Should oral steroids be given after high-dose intravenous (IV) methylprednisolone in patients with multiple sclerosis (MS)?

Oral Steroids After High-Dose IV Methylprednisolone in Multiple Sclerosis

Oral steroids following high-dose intravenous methylprednisolone are not recommended for patients with multiple sclerosis as they do not improve disability or recovery from relapses compared to IV methylprednisolone alone.

Evidence on Oral Steroid Tapering After IV Treatment

• A retrospective study of 285 MS relapses showed that oral prednisone taper following IVMP did not lead to improved neurological outcomes after 12 months compared to treatment with IVMP alone 1
• The common practice of using oral prednisone taper following IVMP raises concerns about unnecessary exposure to systemic corticosteroids and their associated toxicity 1

Recommended Treatment Approach for MS Relapses

Initial Treatment

• High-dose intravenous methylprednisolone (1000 mg daily for 3-5 days) is effective for acute exacerbations of multiple sclerosis 2
• Alternative dosing regimens may include:
  • Standard high-dose oral methylprednisolone (1250 mg/day for 3 days) 3
  • Lesser high-dose oral methylprednisolone (625 mg/day for 3 days), which may not be inferior to standard high dose in terms of clinical and radiological response 3

Post-IV Treatment Considerations

• Once clinical improvement is noted, treatment can be discontinued without an oral taper 1
• If conversion to oral steroids is deemed necessary (though evidence doesn't support this practice), a suggested oral prednisolone taper would be 4-8 weeks 2

Bioavailability Considerations

• The bioavailability of 1250 mg oral prednisone is similar to 1 gram IV methylprednisolone, suggesting that the amount of absorbed corticosteroid is similar at these doses 4
• This equivalence in bioavailability supports the finding that there's no additional benefit to oral tapering after IV treatment 4, 1

Route of Administration for Initial Treatment

• There is no significant difference in clinical, radiological, or pharmacological outcomes between oral and intravenous steroids for MS relapses 5
• Oral administration may be preferable for reasons of patient convenience, safety, and cost 6

Monitoring and Precautions

• Common side effects of steroid treatment include gastrointestinal symptoms, psychic disorders, hyperglycemia, and insomnia 2
• Monitor for hyperglycemia, hypertension, and psychiatric reactions 2
• Exercise caution in patients with comorbidities such as diabetes, hypertension, glaucoma, tuberculosis, or peptic ulcer disease 2
• Consider prophylaxis for Pneumocystis jirovecii pneumonia if steroid treatment exceeds 4 weeks, and vitamin D supplementation for longer courses 2

Clinical Pitfalls to Avoid

• Adding unnecessary oral steroid taper after IV methylprednisolone increases exposure to steroids and their associated side effects without improving outcomes 1
• Failing to consider oral high-dose steroids as an alternative to IV administration when appropriate (both have similar efficacy) 5, 6
• Not monitoring for steroid-related complications, especially in patients with pre-existing conditions like diabetes or hypertension 2