Types

The use of steroid-based drugs for ‘attacks’ or ‘relapses’ of MS has been the standard treatment for MS for some years, and many people may still find that this is the first line of treatment offered to them.
There are several types of steroid drugs:

• Adrenocorticosteroids (such as ACTH – AdrenoCorticoTrophic Hormone), used to be one of the most commonly used steroids in MS.
• Glucocorticosteroids (such as prednisolone, given by mouth; or methylprednisolone, usually given through a drip, intravenously) are used more commonly now.

Effects of steroids

There is substantial evidence that both types reduce the inflammation at active disease sites in the CNS and, in particular, reverse disruptions of the blood–brain barrier (see Chapter 1) that may occur when the disease is active. These effects, in turn, should reduce the duration and degree of symptoms. However, most studies suggest that the effects of steroids are relatively short term, perhaps lasting a few weeks, although there have been one or two studies which suggest tantalizingly that there may be far longer positive effects of the combined short-term use of methyl- prednisolone and prednisolone.
There is also some interesting evidence from a trial on the use of steroids (methylprednisolone and prednisolone) following an initial episode of ‘optic neuritis’ (inflammation of the optic nerve, which makes things seem blurred). This is a significant symptom, which often acts as a forerunner of MS. There is more information on this trial in Chapter 18.
Overall there is a sense, at the moment, that further definitive trials to assess the most effective steroid, as well as its dose and mode of administration in MS, are now almost a waste of time and resources, as newer drugs – such as the beta-interferons, glatiramer acetate and others – show so much more promise for the control of MS, in relation not only to relapses, but also to the course of the disease.

How are steroids given?

ACTH has now been replaced by the use of methylprednisolone and prednisolone, but there is widespread debate amongst neurologists about the most appropriate steroid and mode of administration in MS. People with MS are likely to come across different ways in which steroids are currently given – intravenously administered methylprednisolone (called IVMP for short) normally requires a hospital stay for one to several days, depending on precisely how the drug is administered. There may need to be other hospital stays for assessment purposes.

Side effects

As with all powerful drugs, side effects – that is unwanted effects – can occur. Side effects appear to depend very much on both the type of steroid and how it is administered. When methylprednisolone is given in the usual short-term high intravenous doses, facial flushes, a metallic taste in the mouth during the treatment and sometimes acne occur. Most other reactions are not serious, but occasionally sleep disturbances, stomach upsets and mild mood changes occur. Very occasionally more serious psychological changes are seen.
With longer term administration of methylprednisolone, often followed by oral prednisolone, a range of unwanted effects may occur. These are very highly dependent on exactly how the steroids are given, for how long and the level of dose. Often signs of some water retention may occur: a ‘moon-shaped face’ and modest swelling (oedema) in several parts of the body. Normally, the cells of the body are bathed inside and outside in water, and this water is regulated by hormones, sodium (salt) levels and the kidneys. Steroids tend to cause the kidneys to retain
sodium: an increase in sodium levels leads to an increase in water retention in the body, resulting usually in a modest but noticeable swelling – the oedema.
Steroids can also produce a temporary ‘masculinization’ in women through their hormonal effects, which can include increased body hair, menstrual irregularities, acne and, paradoxically, a loss of scalp hair. Very prolonged administration can produce a range of other effects, some of them very serious.
There is always a balance to be struck between probable improvement in some MS symptoms following a relapse, and the avoidance of as many of these side effects as possible. It may not be an easy decision for either the clinician or the person with MS. Usually the pressing nature of the symptoms produced by a relapse decides the immediate outcome. Nevertheless, the use of steroids must be very carefully monitored. The objective is to gain the maximum possible beneficial effects following dosage for the shortest possible time. However, longer term administration of steroids is thought on balance to be important in special circumstances, to try to contain the Multiple Sclerosis.