The effects of high-dose intravenous methylprednisolone on event-related potentials in patients with multiple sclerosis

Cognition in acute relapses: A psychometric evaluation and its correlation with event-related potential, P300 in multiple sclerosis

OBJECTIVE

During acute relapses of multiple sclerosis (MS), physical symptoms attract utmost care. However, cognitive impairment may constitute an substantial part of a new relapse. In this study, we evaluated the cognitive status of MS patients during acute relapses.

MATERIALS AND METHODS

We enrolled 35 definite MS patients and 21 healthy subjects. Neuropsychometric tests and the event-related potential, P300 were administered to the MS patients before corticosteroid treatment, and 3 months later. The control subjects were tested only once.

RESULTS

The differences between the scores of the Timed 25-Foot Walk test, the Brief Repeatable Battery subtests (10/36 SPART, SDMT, SRT, SRT-LTM) in the relapse and remission phases were statistically significant (p = .005, p = .007, p = .05, p = .029, p = .001, respectively). The latencies of P300 waves during the relapses were significantly prolonged than the ones in the remission and the controls' (p = .004, p < .001, respectively).

CONCLUSIONS

In this study, we observed a significant involvement of visual-spatial perception, remote memory, and recall, as well as P300 latencies in acute relapses. The inclusion of cognitive assessment during a relapse can provide accurate information on cognitive status for future treatment modalities.

A Prospective Observational Registry of Repository Corticotropin Injection (Acthar® Gel) for the Treatment of Multiple Sclerosis Relapse

Background and Purpose: Effective relapse treatment is critical for minimizing disability in patients with multiple sclerosis (MS). Repository corticotropin injection (RCI; Acthar® Gel) has demonstrated efficacy for the treatment of MS exacerbations. However, there is limited real-world evidence available regarding the relationship between the use of RCI for MS relapses and patient demographics, disease characteristics, and dosing regimens. In this multicenter, prospective, observational registry, patients receiving RCI for acute MS relapse were characterized, and recovery and safety outcomes were described.

Methods: Patients were invited by their treating clinician to participate in the registry during a routine care visit. The decision to initiate RCI occurred before determination of study eligibility. All treatment decisions were made at the discretion of the patient's health care provider and were not mandated by the study design or protocol. Each enrolled patient was followed for up to 24 Months or until the date of study termination. The primary endpoint was the change from baseline in MS Impact Scale Version 1 (MSIS-29v1) physical subscale scores at Month 2. Additional assessments included the MSIS-29v1 psychological subscale, Expanded Disability Status Scale (EDSS), Clinical Global Impression of Improvement (CGI-I), Work Productivity and Activity Impairment Questionnaire: MS (WPAI:MS), and Health Resource Utilization (HRU) questionnaire.

Results: Of 145 patients enrolled, 82 (56.6%) completed 24 Months of follow-up. Mean MSIS-29v1 physical subscale scores improved at 2 Months (−8.0; P = 0.0002) and 6 Months (−9.6; P < 0.0001). Mean MSIS-29v1 psychological subscale scores also improved at 2 Months (−7.9; P = 0.0040) and 6 Months (−9.9; P = 0.0012). Mean EDSS scores improved at 2 Months (−0.4; P < 0.0001) and 6 Months (−0.5; P < 0.0001). CGI-I scores indicated improvement in 63.4% of 71 patients at 2 Months and 61.4% of 57 patients at 6 Months (both P < 0.0001). Improvements on the WPAI:MS activity impairment domain (P < 0.001) and reductions in outpatient, specialist, and emergency department visits were observed at 2 and 6 Months. A total of 35 (28.0%) patients reported 83 adverse events; 11 (8.8%) patients reported 16 serious adverse events.

Conclusions: This observational study found significant improvements in MS assessment scores after RCI treatment and supports the efficacy and tolerability of RCI for MS relapse.

Clinical Trial Registration: This trial is registered on ClinicalTrials.gov with the identifier NCT02633033.

Cognitive Event-Related Potentials-The P300 Wave Is a Prognostic Factor of Long-Term Disability Progression in Patients With Multiple Sclerosis

PURPOSE

Multiple sclerosis (MS) is a chronic disorder with a variable course. The aim of our study was to find out whether cognitive event-related potentials are prognostic for patient disability at the 15-year follow-up.

METHODS

In the observed cohort of patients with MS, we examined the event-related potentials at baseline (2003). Functional status (Expanded Disability Status Scale score) was then assessed 15 years later, and the prognostic model was developed using binary logistic regression analysis. The independent variables included demographic (age, sex, and education), clinical (disability in 2003), radiologic (MRI lesion load), and event-related potentials parameters. The prognostic accuracy of the proposed model was evaluated by calculating the area under the receiver-operating characteristics curve.

RESULTS

The study sample consisted of 85 patients with MS. The mean age was 35.5 (SD, 11.2) years, and the median disability score was 3.0 (1-7) in 2003 and 5.0 (1.5-9.5) in 2018. The significant prognostic factors of poor Expanded Disability Status Scale are higher baseline Expanded Disability Status Scale, longer MS duration, and prolonged P300 latency. The sensitivity and specificity of the cutoff at 5.0 for the disability score were 94% and 89%, respectively, with the area under the receiver-operating characteristics curve 0.94 (95% confidence interval, 0.889-0.984; P < 0.001).

CONCLUSIONS

The results show that out of event-related potentials, the P300 wave latency is a prognostic of long-term disability progression in patients with MS.

Efficacy, safety, and quality-of-life of treatments for acute relapses of multiple sclerosis: results from a literature review of randomized controlled trials

Background

Intravenous methylprednisolone (IVMP), repository corticotropin injection (RCI), plasmapheresis (PMP), and intravenous immunoglobulin (IVIG) are used in the treatment of acute multiple sclerosis (MS) relapse. A systematic literature review (SLR) of randomized controlled trials (RCTs) was conducted to examine the highest quality evidence available for these therapies.

Methods

English-language articles were searched in MEDLINE, Embase, and Cochrane Library through May 2016 per Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. MS conferences, SLRs, and bibliographies of included studies were also searched. Eligible studies included adults treated with ≥1 aforementioned therapy.

Results

Twenty-three RCTs were identified: 22 on efficacy, 11 on safety, and 3 on QOL (ie 18 IVMP, 2 RCI, 2 PMP, and 2 IVIG). IVMP and RCI improved relapse-related disability; however, IVIG and PMP showed inconsistent efficacy. QOL data were only ascertained for IVMP.

Conclusions

RCTs indicate IVMP and RCI are efficacious and well tolerated treatments for MS relapse. Overall, many RCTs were dated, with sample sizes of fewer than 30 patients and no definitions for relapse nor clinically significant change. Contemporary evidence generation for all relapse treatments of interest, across efficacy, safety, and QOL outcomes, is still needed.

Neurophysiological Assessment of Cognitive Dysfunction in Patients with Multiple Sclerosis

Cognitive impairment occurs in a high percentage in all forms of multiple sclerosis, regardless of physical disability. Slowing the speed of information processing is one of the most difficult and the most frequently mentioned, but impairment of memory, attention, executive functions are included also. Long latency event related potentials (ERP) are much more objective means of cognitive functioning evaluation. Different types of immunomodulatory therapies which are used for relapsing- remitting forms of multiple sclerosis may affect the results of ERP. ERP can evaluate subclinical changes and provide important information on the evolution of cognitive changes in patients with MS.

Residual disability after severe relapse in people with multiple sclerosis treated with disease-modifying therapy

BACKGROUND

The rate of post-relapse residual disability in patients with relapsing-remitting multiple sclerosis (RRMS) treated with disease-modifying drugs (DMD) has not been studied.

OBJECTIVE

To assess relapse residual disability in DMD-treated RRMS patients.

METHODS

We followed DMD-treated RRMS patients presenting with acute relapse who received high-dose steroids. Increases in Expanded Disability Status Scale (EDSS) of at least 2.0, 1.0-1.5 or 0.5 were defined as severe, moderate or mild relapses, respectively. The proportions of patients with post-relapse residual disability defined as the failure to regain pre-relapse neurological status at 1, 4 and 12 months were evaluated.

RESULTS

Out of 1672 relapses in DMD-treated RRMS patients, 17% were severe. In patients who presented with a severe relapse, we observed post-relapse residual disability of at least 1.0 EDSS point in 60.1%, 55.9% and 48.2% of patients at 1, 2 and 12 months of follow-up, respectively. Post-relapse residual disability of at least 2.0 EDSS points was observed in 37.4%, 30.7% and 20.7% of patients after 1, 2 and 12 months, respectively.

CONCLUSION

A high rate of incomplete recovery was seen 12 months following severe relapse among RRMS patients and may contribute to the accumulation of long-term disability.

Corticosteroids in the management of acute multiple sclerosis exacerbations

Multiple sclerosis (MS) is an autoimmune, inflammatory demyelinating disease of the central nervous system characterized in the majority of the patients by a relapsing-remitting disease course. For decades high-dosage corticosteroids (CS) are considered the cornerstone in the management of acute MS relapses. However, many unanswered questions remain when it comes to the exact modalities of CS administration. In this review on behalf of the Belgian Study Group for MS we define the efficacy of CS in reducing MS-related morbidity and examine whether the effect is different according to type of CS, route of administration, cumulative dosage, timing of initiation and disease course. We also review the use of CS in combination with other MS treatments and during pregnancy and lactation. Furthermore, we delineate the relevant adverse events due to a pulse CS regimen and present a decision tree that can be used when treating MS relapses in clinical practice.

Neurotherapeutic Strategies for Multiple Sclerosis

Multiple sclerosis (MS) is the most common disabling neurologic disease of young adults. There are now 16 US Food and Drug Administration (FDA)-approved disease-modifying therapies for MS as well as a cohort of other agents commonly used in practice when conventional therapies prove inadequate. This article discusses approved FDA therapies as well as commonly used practice-based therapies for MS, as well as those therapies that can be used in patients attempting to become pregnant, or in patients with an established pregnancy, who require concomitant treatment secondary to recalcitrant disease activity.

Posturography in MS patients treated with high dose methylprednisolone

OBJECTIVES

To evaluate the sensitivity of the balance sway index (SI) to drug-induced functional changes during acute relapse in patients with MS.

METHODS

Dynamic posturography was used to derive the SI in 11 healthy subjects and 13 MS patients before and after intravenous high dose methylprednisolone (HDMP).

RESULTS

In both groups, SI was lower in the least demanding task and increased with test complexity. Compared to the healthy group, patients were distinguished by a higher SI both prior to and following administration of HDMP (p < 0.008). However, the effect of the drug on patients' SI was unremarkable. Total Expanded Disability Status Scale score was lower after treatment compared to pre-treatment values (p < 0.001), with significantly lower mean score recorded in patients with pyramidal and cerebellar abnormalities (p = 0.017 and p = 0.011, respectively).

DISCUSSION

The SI measure of dynamic posturography is not sensitive to short-term HDMP-induced functional changes during acute relapse in patients with MS. Further studies are needed to evaluate modified balance protocols and the possible long-term treatment effects of HDMP on SI.

Multidisciplinary rehabilitation and steroids in the management of multiple sclerosis relapses: a randomized controlled trial

INTRODUCTION

Periodic relapses are one of the main characteristics of multiple sclerosis (MS), from which recovery is often incomplete despite high-dose methylprednisolone (HDMP) treatment. The aim of our study was to evaluate the potential benefits of short-term HDMP combined with multidisciplinary rehabilitation (MDR) in persons with MS in relapse in order to assess whether combination of steroid therapy with MDR is more beneficial than steroid therapy alone.

MATERIAL AND METHODS

This investigation was conducted as a randomized controlled trial. The MS patients were eligible if they had an established diagnosis and relapse requiring application of HDMP. Forty-nine patients were included in the study and randomized to control and treatment groups, and 37 completed the study. High-dose methylprednisolone was administered to all patients. The treatment group additionally underwent an MDR program over a 3-week period. All outcome measures were completed at baseline and 1 and 3 months later.

RESULTS

The Expanded Disability Status Scale (EDSS) and Functional Independence Measure (FIM) motor scores improved statistically significantly 1 month after HDMP, in both treatment and control groups. During the study period, in the treatment group, a sustained large effect size (ES) was found for both physical and mental composite scores of Multiple Sclerosis Quality of Life-54 (MSQoL-54), while in the controls, a sustained moderate ES was demonstrated only for physical composite score.

CONCLUSIONS

Our findings suggest that MDR improves MS relapse outcome.

Clinical experience with repository corticotropin injection in patients with multiple sclerosis experiencing mood changes with intravenous methylprednisolone: a case series

The elevated prevalence of neuropsychiatric symptoms and disorders among patients with multiple sclerosis (MS) is well recognized, as are potential neuropsychiatric side effects of treatment with corticosteroids. Both methylprednisolone (MP) and repository corticotropin injection (HP Acthar(®) gel) have demonstrated efficacy in reducing short-term disability after exacerbations of MS. Although historical data are limited, repository corticotropin injection has not generally been associated with detrimental neuropsychiatric effects. We describe six cases of patients with relapsing-remitting MS who had previously experienced detrimental mood changes with MP treatment. Some of these patients had previous histories of mood disorders or other neuropsychiatric symptoms prior to MS diagnosis. All six patients were subsequently treated with repository corticotropin injection for MS exacerbations and each demonstrated improvements in MS symptoms. This clinical experience suggests that repository corticotropin injection should be considered as an alternative for patients who do not tolerate corticosteroids or have difficulties associated with intravenous medication. Furthermore, the rate of neuropsychiatric side effects observed in these patients was low. These observations support repository corticotropin injection as a viable alternative for the treatment of acute exacerbations of MS, particularly in patients who have a history of neuropsychiatric disorders or symptoms either independently or in response to MP treatment. In reviewing both the published data and our own clinical experience regarding potential neuropsychiatric adverse events with treatment for MS exacerbations, we hope to stimulate further research into the potential efficacy and safety of repository corticotropin injection among patients with some form of neuropsychiatric complications that must be considered when establishing a treatment plan for MS.

Clinical neurophysiology of multiple sclerosis

The availability of new treatments able to modify the natural course of multiple sclerosis (MS) has generated interest in paraclinical measures to monitor disease evolution. Among these, neurophysiologic measures, mainly evoked potentials (EPs), are used in the functional assessment of central sensorimotor and cognitive networks affected by MS. EP abnormalities may reveal subclinical lesions, objectivate the involvement of sensory and motor pathways in the presence of vague disturbances, and provide indications of the demyelinating nature of the disease process. However, their diagnostic value is much lower than that of magnetic resonance imaging, and is more sensitive to brain and cervical spinal cord lesions. The application of EPs in assessing disease severity and monitoring the evolution of nervous damage is more promising, thanks to their good correlation with disability in cross-sectional and longitudinal studies, and potential use as paraclinical endpoints in clinical trials. Recent evidence indicates that EPs performed early in the disease may help to predict a worse future progression in the long term. If confirmed, these data suggest the possible usefulness of EPs in the early identification of patients who are more likely to develop future disability, thus requiring more frequent monitoring or being potential candidates for more aggressive disease-modifying treatments.

Do resting brain dynamics predict oddball evoked-potential?

Background

The oddball paradigm is widely applied to the investigation of cognitive function in neuroscience and in neuropsychiatry. Whether cortical oscillation in the resting state can predict the elicited oddball event-related potential (ERP) is still not clear. This study explored the relationship between resting electroencephalography (EEG) and oddball ERPs. The regional powers of 18 electrodes across delta, theta, alpha and beta frequencies were correlated with the amplitude and latency of N1, P2, N2 and P3 components of oddball ERPs. A multivariate analysis based on partial least squares (PLS) was applied to further examine the spatial pattern revealed by multiple correlations.

Results

Higher synchronization in the resting state, especially at the alpha spectrum, is associated with higher neural responsiveness and faster neural propagation, as indicated by the higher amplitude change of N1/N2 and shorter latency of P2. None of the resting quantitative EEG indices predict P3 latency and amplitude. The PLS analysis confirms that the resting cortical dynamics which explains N1/N2 amplitude and P2 latency does not show regional specificity, indicating a global property of the brain.

Conclusions

This study differs from previous approaches by relating dynamics in the resting state to neural responsiveness in the activation state. Our analyses suggest that the neural characteristics carried by resting brain dynamics modulate the earlier/automatic stage of target detection.

Corticosteroids in the treatment of multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is an immune-mediated inflammatory disease of the central nervous system (CNS) that usually is clinically characterized by repeated subacute relapses followed by remissions. Therapeutic strategies include corticosteroid treatment of relapses and immunomodulatory- or immunosuppressive treatment to prevent new relapses and progression of disability.

OBJECTIVES

To review the evidences for the use of corticosteroids in the treatment of relapses in MS as well as its possible disease modifying potential.

MATERIALS & METHODS

Available literature from PubMed search and personal experiences on corticosteroid treatment in multiple sclerosis were reviewed.

RESULTS

High dose short-term oral or intravenous methylprednisolone for 3-5 days speed up recovery from relapses, but the treatment has no influence on the occurrence of new relapses or long-term disability. There is also some evidence that pulsed treatment with methylprednisolone have beneficial long-term effects in multiple sclerosis.

CONCLUSION

Relapses with moderate to serious disability should be treated with high dose intravenous or oral methylprednisolone. More data is needed to determine long-term disease modifying effects of corticosteroids.

Corticosteroids for multiple sclerosis: I. Application for treating exacerbations

Multiple sclerosis (MS) is an inflammatory demyelinating disorder characterized by a multiphasic course of neurological exacerbations, periods of clinical remission, and, in most patients, ultimately progressive deterioration of functional capabilities. The relapsing-remitting phase of the disease involves acute interruption in neurological functioning relating to areas of inflammation in discrete central-tract systems. The treatment of MS exacerbations with anti-inflammatory agents such as corticosteroids and adrenocorticotropic hormone has represented an established practice throughout the neurology community. Although there is scientific rationale supporting application of these agents for this purpose, the broad diversity of approaches to using these drugs in clinical practice is a derivative of expert opinion and anecdotal experience. Ultimately, the treatment of MS-related exacerbations is part science, but mostly art. This review discusses the pharmacology of these agents, to better understand how they may act to mitigate attacks and to provide some practical formulations for how to use them in the clinic for the benefit of patients.

Cognitive impairment and neurophysiological correlates in MS

Cognitive impairment in multiple sclerosis (MS) has received considerable interest over the last decades. Heterogeneous patterns of cognitive dysfunction have been reported in literature in relation to the subtype of the disease and the severity of specific cognitive domains affected. Event related potentials (ERPs), especially P300, have been employed to evaluate the cognitive decline in MS and neurophysiological findings agree with data obtained by neuropsychological testing. The objectivity, the reliability and the easy administration are the main features of ERP technique but more specific attention and memory tasks are needed to enhance the clinical value of the methodology. Moreover, ERP recording has the advantage of being feasible even in severe disabled patients. Finally, longitudinal ERP studies are required to investigate the natural course of cognitive dysfunction in MS, to estimate the prognostic value of subclinical defects in different clinical form of the disease and to evaluate clinical benefits of therapeutic and rehabilitative interventions.

EFNS guideline on treatment of multiple sclerosis relapses: report of an EFNS task force on treatment of multiple sclerosis relapses

Relapses, exacerbations or attacks of multiple sclerosis are the dominating feature of relapsing-remitting multiple sclerosis (MS), but are also observed in patients with secondary progressive MS. High-dose methylprednisolone is the routine therapy for relapses at present, but other treatments are also in current use. The objective of the task force was to review the literature on treatment of MS relapses to provide evidence-based treatment recommendations. Review was carried out on the literature with classification of evidence according to the EFNS guidelines for scientific task forces. Short-term, high-dose methylprednisolone treatment should be considered for the treatment of relapses of MS (level A recommendation). The optimal glucocorticoid treatment regimen, in terms of clinical efficacy and adverse events, remains to be established. A more intense, interdisciplinary rehabilitation programme should be considered as this probably further improves recovery after treatment with methylprednisolone (level B recommendation). Plasma exchange is probably efficacious in a subgroup of patients with severe relapses not responding to methylprednisolone therapy, and should be considered in this patient subgroup (level B recommendation). There is a need for further randomized, controlled trials in order to establish the optimal treatment regimen for relapses of MS.

Event-related potentials in different subtypes of multiple sclerosis--a cross-sectional study

Impairment of cognitive skills is found in up to 65% of patients suffering from multiple sclerosis (MS). Little is known concerning the natural history or characteristics of progression of these cognitive dysfunctions. Furthermore, it has not been investigated to date whether there are differences in the course of cognitive impairment with respect to different diagnostic subgroups of MS. Event-related potentials (ERP) are an objective tool to evaluate cognitive processing. We performed a cross-sectional study on 179 consecutive patients suffering from MS (107 relapsing-remitting MS; 17 primary progressive MS; 50 secondary progressive MS; 5 undetermined). ERP were measured by a visual oddball paradigm, latencies of P3 components were correlated with demographic and clinical data. We found pathologically increased P3 latencies in 56% of all patients. Patients with secondary progressive MS showed significantly increased P3 latencies as compared to the other subgroups. There was a significant correlation between expanded disability status scale (EDSS) score and P3 latency (r=0.48; p<0.001). We conclude that ERP are an appropriate method to follow up cognitive dysfunction in MS and that cognitive dysfunction as measured by ERP is progressively impaired in the course of MS, in particular in the secondary progressive subtype.

Rapid non-genomic inhibition of ATP-induced Cl- secretion by dexamethasone in human bronchial epithelium

A non-genomic antisecretory role for dexamethasone at low concentrations (0.1 nM to1 microM) is described in monolayers of human bronchial epithelial cells in primary culture and in a continuous cell line (16HBE14o- cells). Dexamethasone produced a rapid decrease of [Ca(2+)](i) (measured with fura-2 spectrofluorescence) to a new steady-state concentration. After 15 min exposure to dexamethasone (1 nM), [Ca(2+)](i) was reduced by 32 +/- 11 nM (n = 7, P < 0.0001) from a basal value of 213 +/- 36 nM (n = 7). We have shown previously that aldosterone (1 nM) also produces a rapid fall in [Ca(2+)](i); however, after the decrease in [Ca(2+)](i) induced by dexamethasone, subsequent addition of aldosterone did not produced any further lowering of [Ca(2+)](i). The rapid response to dexamethasone was insensitive to pretreatment with cycloheximide and unaffected by the glucocorticoid type II and mineralocorticoid receptor antagonists RU486 and spironolactone, respectively. The rapid [Ca(2+)](i) decrease induced by dexamethasone was inhibited by the Ca(2+)-ATPase pump inhibitor thapsigargin (1 microM), the adenylate cyclase inhibitor MDL hydrochloride (500 microM) and the protein kinase A inhibitor Rp-adenosine 3',5'-cyclic monophosphorothioate (200 microM), but was not affected by the protein kinase C inhibitor, chelerythrine chloride (0.1 microM). Treatment of 16HBE14o- cell monolayers with dexamethasone (1 nM) inhibited the large and transient [Ca(2+)](i) increase induced by apical exposure to ATP (10(-4) M). Dexamethasone (1 nM) also reduced by 30 % the Ca(2+)-dependant Cl(-) secretion induced by apical exposure to ATP (measured as the Cl(-)-sensitive short-circuit current across monolayers mounted in Ussing chambers). Our results demonstrate, for the first time, that dexamethasone at low concentrations inhibits Cl(-) secretion in human bronchial epithelial cells. The rapid inhibition of Cl(-) secretion induced by the synthetic glucocorticoid is associated with a rapid decrease in [Ca(2+)](i) via a non-genomic mechanism that does not involve the classical glucocorticoid or mineralocorticoid receptor. Rather, it is a result of rapid non-genomic stimulation of thapsigargin-sensitive Ca(2+)-ATPase, via adenylate cyclase and protein kinase A signalling.

Neurophysiological investigations in multiple sclerosis

The advent of magnetic resonance imaging techniques has greatly reduced the diagnostic value of neurophysiological tests, particularly evoked potentials, in multiple sclerosis patients, because of the higher sensitivity in revealing subclinical involvement of the central nervous system. Technical progress and new methods of investigating afferent and efferent nervous pathways would seem to increase the sensitivity in detecting neural dysfunction, but the 'clinical gain' is modest at best. More promising is the utilization of neurophysiological tests to quantify the severity of white matter involvement. Transversal and longitudinal studies have demonstrated good correlations between neurophysiological parameters and disability measures, indicating that a battery of neurophysiological tests could be useful in monitoring the disease evolution in single patients and as surrogate endpoints in clinical trials. Further studies are needed for a better definition of the applications of evoked potentials and other neurophysiological techniques. Finally, event-related potentials and advanced electroencephalogram techniques, such as coherence analysis, could provide useful information on the pathophysiology of cognitive dysfunction, so common in multiple sclerosis patients, and with a strong impact on the quality of life.

Corticosteroids or ACTH for acute exacerbations in multiple sclerosis

BACKGROUND

Corticosteroids are often used to improve the rate of recovery from acute exacerbation in multiple sclerosis (MS) patients. However, it is still unclear just how relatively effective these agents are and the type of drug, optimal dose, frequency, duration of treatment and route of administration are unknown.

OBJECTIVES

The object of this review was to determine the efficacy and safety of corticosteroids or ACTH in reducing the short and long term morbidity from MS. Moreover, we wished to examine from indirect comparisons if the effect of corticosteroids is different according to different doses and drugs, routes of administration, length of treatment.

SEARCH STRATEGY

A search strategy developed for the Cochrane MS Group (last searched: June 1999) completed with handsearching and personal contacts with trialists and pharmaceutical companies was used.

SELECTION CRITERIA

All randomised, double-blind, unconfounded trials comparing corticosteroids or ACTH to placebo in patients with MS, treated for acute exacerbations, without any age or severity restrictions, were evaluated.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected articles for inclusion, assessed trials' quality and extracted the data. A third reviewer cross-checked them and disagreements were resolved by a joint discussion.

MAIN RESULTS

Six trials contributed to this review; a total of 377 participants (199 treatment, 178 placebo) were randomised. The drugs analysed were methylprednisolone (MP) (four trials, 140 patients) and ACTH (two trials, 237 patients). Overall, MP or ACTH showed a protective effect against the disease getting worse or stable within the first five weeks of treatment (odds ratio[OR]=0.37, 95% confidence interval [CI] 0.24-0.57) with some but non significant greater effect for MP and intravenous administration. Short (five days) or long (15 days) duration of treatment with MP did not show any significant difference. Only one study (with 51 patients) reported data after one year of follow-up: no difference between oral MP and placebo in the prevention of new exacerbations or improvement in long term disability was detected. No data are available beyond one year of follow-up to indicate whether steroids or ACTH have any effect on long-term progression. One study reported that a short term treatment with high dose intravenous MP was not attended by adverse events. On the contrary, gastrointestinal symptoms and psychic disorders were significantly more common in the oral, high-dose MP than in the placebo group. Weight gain and edema were significantly more frequent in the ACTH group than in controls.

REVIEWER'S CONCLUSIONS

We found evidence favouring the corticosteroid MP for acute exacerbation in MS patients. Data are insufficient to reliably estimate effect of corticosteroids on prevention of new exacerbations and reduction of long-term disability. Studies assessing long term risk/benefit and adverse effects of corticosteroids in MS patients are urgently needed.

Equivalent doses and relative drug potencies for non-genomic glucocorticoid effects: a novel glucocorticoid hierarchy

Glucocorticoids have three distinct therapeutically relevant effects (genomic, specific nongenomic, and unspecific non-genomic), raising the hypothesis that the relative potencies of non-genomic and genomic effects of glucocorticoids may differ. Therefore, we measured the unspecific non-genomic potencies of five clinically important glucocorticoids and compared them with the classical (genomic) potencies. We studied the immediate glucocorticoid effects on respiration, on protein synthesis, and on Na+-K+-ATPase and Ca2+-ATPase in concanavalin A-stimulated rat thymocytes. We titrated the respiration of the cells with methylprednisolone, prednylidene, dexamethasone, prednisolone or betamethasone, and then interpolated the glucocorticoid concentrations needed to inhibit concanavalin A-stimulated respiration back to normal. These "equivalent doses" produced equal inhibition of respiration, of specific energy-consuming pathways, and of the concanavalin A effect on quiescent cells. The relative drug potencies were calculated as the inverse of the equivalent doses normalized to methylprednisolone and were: prednylidene (3.0) > dexamethasone (1.2) > methylprednisolone (1.0) > prednisolone (0.4) > betamethasone (0.2). This hierarchy is completely different from that for the classical effects. These new data are of crucial relevance for in vitro experiments and clinical use, especially in glucocorticoid high-dose therapy. Examples are the choice between methylprednisolone and prednisolone in pulse therapy, and the completely different clinical usage of dexamethasone and betamethasone, despite their similar affinities for nuclear receptors.

Recent developments in drug therapy for multiple sclerosis

Symptomatic treatment of multiple sclerosis (MS) includes a diverse range of drugs intended to relieve the specific symptoms with which a patient may present at a particular point in the progression of the disease. These drugs, not specifically designed for the treatment of MS, may include antispastic agents (e.g. baclofen), drugs to reduce tremor (e.g. clonazepam), anticholinergics (e.g. oxybutynin) which relieve urinary symptoms, anti-epileptics (e.g. carbamazepine) to control neuralgia, stimulants to reduce fatigue (e.g. amantadine), and antidepressants (e.g. fluoxetine) to treat depression. The treatment of acute relapses or exacerbations is dominated by corticosteroids such as methylprednisolone. The most active area of current investigation is the development of drugs which will inhibit the progression of the disease process itself, and in this category the beta- and alpha-interferons are the most effective drugs currently available, although many new treatments are currently in trials, including immunoglobulin, copolymer-1. bovine myelin, T-cell receptor (TCR) peptide vaccines, platelet activating factor (PAF) antagonists, matrix metallo-proteinase inhibitors, campath-1, and insulin-like growth factor (IGF).