Stephen Krieger, MD: Well, you said the key word: steroids. So let’s talk a little bit about the nitty-gritty of how we treat relapses. And I like how you said it, that people who live and breathe MS [multiple sclerosis] will have nuances in how they go about things, but we can try to have at least some fundamental information to share about how we go about treating an MS relapse. Joe, why don’t we start with you? Tell us about corticosteroid use for an MS relapse. What’s your approach?
Joseph R. Berger, MD: My approach is the traditional approach. My approach has been to administer 1000 mg. I typically give it over the course of 5 days intravenously. I arrange that with home infusion. Most of my patients are accessible by home infusion currently. That wasn’t always the case because for 20 years I practiced in Kentucky, and many of my patients were coming from 4 hours away down country dirt roads, and it would be very difficult for them to either come in or to have somebody go out there to provide the steroids. That’s been the tradition.
Now, mind you, the conventional wisdom has been that steroids don’t make you ultimately any better, they just make you better faster. And there may be some truth in that, but I think there are both practical and theoretical reasons for treating MS relapses. With respect to the practical, this patient has a problem. It may be a disturbance in vision. It may be weakness. It may be some discomfort. Whatever it is, if you can get them better faster, there’s an advantage to it. The second is the theoretical. And the theoretical is, when they have a relapse, that’s telling me that there is inflammation in an area of their brain. And if I have something that could suppress that inflammation, I would think that ultimately, they’re going to be better. Whether the proof exists or not is another story. But just theoretically that makes sense to me.
The conventional approach has been to give 1000 mg intravenously of steroids for 3 to 5 days. And many of us, as I do, will follow that with a course of prednisone for a period of time thereafter, usually not exceeding 10 or 12 or 14 days. There are other approaches. You can administer the steroid orally, and that’s been demonstrated to be equally effective and certainly a lot cheaper.
Stephen Krieger, MD: And orally with comparable dose.
Joseph R. Berger, MD: Yes, I’m not talking about a Medrol Dosepak.
Stephen Krieger, MD: Right.
Joseph R. Berger, MD: Although that is commonly used. It is not a Medrol Dosepak. We’re talking about the equivalent. Perhaps something on the order of 1250 mg of prednisone. There are a lot of tablets in that. As Rob was telling us before we came on panel, he actually has it written in the order set to the pharmacist that, “This is not a mistake,” which I simply adore, and I think we’ll adopt. So steroids are one approach. Another might be the use of ACTH [adrenocorticotropic hormone]. You can give that either subcutaneously or intramuscularly. And that is used on occasion, particularly in people who are intolerant of prednisone or the corticosteroids for some reason or have limited venous access, or if there are logistical difficulties to get it to them, because this can be self-administered. And then in individuals who have very bad relapses. Those individuals who have tumefactive MS, for instance. Or something extremely debilitating. They’re probably best hospitalized for plasma exchange.
Stephen Krieger, MD: Let’s break that down a little bit. I think you outlined the traditional approach with steroids. You mentioned the high-dose oral steroids. That is something that you do at Cleveland Clinic, the high-dose oral?
Robert Bermel, MD: Correct. I think we do buy into both the theoretical and the practical reasons why the patient is getting this as quickly as we’ve talked about; the reason why they’re taking time out of their calendar to come into the doctor’s office is because this is meaningful to them. They’re having a problem, they come to the doctor or their advance practice provider, and they want it taken care of. And if something can get them better faster, and they don’t have contraindications—they don’t have bad diabetes, and they don’t have cataracts or osteoporosis, and they don’t have a bad history of psychosis with steroids—then we’ll typically err on the side of trying to get them treatment. Joe, you mentioned the optic neuritis treatment trial, and that is probably our best source of data for the impact of treating relapses.
And we use the visual system as an example here. We’ll say, “Well, if they’re 20/40 vision or better with an optic neuritis—type relapse, then we’ll probably not treat them unless the patient or the provider are very worried about them or insistent. And if the patient has what we would call a disabling relapse where it looks like interfering with their function, we definitely will treat. We tend to try to use intravenous methylprednisolone either, in an outpatient infusion center or home care.
But if there are barriers to that, if the patient lives in Kentucky over mountain roads and things like that, and we can get them oral high-dose prednisone that would be 25 pills of 50 mg prednisone per day for 3 to 5 days. And that’s why we have to instruct the pharmacist: this is not a mistake, because it looks like a mistake when they see the prescription come across.
Stephen Krieger, MD: How often do you still get a call from the pharmacy, even though you’ve written that?
Robert Bermel, MD: It still happens, to be honest, but it’s cheaper, sometimes more accessible for patients, so it’s becoming an increasingly common practice for us.
Stephen Krieger, MD: And there are good data for it too.
Amy Perrin Ross, APN, MSN, CNRN, MSCN: Absolutely, absolutely. Dr Luanne Metz from the University of Calgary and her colleagues did some of the bio-equivalency work on this and put this in a published paper, which I sometimes need to send off. But for our colleagues who might be viewing this who may not live and breathe MS all day, every day, might be thinking, “I’m not so sure about this oral steroid stuff.” Honestly, it’s not a new concept. It’s a concept that is incredibly widely used. Most people in the UK now are only accessible with the oral steroids unless they are hospitalized for something else. A number of places in Italy and certain provinces in Canada are using oral steroids exclusively. So it’s not as far-fetched as it might seem to some of us prescribers, to the pharmacists, or even to the patients.