Acute Attacks

• Indication for treatment

o Functionally disabling symptoms

o Objective evidence of neurological impairment

• Mild sensory attacks often not treated

• Treat infection if it is trigger

IV Steroids

• Standard treatment - Methylprednisolone IV500-1000mg daily for 3-5 days +/- short prednisolone taper

• Evidence:

o A number of trials with quite variable protocols conducted 1970’s and 1980’s

o Cochrane review (2000)

- Chance of worsening at 5 weeks is reduced (OR 0.37, ARR 25%)

- EDSS at 4 weeks slightly lower (by 0.76pts)

- No great long term data – probably no difference in outcomes at one year.

- No difference between short course (up to 5 days) and long course (15 days)

o Some studies have looked at adding regular doses of IVMP to long term treatment – generally a trend to improved results (see Primer on MS by Giesser)

High dose oral steroids

• A number of smaller trials generally suggesting equivalence, bigger trial in 2015:

• COPOUSEP trial, Lancet 2015, French trial

o 100 patients in each arm – oral methylprednisolone 1000mg x 3 days (30 x 100mg tab) vs 1000mg x 3 days IV methylprednisolone

o Within 15 days of relapse, severity – at least 1 point drop on Kurtzke disability scale.

o No difference in outcomes at 1 month and 6 months (~40% fully recovered at 1 months and 66% by 6 months, no difference in subsequent relapses ~30% in both groups)

o Similar side effect profile – slightly more insomnia in oral group.

Plasma exchange

• Has been shown to be beneficial in severe or refractory cases.