How should Solumedrol (methylprednisolone sodium succinate) be administered as pulse therapy for an acute multiple sclerosis relapse according to Neurology in Clinical Practice (Hankey)?

Methylprednisolone Administration for Acute Multiple Sclerosis Relapse

For acute MS relapses, administer intravenous methylprednisolone 1000 mg daily for 3-5 consecutive days, infused over several minutes to hours, without requiring a subsequent oral prednisone taper. 1, 2

Standard Dosing Protocol

• Administer 1000 mg IV methylprednisolone daily for 3-5 days as the established regimen for moderate to severe MS relapses 1, 2
• The FDA-approved alternative dosing from clinical trials is 160 mg daily for 7 days (one week), followed by 64 mg every other day for 1 month 1
• Infuse each dose intravenously over several minutes, though the medication may be diluted in 5% dextrose, isotonic saline, or 5% dextrose in saline for slower infusion if desired 1

Preparation and Administration

• Reconstitute the powder with Water for Injection per package instructions, then administer directly IV or further dilute for infusion 1
• Use reconstituted solution within 48 hours when stored at room temperature (20-25°C) 1
• If further diluted, use within 4 hours at room temperature or within 24 hours if refrigerated at 2-8°C 1

Clinical Efficacy and Timing

• This regimen accelerates recovery from acute relapses but does not influence long-term disability or prevent future relapses 2
• Methylprednisolone produces more rapid clinical improvement than ACTH, with benefits apparent within 7 days, though no additional benefit is seen at 3 months compared to ACTH 3
• The treatment is effective and safe for MS relapses, with well-established short-term benefits 4

Oral Alternative (Lower Evidence)

• Oral methylprednisolone 1250 mg daily for 3 days may be considered as an alternative, though IV administration remains standard 5
• A lesser dose of 625 mg daily for 3 days showed non-inferiority at 30 days but inferior EDSS improvement at day 7 compared to 1250 mg daily 5

Critical Monitoring Requirements

• Monitor cardiac rhythm during and for 18 hours post-infusion in patients who smoke or have autonomic dysfunction (urinary/bowel symptoms), as these patients have significantly higher risk of serious arrhythmias including ventricular tachycardia, sinus arrest, and sinus exit block 6
• Sinus bradycardia occurs in up to 42% of patients post-infusion, with most serious arrhythmias developing 12 hours after infusion 6
• Atrial fibrillation and ventricular tachycardia can occur, particularly in smokers and those with sphincter dysfunction 6

Important Caveats

• No oral prednisone taper is required after completing the 3-5 day pulse course for standard MS relapse treatment 1, 2
• Routine laboratory monitoring (urinalysis, blood glucose, blood pressure, weight, chest X-ray) should be performed at regular intervals during prolonged therapy, though this is less relevant for short pulse courses 1
• Upper GI imaging is recommended in patients with ulcer history or significant dyspepsia 1
• The treatment has no proven long-term disease-modifying effect on MS progression or relapse prevention, so disease-modifying therapies should be considered separately 2