While there have been frequent updates about long-term immunotherapy for MS recently, the approach to treating MS relapses has remained unchanged for years. The treatment of acute MS relapses typically involves a high-dose corticosteroid preparation administered intravenously, usually Methylprednisolone at a dosage of 1000 mg over a period of 3 – 5 days. It can be assumed that approximately 25% of patients respond insufficiently to this first dose of cortisone. If a neurological deficit relevant to daily life still exists, then – according to current MS therapy guidelines – an escalation of relapse therapy should be carried out. Admittedly, the definition is not quite clear-cut, but in clinical practice, a deficit relevant to daily life is understood to mean persistent paralysis, balance and coordination disorders or visual disturbances – sensory disorders and abnormal sensations do not necessarily fall under this definition.
According to current therapy guidelines, a repeat high-dose corticosteroid therapy with up to 2,000 mg Methylprednisolone over 3-5 days is available for escalating relapse therapy. An alternative is immunoadsorption, which has shown a response rate of 50 – 86% in clinical trials for steroid-refractory (i.e., no therapeutic success could be achieved by administering high doses of corticosteroids) MS relapses. The downside of this method, however, is its invasiveness – many patients require a large-lumen venous catheter – and the significantly higher effort/higher costs. Nevertheless, the question arises as to whether immunoadsorption represents a viable alternative to repeated administration of high-dose cortisone for primarily steroid-refractory relapses.
Immunoadsorption or repeated corticosteroid administration?
An answer to this important question is now provided by a prospective study carried out in cooperation by the universities of Düsseldorf and Münster (Immunoadsorption versus double-dose methylprednisolone in refractory multiple sclerosis relapses). Between 2018 and 2020, 42 patients with persistent neurological deficits despite previous corticosteroid treatment were included. For relapse escalation therapy, 26 patients received another high-dose cortisone shock with 2000 mg over 5 days, 16 patients received immunoadsorption with six sessions over 6 – 8 days. The patients were examined upon admission and discharge and also received a follow-up examination after 3 months. It was found that 9 of the 26 patients treated with cortisone still required subsequent immunoadsorption. On the other hand, all 16 patients who received immunoadsorption as relapse escalation therapy required no further therapy to achieve satisfactory therapy response.
Furthermore, the EDSS also showed significant improvement in the immunoadsorption group compared to the patients who received cortisone at the follow-up examination. The assessment of the therapy response to immunoadsorption was highly significantly better than to the repeated administration of cortisone. Similar results were also observed in terms of evoked potentials, quality of life and measurement of neurofilament light chains. This analysis also showed an advantage for immunoadsorption. In addition to the clinical observations, extensive analyses of inflammatory cells were carried out in the study. There was a strong reduction in B cells after immunoadsorption, which closely correlated with the clinical results, while methylprednisolone only had a minimal effect on the B-cell populations.
The study thus proves that immunoadsorption is a viable strategy in the treatment of steroid-refractory relapses and should ultimately be used early in such cases. In view of the study data, it seems sensible to perform immunoadsorption rather than repeated corticosteroid treatment if there is an insufficient response to an initial relapse treatment with cortisone with persistence of a deficit relevant to daily life.