Corticosteroids and optic neuritis

Long term effects of corticosteroids in multiple sclerosis in terms of the "no evidence of disease activity" (NEDA) domains

BACKGROUND

Multiple sclerosis (MS) is a chronic immune-mediated inflammatory disease of the central nervous system (CNS) that usually is clinically characterized by multiple subacute relapses and remissions. The established therapeutic strategies include intravenous methylprednisolone (IV-MP) for treatment of relapses and immunomodulatory or immunosuppressive treatment to prevent new relapses and progression of disability. Despite not being one of the recommended immunomodulatory or immunosuppressive treatments, monthly IV-MP is frequently seen in clinical practice especially in the low income developing countries.

OBJECTIVES

To review the evidences for the possible disease modifying potential of corticosteroids in the treatment of MS in terms of the NEDA 3 domains.

MATERIALS & METHODS

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

RESULTS

There is some evidence that pulsed treatment with methylprednisolone have beneficial long-term effects on relapse rate, MRI findings and disability progression.

CONCLUSION

More data is needed to determine long-term disease modifying effects of corticosteroids. The findings of this study suggest that, perhaps, regular pulse glucocorticoid treatment may have important long-term consequences (beneficial) for patients with MS and it may achieve the NEDA target. Certainly, the magnitude of the reported effects deserves further investigation in both relapsing and progressive MS populations.

Glucocorticoid treatment of multiple sclerosis

Glucorticorticoids have both anti-inflammatory and immunosuppressive properties and both synthetic and natural glucocorticoid medications have been used to treat a number of inflammatory and autoimmune conditions, including the management of acute multiple sclerosis (MS) attacks. Many of the studies supporting the use of this approach to MS treatment have important limitations. Nevertheless, on balance, the data seem to support the notion that a brief glucocorticoid treatment regimen (~2 weeks) hastens recovery from an acute MS flare and that this treatment, in general, is well tolerated. However, such treatment does not seem to alter the final degree of recovery from the MS attack. Among the practice community, even within MS centers, there seems to be a general belief that the selection of the optimal agent, route of administration, and the duration of therapy can be made on the basis of personal experience and/or theoretic considerations. As a result, currently, there are a variety of idiosyncratic regimens (often vigorously defended), which are commonly used to treat patients. Nevertheless, it is important to recognize that the best route of administration, the optimal dose and duration of treatment, and the preferred agent or agents have yet to be firmly established. Moreover, although it may well turn out that some of these factors are more important than others, the best current evidence for the efficacy of glucocorticoid treatment in MS, by far, comes from the optic neuritis treatment trial, which used high-dose intravenous methylprednisolone for the first 3 days followed by an 11-day course of low-dose oral prednisone.

New directions in optic neuritis and multiple sclerosis

Optic neuritis (ON) is the initial presentation in 15% to 20% of cases of multiple sclerosis (MS). Thirty-eight percent to 50% of patients with MS develop ON at some point during the course of their disease. The Optic Neuritis Treatment Trial (ONTT) provided much prospective data about the clinical presentation, clinical course with respect to treatment, and development of MS in patients with ON. The clinical course of MS initially involves episodes of demyelination followed by full recovery; however, later attacks often leave persistent deficits that lead to secondary progression of the disease. The risk of developing progressive neurologic deficits can be reduced by starting therapy with immunomodulating drugs early in the course of the disease. Optical coherence tomography is a noninvasive way to monitor patients with ON to determine if they are undergoing subclinical axonal loss of ganglion cells. Progression of axonal loss on optical coherence tomography may prompt a change in therapy or further imaging.

Névrite optique rétrobulbaire et varicelle chez un enfant

We report here the case of a three-year-old boy presenting with an optic neuritis during the invasive phase of a chicken pox. This clinical, infrequent picture, can be directly due to the virus or be secondary to an auto-immune mechanism. The examination of the ocular fundus, the profile of the spinal fluid, the MRI and the measure of visual evoked potential allow to reach diagnosis and to identify the type of lesion. There is no consensus on the treatment of this optic neuritis and the current attitude is therapeutic abstention because of a rapid spontaneous improvement. Cerebellitis, meningitis can also be seen during chicken pox. Their evolution is quickly favorable, not requiring additional exam. Encephalitis can result from an auto-immune lesion of the white matter and require then the use of corticoids with antiviral drugs.

Multiple sclerosis, acute disseminated encephalomyelitis, and related conditions

Multiple sclerosis (MS) and acute disseminated encephalomyelitis (ADEM) are conditions whose closely related pathology suggests shared pathophysiological elements, but whose clinical courses are usually, but not always quite dissimilar. The former is largely a disease of adulthood, the latter of childhood. Optic neuritis, demyelinative transverse myelitis, and Devic's syndrome are neurological syndromes that may occur as manifestations of either MS or ADEM. Patients with Miller-Fisher syndrome and encephalomyelradiculoneuropathy usually have features suggesting ADEM in combination with acute demyelinative polyneuropathy. These various conditions and other forms of ADEM share an indistinct border with encephalitides, granulomatous, and vasculitic conditions. MS, ADEM, and the pertinent syndromic subtypes, their differential diagnosis, treatment, and prognosis are considered in this review. Acute cerebellar ataxia is a syndrome that is likely to be pathophysiologically distinct from ADEM, although its occurrence as a postinfectious illness suggests a distant kinship. It is also reviewed.

The impact of the optic neuritis treatment trial on the practices of ophthalmologists and neurologists

OBJECTIVE

To determine whether the Optic Neuritis Treatment Trial (ONTT) results have altered the practice patterns of ophthalmologists and neurologists.

DESIGN

Mail survey.

PARTICIPANTS

A random sample of 987 ophthalmologists and 900 neurologists practicing in the United States were mailed a questionnaire that inquired into decision-making with regard to management of optic neuritis before and after the publication of the ONTT results.

MAIN OUTCOME MEASURES

Responses received from 202 ophthalmologists and 244 neurologists, a response rate of 47%.

RESULTS

Following the ONTT reports, nearly all ophthalmologists and neurologists have reduced their use of oral prednisone alone, substituting a regimen that includes intravenous methylprednisolone. A large proportion of practitioners in both specialties mistakenly believe that intravenous methylprednisolone treatment improves final visual outcome. Only 7% of neurologists and 36% of ophthalmologists (P = 0.0001) are adhering to the ONTT suggestion to use magnetic resonance imaging as a basis for initiating treatment.

CONCLUSIONS

The ONTT has led to a dramatic reduction in the use of oral prednisone without a preceding course of intravenous methylprednisolone in the treatment of acute optic neuritis. Ophthalmologists and neurologists have changed some of their practices without fully understanding the results of the ONTT.

A randomized, controlled trial of oral high-dose methylprednisolone in acute optic neuritis

OBJECTIVE

To assess the efficacy of oral high-dose methylprednisolone in acute optic neuritis (ON).

BACKGROUND

It has been determined that oral high-dose methylprednisolone is efficacious in attacks of MS.

METHODS

A total of 60 patients with symptoms and signs of ON with a duration of less than 4 weeks and a visual acuity of 0.7 or less were randomized to treatment with placebo (n = 30) or oral methylprednisolone (n = 30; 500 mg daily for 5 days, with a 10-day tapering period). Visual function was measured and symptoms were scored on a visual analog scale (VAS) before treatment and after 1, 3, and 8 weeks. Primary efficacy measures were spatial vision and VAS scores the first 3 weeks (analysis of variance with baseline values as the covariate), and changes in spatial vision and VAS scores after 8 weeks. A significance level of p < 0.0125 was employed.

RESULTS

The VAS score (p = 0.008) but not the spatial visual function (p = 0.03) differed in methylprednisolone- and placebo-treated patients during the first 3 weeks. After 8 weeks the improvement in VAS scores (p = 0.8) and spatial visual function (p = 0.5) was comparable with methylprednisolone- and placebo-treated patients. A post hoc subgroup analysis suggested that patients with more severe baseline visual deficit and patients treated early after onset of symptoms had a more pronounced response to treatment. The risk of a new demyelinating attack within 1 year was unaffected by treatment. No serious adverse events were seen.

CONCLUSION

Oral high-dose methylprednisolone treatment improves recovery from ON at 1 and 3 weeks, but no effect could be demonstrated at 8 weeks or on subsequent attack frequency.

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).

Glucocorticosteroid therapy for multiple sclerosis: a critical review

Controversy remains as to the efficacy, route of administration and dose of glucocorticosteroid (GCS) in multiple sclerosis (MS) therapy. With the recent approval of new disease modifying treatments and increasing interest in cost-benefit assessments, it is timely to critically consider their role in MS therapeutics. In this paper we review our current understanding of the cellular and molecular mechanisms of action of GCS as they relate to the postulated pathophysiology of MS. We also critically review the use of glucocorticosteroid therapy to: (1) improve recovery from exacerbations of MS, (2) delay the onset of MS in patients who experience a first episode of monosymptomatic optic neuritis, and (3) delay the time to onset of sustained progression of disability in patients with clinically definite MS.

Optic neuritis progressing to multiple sclerosis

We report a partially retrospective and longitudinal study of patients with optic neuritis (ON) that developed multiple sclerosis (MS). We assessed clinical features or factors that might differentiate these patients from those with ON that did not develop MS. Of the cases followed, 110 (67%) were found to have an idiopathic origin of the disease; whereas 55 (33%) were found to develop it secondary to another disease. Of the 110 idiopathic cases, 13 (12%), developed MS over an average of 2 years. The results of these patients in the laboratory analyses of blood and CSF as well as the results of the MRI and evoked potential studies, were significantly different from the ON patients without MS. We conclude that the percentage of patients with ON in our sample that developed MS is similar to that found in Japan and is relatively low in comparison to other reports.