Regina Berkovich, MD, PhD: The use of corticosteroids as a first-line therapy for MS [multiple sclerosis] relapse is, first of all, supported by scientific evidence. The clinical experience is vast, and it has been FDA approved since 1979. We use them as a first-line treatment for MS relapse. A typical dose is 1 g or 1000 mg by IV [intravenously] once a day for 3 to 7 days. Usually, the practices are 3 to 5 days. That is the most-used regimen for the daily administration. Lately, we have been aware of clinical data and some publications on the use of oral systemic steroids, but I would like to mention that when it comes to the oral steroids, they also have to be used in high dosages, which are equivalent to 1 g of methylprednisolone. In that case, they can be used as an alternative. Although they are not specifically approved with as much clinical evidence as IV steroids, they appear to be a viable option.
The reasons that alternatives to systemic steroids are fairly limited in my practice is an inability to tolerate the systemic steroids or lack of efficacy. I must say that the lack of efficacy of systemic steroids and the hope that other medications still may work requires deeper clinical evaluations and better scientific and clinical support. However, I’m basing this completely on my professional experience, when I have patients not responding to the steroids or being steroid resistant for various reasons. We have good experience accumulated over the years that those patients may respond to corticotropin or ACTH [adrenocorticotropic hormone]. We use the ACTH gel, which is known as Acthar gel. Some of the cases will respond to that treatment option. I think the reason is that it has a completely different mechanism of action.