To begin with, there’s not much you can do wrong with a corticosteroid therapy. Sometimes MS patients get a bit confused when they are confronted with different approaches – then they ask, “Why did one doctor give me five infusions, the other only three? Why did I have to take pills after the infusion with one doctor and not with the other?”The generally accepted standard for treating acute MS relapses is the intravenous administration of 1000 mg of methylprednisolone (brand name e.g. Urbason®) on three consecutive days. Sometimes the administration is extended to five consecutive days. I do this when I – especially in the case of severe symptoms (significant visual impairment, paralysis) – see no tendency towards improvement after three days. I usually don’t treat for more than five consecutive days – after five days I prefer to wait for the next one to two weeks. If there is still no tendency towards improvement in the case of severe symptoms, either the corticosteroid therapy can be repeated at a double dose (2000mg/day for five consecutive days) or a plasma exchange treatment can be performed.
I often observe too high expectations of the therapy’s effect. Of course, it is desirable for the symptoms to completely recede during the cortisone administration, but it often requires a bit more patience, sometimes even months.
As for the oral tapering off of corticosteroid therapy after infusion, this has more historical reasons. I hardly ever do this anymore. Because the effective part of a corticosteroid treatment of acute relapse is the high-dose, intravenous administration with at least 500 mg of methylprednisolone per infusion. So, oral tapering off is no longer a “must” these days, but it is also not a mistake. In the sense of the concept “as much as necessary” I usually prefer to do without it.
In chat forums, there is often discussion about the “right” drug. To my knowledge, there are patient groups that advocate the administration of dexamethasone (trade name: Fortecortin®). This is a synthetic, fluorinated corticosteroid with an equivalence dose of 1:10 – i.e., 1 mg of dexamethasone is approximately equivalent to 10 mg of prednisolone. To treat relapses with dexamethasone, at least 40 mg per day should be used. In neurology, we don’t like fluorinated corticosteroids so much because they often lead to muscle complaints (steroid myopathy) – this is one reason why neurologists in Germany prefer methylprednisolone for relapse treatment of MS.
But no matter which drug you use, it is important that it is dosed high enough. Because for the treatment of relapses, we need the so-called direct membrane effects of corticosteroids, and they only come into play above at least 250 mg, better 500 mg of prednisolone (equivalent). This is also the reason why long-term therapy with low-dose cortisone makes no sense in MS. Here, you really only have the (serious) side effects of long-term corticosteroid therapy and no meaningful effect on MS.
Sometimes it is asked whether one could not also take high-dose tablets instead of a high-dose infusion. Personally, I trust the high-dose infusion more, even though there are study data on the effectiveness of high-dose tablets. But there are special situations – e.g. holiday in a country with poor medical care – it is certainly a sensible thing to have high-dose tablets at hand in case of a relapse, rather than having an infusion on site.
In summary: there are differences in approach, especially situation-related, but the standard for treating active MS relapses is the administration of 1000 mg of methylprednisolone per day for 3 – 5 days. It is incorrect to only have a low-dose long-term therapy with cortisone.
You can learn more about how cortisone works in a layman-friendly animation at www.amsel.de/ms-behandeln
