Initial Treatment for Acute Multiple Sclerosis Attack
High-dose corticosteroids—either intravenous methylprednisolone 1000 mg daily for 3-5 days OR oral methylprednisolone 1250 mg daily for 3-5 days—should be administered to treat acute MS relapses with moderate to serious disability. 1, 2, 3
Treatment Regimen
First-Line Corticosteroid Options
Both routes of administration are equally effective, allowing selection based on patient preference, convenience, and clinical setting 2, 4:
- Intravenous methylprednisolone: 1000 mg daily for 3-5 days, administered over several minutes or by infusion 1
- Oral methylprednisolone: 1250 mg daily (equivalent to 25 tablets of 50 mg prednisone) for 3-5 days 2, 5
The FDA label specifies that for acute MS exacerbations, 160 mg of methylprednisolone daily for one week followed by 64 mg every other day for one month has been shown effective, though shorter high-dose regimens are more commonly used in practice 1.
Route Selection Considerations
Oral administration offers significant practical advantages with equivalent efficacy 2, 4:
- A randomized controlled trial of 80 patients found no significant difference between oral and intravenous routes at any timepoint (mean EDSS difference at 4 weeks: 0.07 grades, 95% CI -0.46 to 0.60) 2
- Patient compliance with high-dose oral prednisone is excellent at 94.3%, with 69.8% of patients preferring oral therapy for future relapses 5
- Oral therapy reduces viral exposure risk (particularly relevant during infectious disease outbreaks), avoids hospitalization, and decreases costs 4
Intravenous administration may be preferred in specific circumstances 6:
- Severe brainstem or cerebellar relapses where blood-brain barrier penetration is critical
- Patients unable to tolerate oral medications due to gastrointestinal symptoms
- Life-threatening presentations requiring closer monitoring 6, 7
Expected Outcomes and Limitations
Corticosteroids accelerate recovery from acute relapses but do not alter long-term disability or prevent future relapses 3, 8:
- Meta-analysis shows protective effect against disease worsening within 5 weeks (OR 0.37,95% CI 0.24-0.57) 8
- No evidence of benefit beyond one year for preventing new exacerbations or reducing long-term disability 8
- Treatment speeds recovery but does not affect the ultimate outcome or natural history of MS 1
Monitoring and Safety
Common adverse effects differ by route 2, 5, 8:
- Oral therapy: Gastrointestinal symptoms, psychic disorders, insomnia, mood changes, and increased appetite are more frequent 2, 5
- Intravenous therapy: Generally better tolerated acutely, though short-term high-dose IV methylprednisolone carries minimal adverse events 8
Vigilant monitoring is required for severe presentations, particularly with prominent CNS involvement affecting vital signs and respiratory function 6.
Post-Treatment Management
Following acute treatment, assess need for disease-modifying therapy 7:
- Evaluate for DMT initiation if patient is treatment-naïve
- Consider DMT escalation to high-efficacy agents for highly active disease despite current treatment 7
- For incomplete recovery after corticosteroids, reassess DMT adequacy 7
Implement rehabilitation strategies immediately after the acute phase, focusing on physical, social, and emotional functioning during recovery 7.
Obtain follow-up MRI within 3-12 months using T2-weighted, FLAIR, and gadolinium-enhanced T1-weighted sequences to detect new lesions and active inflammation 7.
Critical Caveats
Do not use corticosteroids intrathecally—severe medical events have been associated with this route 1.
Rarely, high-dose pulsed IV methylprednisolone can induce toxic hepatitis with onset several weeks after treatment; discontinue if this occurs and avoid rechallenge 1.
Screen for contraindications before initiating treatment 1:
- Active infections (particularly varicella, measles, fungal infections, strongyloides, hepatitis B)
- Peptic ulcer disease or gastrointestinal perforation risk
- Uncontrolled hypertension or heart failure
- Recent live vaccine administration