The intravenous administration of massive doses of methylprednisolone (a bolus of 500 to 1,000 mg daily for 3 to 5 days) followed by high oral doses of prednisone (beginning with 60 to 80 mg daily and tapering to a lower dosage over a 12to 20-day period) is generally effective in shortening an acute or subacute exacerbation of MS or optic neuritis. Whether the tapering oral course is necessary is unclear. When it is impractical to administer parenteral methylprednisolone, one may substitute oral methylprednisolone (48 mg in a single daily dose for 1 week, followed by 24 mg daily for 1 week, and finally 12 mg daily for 1 week) or the equivalent amount of prednisone (Barnes et al).
A brief period of corticosteroid administration generally produces few adverse effects but some patients complain of insomnia and a few will develop depressive or manic symptoms. Patients who require oral treatment for more than several weeks because of clinical relapse on withdrawal of the medication are subject to the effects of hypercortisolism, including the facial and truncal changes of Cushing syndrome, hypertension, hyperglycemia and erratic diabetic control, osteoporosis, avascular necrosis of the head of the femur, and cataracts; less often, there may be gastrointestinal hemorrhage and activation of tuberculosis or pneumocystis.
As mentioned under “Acute Multiple Sclerosis,” there may be a role for plasma exchange (see Weinshenker et al, 1999; Rodriguez et al) and perhaps immunoglobulin in fulminant cases. One limited trial has shown possible but mild benefit in patients with relapsing–remitting disease of monthly infusions of intravenous immunoglobulin (0.2 g/kg) for 2 years (Fazekas et al).
Treatment of optic neuritis (see Chap. 12) The Optic Neuritis Treatment Trial, reported by Beck and colleagues, cautioned against the use of oral prednisone in the treatment of acute optic neuritis (see also Lessell). In this study, it was found that the use of intravenous methylprednisolone followed by oral prednisone did, indeed, speed the recovery from visual loss, although at 6 months there was little difference in visual outcome between patients treated in this way and those treated with placebo. They reported that treatment with oral prednisone alone slightly increased the risk of new episodes of optic neuritis. In a subsequent randomized trial conducted by Sellebjerg and colleagues, it was found that methylprednisolone 500 mg orally for 5 days had a beneficial effect on visual function at 1 and 3 weeks. However, at 8 weeks, no effect could be shown (compared with the placebo-treated group), nor was there an effect on the subsequent relapse rate. The putative deleterious effects of oral glucocorticoids on relapse of optic neuritis have been disputed and most clinicians consider them equivalent to intravenous administration for this disorder.