What is the initial treatment order for a patient admitted with a multiple sclerosis (MS) relapse?

Initial Treatment Orders for Multiple Sclerosis Relapse

High-dose methylprednisolone (1000 mg daily for 3 days) is the first-line treatment for MS relapse, with oral administration being as effective as intravenous administration and should be initiated immediately upon diagnosis of a relapse. 1

Corticosteroid Therapy

First-Line Treatment

• Methylprednisolone dosing options:
  • Oral methylprednisolone: 1000 mg once daily for 3 days
  • Intravenous methylprednisolone: 1000 mg once daily for 3 days
  • Both routes have equivalent efficacy for improvement of disability scores at 1 month 1

Administration Considerations

• Oral administration advantages:
  • More convenient for patients
  • Lower direct and indirect costs
  • Avoids hospitalization or home infusion services
  • High compliance rate (94.3%) even with multiple tablets 2
  • Similar safety profile to IV administration 1

Monitoring During Treatment

• Monitor for common adverse effects:
  • Insomnia (more common with oral administration - 77% vs 64% for IV) 1
  • Mood changes
  • Increased appetite
  • Gastrointestinal disturbances

MRI Assessment

• Baseline MRI recommended with the following sequences 3:

  • T2-weighted FLAIR sequences
  • T2-weighted fast/turbo spin echo sequences
  • Gadolinium-enhanced T1-weighted sequences
  • Diffusion-weighted imaging (for patients at risk of PML)

• Technical considerations 3:

  • Field strength of at least 1.5T
  • Slice thickness no more than 3mm
  • Consistent positioning between scans

Adjunctive Treatments to Consider

For Severe Relapses

• Plasma exchange may be considered as adjunctive therapy in severe cases not responding to high-dose corticosteroids 3

For Specific Symptoms

• Symptomatic management based on presenting symptoms:
  • Spasticity management
  • Pain control
  • Bladder/bowel dysfunction management
  • Fatigue management

Clinical Assessment

• Document baseline Expanded Disability Status Scale (EDSS) score
• Schedule follow-up assessment at 4 weeks post-treatment to evaluate response 1
• Consider combining EDSS with Multiple Sclerosis Functional Composite (MSFC) for better sensitivity 3

Important Considerations

Timing of Treatment

• Initiate treatment as soon as possible after relapse diagnosis
• Early treatment (within first 2-10 years of symptom onset) is critical to prevent long-term disability 3

Patient Education

• Inform patients about expected side effects
• Advise on the importance of completing the full course of treatment
• Discuss disease-modifying therapy options if not already on treatment

Pitfalls to Avoid

1. Delaying treatment - Early intervention is critical to prevent long-term disability
2. Underestimating subclinical disease activity - Regular monitoring with MRI is important even in the absence of clinical symptoms 3
3. Inadequate follow-up - Schedule appropriate follow-up to assess treatment response
4. Neglecting to assess for disease-modifying therapy - Relapse indicates active disease and may warrant initiation or change of disease-modifying therapy

The evidence strongly supports that oral high-dose methylprednisolone is non-inferior to intravenous administration for MS relapses, making it a practical and effective option that can be initiated immediately upon diagnosis of a relapse 1, 4.