Oral vs IntraVenous Steroids
In Multiple Sclerosis

We investigated the effect of Oral and IntraVenous MethylPrednisolone treatment on subsequent relapse rate in patients with Multiple Sclerosis.

Following a double blind trial designed to compare the effect of Oral and IntraVenous MethylPrednisolone treatment on promoting recovery from acute relapses of Multiple Sclerosis.

80 patients were followed for two years with six-monthly assessments during which all subsequent relapses were recorded.

The annual relapse rate was slightly higher in the Oral compared with the IntraVenous MethylPrednisolone treated patients (1.06 vs. 0.78).

But, the adjusted difference between the two groups was not statistically significant (0.18; 95% CI -0.19 to 0.55, P=0.3).

The time to onset and the severity of the first relapse after treatment, the number of relapse free patients at the end of the follow-up period, and the severity of the relapses during the follow-up period were similar in the two groups.

This trial did not show a statistically significant difference in relapse rate during the first two years following Oral compared with IntraVenous MethylPrednisolone treatment.

The efficacy of GlucoCorticoid treatment in Multiple Sclerosis (MS) is uncertain. We assessed the effect of Oral high-dose MethylPrednisolone in attacks of MS.

Twenty-five patients with an attack of MS with a duration of less than four weeks were randomized to placebo, 26 patients received Oral MethylPrednisolone (500 mg once daily for five days with a 10 days tapering period).

Scripps Neurological Rating Scale scores differed significantly in MethylPrednisolone and placebo-treated patients the first three weeks (p = 0.005) and after eight weeks (p = 0.0007).

Subjective symptom assessment on a Visual Analogue Scale the first three weeks (p = 0.02) and the answers to an efficacy questionnaire administered after eight weeks (p = 0.05) also favored a beneficial effect of MethylPrednisolone treatment.

The risk of a new attack of MS was not influenced by the treatment at short-term follow up. No serious adverse events were seen. Oral high-dose MethylPrednisolone is recommended for treatment of attacks of MS.

Objectives
To survey the use of CorticoSteroids in Multiple Sclerosis as recommended by United Kingdom consultant Neurologists.

Methods
A postal questionnaire covering the use of CorticoSteroids for acute Multiple Sclerosis relapse and Chronic Progressive Multiple Sclerosis.

With regard to frequency of use, type of CorticoSteroid, and dosage regime was sent to all members of the Association of British Neurologists with a United Kingdom address.

Results
Two hundred and twelve United Kingdom consultant Neurologists replied to the survey (74% response rate).

Eighty six per cent indicated that they prescribed CorticoSteroids in more than one quarter of acute Multiple Sclerosis relapses seen.

IntraVenous MethylPrednisolone was recommended at some time by 99% of consultant Neurologists, the most popular regime being 1g daily for 3 days (74%;154/ 208).

Over one half (53%; 109/206) never recommended a subsequent tapering course of Oral CorticoSteroids; of those that did, 25% (24/96) recommended a tapering course lasting more than 1 month.

Eighty eight per cent (1811206) of prescribers of IntraVenous MethylPrednisolone were able to offer the course as a day case on the ward; 7% (151206) at an outpatient clinic; and 5% (111206) at home.

Almost three quarters of Neurologists recommended Oral CorticoSteroids for some acute relapses, although the most popular response was for occasional use only (48%; 1011212).

Forty five per cent (961211) at least occasionally recommended Steroids for patients with Chronic Multiple Sclerosis not experiencing an acute relapse.

Conclusions
Although the vast majority of consultant Neurologists would prescribe IntraVenous MethylPrednisolone for acute Multiple Sclerosis relapse at some time, the use of CorticoSteroids for Multiple Sclerosis was otherwise variable.

There seemed to be little consensus about the use of Oral Steroids in acute relapse, the prescribing of a tapering course of Oral Steroids after IntraVenous MethylPrednisolone, or the utility of Steroids in Chronic Multiple Sclerosis.

Variability of prescribing recommendations probably reflects a lack of clear evidence in the face of a wide range of clinical situations, variable access, and timing of access to Neurologists in the acute phase of relapse.

And, pressure on Neurologists to treat in an otherwise "hopeless" situation. Large multicenterd trials are needed to consider these issues.

Background
An IntraVenous rather than Oral course of MethylPrednisolone is often prescribed for treating acute relapses in Multiple Sclerosis (MS) despite the lack of evidence to support this route of administration.

Our double-blind placebo-controlled randomized trial was designed to compare the efficacy of commonly used IntraVenous and Oral Steroid regimens in promoting recovery from acute relapses in MS.

Methods
42 patients with Clinically Definite relapse in MS received Oral, and 38 IntraVenous, MethylPrednisolone.

Clinical measurements at entry and at 1 week, 4 weeks, 12 weeks, and 24 weeks included Kurtzke's Expanded Disability Status Scale (EDSS), Hauser's Ambulatory Index, and an arm-function index.

The primary outcome criterion was a difference between the two treatment groups of one or more EDSS grades at 4 weeks.

Findings
There were no significant differences between the two groups at any stage of the study in any measurement taken: the mean difference in EDSS at 4 weeks (adjusted for baseline level) was 0.07 grades more in those taking Oral Steroids (95% CI -0.46 to 0.60).

The most optimistic outcome for IntraVenous therapy is an average benefit of less than half a grade improvement on EDSS over Oral treatment.

Interpretation
Since our study did not show any clear advantage of the IntraVenous regime we conclude that it is preferable to prescribe Oral rather than IntraVenous Steroids for acute relapses in MS for reasons of patient convenience, safety, and cost.