Treatment of Acute Multiple Sclerosis Relapse
High-dose intravenous methylprednisolone (1000 mg daily for 3-5 days) is the first-line treatment for acute multiple sclerosis relapses, though high-dose oral methylprednisolone (1250 mg daily for 3-5 days) is an equally effective alternative. 1
First-Line Treatment Options
Intravenous Methylprednisolone (Preferred)
- Dosing: 1000 mg IV daily for 3-5 days 1
- Administration: Can be given as IV push over several minutes or as infusion 1
- Rationale: Speeds recovery from relapses more rapidly than ACTH, though provides no additional long-term benefit at 3 months 2
- Evidence: High-dose short-term methylprednisolone accelerates recovery from relapses but does not influence occurrence of new relapses or long-term disability 3
Oral Methylprednisolone (Equally Effective Alternative)
- Dosing: 1250 mg oral prednisone daily for 3-5 days 1, 4
- Practical consideration: Requires taking 25 tablets of 50 mg prednisone daily 4
- Compliance: Excellent reported compliance rate of 94.3% despite high pill burden 4
- Patient preference: Two-thirds of patients prefer oral medication for future relapses 4
- Equivalence: Oral and IV routes show comparable clinical and radiological effectiveness 5
Dosing Considerations
Standard High-Dose Regimen
- Methylprednisolone: 160 mg daily for 1 week, followed by 64 mg every other day for 1 month has been shown effective 1
- Prednisone equivalent: 200 mg daily for 1 week, followed by 80 mg every other day for 1 month 6
- Timing: Administer in the morning prior to 9 AM to minimize adrenal suppression 6
Lower Dose Considerations
- A lesser high-dose regimen of 625 mg oral methylprednisolone daily for 3 days may be non-inferior to 1250 mg at 30 days, though the standard dose yields superior improvement at day 7 5
- Clinical caveat: For moderate to severe relapses, use the standard high dose (1000-1250 mg) rather than lower doses 3
Treatment Algorithm
For relapses with moderate to serious disability:
- Initiate high-dose IV methylprednisolone 1000 mg daily for 3-5 days 1, 3
- Alternative: High-dose oral prednisone 1250 mg daily for 3-5 days if IV access problematic or patient preference 4
- Administer in morning hours when possible 6
- Monitor for common side effects: insomnia, mood changes, increased appetite 4
Important pitfall to avoid: Do NOT add an oral prednisone taper following IV methylprednisolone 7. Studies demonstrate that oral prednisone taper after IVMP does not improve neurologic outcomes at 12 months compared with IVMP alone and unnecessarily increases corticosteroid exposure and systemic toxicity 7.
Post-Relapse Management
After treating the acute relapse, evaluate the need to initiate or intensify disease-modifying therapies (DMTs), particularly for patients with highly active disease 8. High-efficacy DMTs should be considered as first-line therapy for patients with markers of aggressive disease 8.
Side Effect Profile
Common adverse effects (occurring in 86% of patients) include 4:
- Insomnia (most common)
- Mood changes
- Increased appetite
- Gastric irritation (can be reduced by taking with food or milk) 6
Key Clinical Points
- No long-term benefit: While corticosteroids speed recovery, they do not prevent future relapses or alter long-term disability 3
- Route equivalence: IV and oral routes are therapeutically equivalent when using appropriate high doses 5, 4
- Avoid tapering: Oral taper after IV pulse therapy provides no additional benefit and increases steroid exposure 7
- Timing matters: Earlier initiation produces better results 8