over 30-60 minutes
• FDA-approved indication for MS exacerbations 1
• Can be followed by oral prednisone taper, though evidence for tapering is limited

Oral High-Dose Corticosteroids

• Dosage: Prednisone 1250mg daily (25 tablets of 50mg) for 3-5 days
• Equally effective as IV methylprednisolone based on randomized controlled trials 3
• High patient compliance rate (94.3%) despite large number of tablets 4
• More convenient, safer, and cost-effective than IV administration 3

Treatment Algorithm

1. Confirm MS flare: New or worsening neurological symptoms lasting >24 hours, occurring at least 30 days after previous attack
2. Rule out infection: Ensure symptoms aren't due to infection which could worsen with steroid treatment
3. Choose administration route:
   • IV methylprednisolone if:
     • Patient has severe symptoms affecting mobility or vision
     • Patient unable to tolerate oral medications
     • Hospitalization required for other reasons
   • Oral prednisone if:
     • Outpatient management is appropriate
     • Patient can tolerate oral medications
     • Patient prefers oral administration (69.8% of patients prefer oral route) 4

Expected Outcomes

• Improvement typically begins within 3-5 days of treatment initiation
• Full recovery may take weeks to months
• Steroids accelerate recovery but don't affect long-term disability progression 5
• Approximately 65% of patients show improvement on disability scales by 8 weeks with methylprednisolone treatment 6

Common Side Effects and Management

• Insomnia: Take medication in morning, consider short-term sleep aid
• Mood changes: Monitor for depression, anxiety, or euphoria
• Increased appetite/weight gain: Temporary during treatment course
• Gastrointestinal symptoms: Take with food, consider proton pump inhibitors
• Elevated blood glucose: Monitor in diabetic patients
• Edema: Temporary fluid retention, usually resolves after treatment

Important Considerations

• No evidence that tapering steroids after short-course high-dose treatment provides additional benefit
• Steroid effects on immune system are immediate and short-term (1 month) but not long-lasting (6 months) 7
• Repeated courses of steroids for frequent relapses may require consideration of disease-modifying therapy adjustment
• For patients with contraindications to corticosteroids, plasma exchange may be considered for severe relapses not responding to steroids

Pitfalls to Avoid

1. Delaying treatment: Early intervention with steroids leads to faster recovery
2. Prolonged steroid use: Long-term steroid therapy has significant side effects without proven benefit in MS
3. Overuse of steroids: Not every symptom fluctuation represents a true relapse requiring steroid treatment
4. Inadequate monitoring: Watch for infection risk, especially in immunocompromised patients
5. Missing the opportunity to reassess disease-modifying therapy: Frequent relapses may indicate need for change in maintenance treatment

The evidence clearly supports high-dose corticosteroids as effective treatment for acute MS flares, with both IV and oral routes showing similar efficacy. The choice between them should be based on practical considerations rather than expected differences in outcomes.